Conditions

Achilles Tendon Rupture

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1. Introduction

The Achilles tendon is located at the back of the ankle and is where the calf muscles join together and attach to the heel bone. The calf muscles will contract to point the foot/toes; this movement generates the powerful push or spring forwards when walking, running or jumping. The Achilles tendon transmits the force from the calf muscles to the foot and is very strong. A rupture of this tendon is not a common injury.

Frequently Asked Questions

A rupture of the Achilles tendon is a complete tear of the tendon which is the tendon that joins your calf muscles to your foot.

  • Achilles tendon rupture is a complete tear of the large tendon at the back of the heel.
  • It is a very rare condition occurring in less than 0.01% of the general population (1, 3).
  • Yes.
  • This is a serious condition and does require medical attention, although not all require surgery (5,8).
  • It is important that if you suspect a significant injury to the tendon that you have it properly assessed as soon as possible.
  • 80% of ruptures occur during recreational sports (2).
  • Approximately 10% of ruptures will have had pre-existing tendon problems (4).
  • Males are more commonly affected.
  • An instant pain, commonly described as a ‘stab’ or a ‘kick’ in the heel / lower leg.
  • An audible ‘crack’ or ‘pop’ sound is often recognised.
  • Reduced ability to point the ankle (plantarflex) or lift the heels off the floor in standing.
  • A noticeable limp when walking.
  • Seek medical attention.
  • Use crutches to walk or immobilise the foot once diagnosis confirmed. 
  • Seek physiotherapist advice for rehabilitation once medical management has been decided. 
  • This will depend upon a number of factors including other existing conditions, stage of injury, adherence to rehabilitation, etc.
  • It can take 3-6 months to return to activities of normal life, although it is likely to take 9-12 months to be able to return to sport (5).

We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk. Book online with us today to get a programme tailored to your specific needs.

2. Signs and Symptoms

When the tendon ruptures people often describe that they feel as if something has hit the back of their ankle. This can be accompanied by a ‘pop’ sound. A tendon rupture can cause severe pain, however, in one study approximately one-third of people do not have any pain at all (1).

Swelling and bruising can occur with ruptures but not always and, if seen, it can be mild. There may be reduced ability to point the toes or heel raise and there may be a noticeable limp when walking.

3. Causes

Rupture of the tendon occurs when a sudden forceful movement is applied to a weak or degenerative tendon. It can also occur following a fall, missing a step or a deep laceration over the tendon.

4. Risk Factors

  • The peak age for rupture is 30-40 years (4).
  • Gender – men are more prone than women (4).
  • Being overweight – increased load on the tendons as well as reducing the health of the tendon (3).
  • Previous Achilles tendon problems.
  • Long term use of corticosteroids – this has been shown to reduce the strength of the tendon.
  • Previous steroid injections to the area.

5. Prevalence

The incidence of Achilles tendon rupture is 18 per 100,000 (5). The majority of ruptures occur during recreational sport (up to 80%), especially in those playing sport when older. The incidence of ruptures is rising, possibly due to sedentary lifestyles and intermittent recreational sport participation in later life (6).

6. Assessment & Diagnosis

All complete tendon ruptures benefit from an orthopaedic consultation. Following an orthopaedic assessment, you may be treated surgically or non-surgically. With both options for treatment, physiotherapy forms the basis of your rehabilitation to help you achieve optimal recovery (5,8).

Your physiotherapist will want to know how your condition affects your day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent reassessment will determine if you are making progress towards your goals and will allow appropriate adjustments to your treatment.

7. Self-Management

At the time of injury try to reduce weight-bearing by using crutches and seek an orthopaedic opinion by going to A&E. 

The evidence does not show that there is clear best management option for Achilles tendon ruptures. There will be consideration between a surgical approach and a non-surgical approach; both have risks and benefits but there are no significant functional differences between approaches. The discussion and decision will be made by you and your medical professional (5). 

8. Rehabilitation

Many factors will be considered before a treatment approach is determined including the level of activity, work, sports that require sprinting/jumping and patient preference (9).

All tendon ruptures will have a period of immobilisation to allow the torn ends of the tendon to heal, either following surgery or naturally. This can be done in a cast or by wearing a walking boot. Initially, the foot will be pointed to put the least amount of stress on the tendon and will help the ends to reconnect if they have not been surgically attached. Gradually the foot will be moved into a more neutral position with increased weight-bearing as the tendon is able (10).

9. Achilles Tendon Rupture
Rehabilitation Plans

No exercise plan as this condition requires protocol driven rehab with guidance from consultant and is very patient specific.  

10. Return to Sport / Normal life

For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you will likely require further progression. Before returning to sport, a rehabilitation programme should incorporate plyometric-based exercises; this might include things like bounding, cutting and sprinting exercises (11).

As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other treatments to support symptom relief and recovery. Whilst recovering you might benefit from further assessment to ensure you are making progress and establish appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future re-occurrence.

11. Other Treatment Options

The management of this condition could be conservative or may involve surgery. There are benefits and risks to both approaches and the specifics of your case will determine the outcome. In the case of conservative, you will likely have a period of time in an ankle boot. For surgery, the Achilles will be repaired. In both cases, the recovery time from surgery is typically 6-12 months (5), however with the right management in input from physiotherapy the recovery is typically good.

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References

  1. Gravlee JR, Hatch RL, Galea AM. Achilles tendon rupture: a challenging diagnosis. J Am Board Fam Pract. 2000;13(5):371.
  2. Flint JH, Wade AM, Giuliani J, & Rue JP. Defining the terms acute and chronic in orthopaedic sports injuries: a systematic review. The American journal of sports medicine, 2014; 42(1), 235-241.
  3. Maffulli N, Sharma P, & Luscombe KL. Achilles tendinopathy: aetiology and management. Journal of the Royal Society of Medicine, 2004; 97(10), 472-476.
  4.  Singh D. Acute Achilles tendon rupture. BMJ 2015; 351
  5. Uquillas CA, Guss MS, Ryan DJ, et al Everything Achilles. Knowledge update and current concepts in management: AAOS exhibit selection. Journal of Bone and Joint Surgery. American 2015; (14), 1187-1195.
  6.  Hess GW. Achilles tendon rupture: a review of etiology, population, anatomy, risk factors, and injury prevention. Foot Ankle Spec 2010;3:29-32.
  7. Jiang N, Wang B, Chen A, Dong F & Yu B. Operative versus nonoperative treatment for acute Achilles tendon rupture: a meta-analysis based on current evidence. Int Orthop. 2012;36(4):765
  8.  Barfod KW, Hansen MS, Hölmich P, et al. Efficacy of early controlled motion of the ankle compared with immobilisation in non-operative treatment of patients with an acute Achilles tendon rupture: an assessor-blinded, randomised controlled trial. Br J Sports Med 2020; 54:719.
  9.  Ochen Y, Beks RB, van Heijl M, Hietbrink F, Leenen LPH, van der Velde D, Heng M, van der Meijden O, Groenwold RHH, Houwert RM. Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis. BMJ. 2019; 364:k5120.
  10. Gulati V, Jaggard M, Al-Nammari SS, Uzoigwe C, Gulati P, Ismail N, Gibbons C and Gupte C. Management of achilles tendon injury: A current concepts systematic review. World journal of orthopedics, 2015; 6(4), 380.
  11.  Zellers JA, Carmont MR, Grävare Silbernagel K. Return to play post-Achilles tendon rupture: a systematic review and meta-analysis of rate and measures of return to play. Br J Sports Med. 2016 Jun
  12.  Trofa DP, Miller JC, Jang ES, Woode DR, Greisberg JK, Vosseller JT. Professional Athletes’ Return to Play and Performance After Operative Repair of an Achilles Tendon. Rupture.Am J Sports Med. 2017;45(12):2864.

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