Achilles Tendon Rupture

A Patient's Guide

The Achilles tendon is the largest and strongest tendon in the human body, connecting the calf muscles to the heel bone. Named after the Greek hero Achilles, who was said to be invulnerable except for his heel, this tendon is crucial for walking, running, and jumping. An Achilles tendon rupture is a significant injury that occurs when this tendon tears, either partially or completely. It can be a debilitating condition, impacting mobility and quality of life. Understanding the causes, symptoms, diagnosis, and treatment options is essential for effective management and recovery.

Symptoms and Signs

Recognising a rupture early can make a significant difference in the treatment outcome. The following are common symptoms and signs associated with this injury:

Sudden Pain: A sudden, sharp pain or “snap” at the back of the ankle or calf, sometimes likened to being struck by a hard object is common.
Swelling and Bruising: This occurs around the ankle and calf making the area appear puffy and tender to touch.
Difficulty Walking: An Achilles tendon rupture significantly impacts walking. Patients usually have trouble bearing weight on the affected leg, pushing off with that foot and might experience a noticeable limp.
Weakness: Weakness or instability in the ankle and lower leg is another sign, making activities like standing on tiptoe or climbing stairs particularly challenging.
Audible Pop: Many patients report hearing a popping or snapping sound at the time of injury.

Assessment

Accurate diagnosis of an Achilles tendon rupture involves a combination of physical examination and imaging studies. Timely and correct diagnosis is critical for effective treatment planning.

Gap in the Tendon: A palpable gap can be felt along the Achilles tendon, usually about 2-6 cm above the heel bone. This gap is where the tendon has torn and is a strong diagnostic clue.
Simmonds Test: Also known as the Thompson test or calf squeeze test, this is a simple yet effective way to diagnose a rupture. The patient lies face down with their feet hanging off the edge of the examination table. If the foot does not move when squeezing the calf muscle, it indicates a possible rupture.
Ultrasound: This is often the first imaging modality used. It is non-invasive, quick, and can provide real-time images of the tendon. Ultrasound can identify partial and complete tears, as well as quantify retraction of the tendon ends.
MRI (Magnetic Resonance Imaging): This provides detailed images of both soft tissues and bones, but is not a dynamic test so is reserved for when ultrasound is inconclusive or in complex and chronic cases.
X-ray: In some cases, additional tests like X-rays might be used to rule out injuries presenting in a similar way, such as avulsion fractures of the heel bone (calcaneus).

Conservative Treatment

Treatment options for an Achilles tendon rupture range from conservative management to surgical intervention. The choice of treatment depends on factors such as the patient's age, activity level, and the severity of the rupture.

Modern treatment has moved towards greater use of non-surgical treatment as functional rehabilitation has been shown to enhance outcome, whilst simultaneously avoiding the risk of surgery.

This typically involves:

Pneumatic Boot: The affected leg is typically immobilised in a specialised Vacoped boot keeping the foot pointed to the floor (equinus). This position helps the tendon ends to approximate and heal. As the tissues start to knit together, the foot is gradually brought back upwards to a standing position.
Physiotherapy: Once the initial healing phase is complete, physiotherapy begins. Therapy focuses on gradually increasing range of motion, strengthening the calf muscles, and improving flexibility. A structured rehabilitation program is crucial for optimal recovery.

Surgical Treatment

Surgery is sometimes recommended if the tendon ends have not approximated well enough when the foot is pointed downwards. This is because a large gap can result in an over-lengthened tendon.

An operation will bring the ends together, and the leg will then be allowed to rehabilitate in a cast and pneumatic boot. After surgery, recovery timelines will be similar to conservative treatment since functional rehabilitation is still employed.

Surgical options are:

Open Surgery: A single longitudinal incision is made along the back of the ankle through which the torn ends of the tendon are located, and stitched together. This method allows for direct visualisation and precise repair of the tendon.
Minimally Invasive Surgery: This involves multiple smaller incisions and the use of special instruments to repair the tendon. This approach reduces the risk of wound complication compared to open surgery but may increase the risk of nerve injury since deeper structures are not directly seen.

Summary

An Achilles tendon rupture is a serious injury that can significantly impact an individual's mobility and quality of life. Prompt recognition of symptoms, accurate diagnosis through physical examination and imaging, and appropriate treatment—whether conservative or surgical—are essential for effective management. With proper care and rehabilitation, most patients can expect to return to their pre-injury activity levels and lead active, healthy lives.