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Achilles Tendon Rupture Management and Physiotherapy

The largest and the strongest tendon in the body is the Achilles tendon in the distal posterior calf. Typical patients with Achilles tendon rupture are men in good health from 30-50 years old and who have not suffered major injuries or any kind of difficulty with the leg before. Rupture occurs typically in people who have not been recently active and who may indulge in infrequent physical activity such as playing weekend sport, players known as “weekend warriors”.

The two large calf muscles, the gastrocnemius and the soleus, each have a tendon and these converge and form the Achilles tendon about 15 centimetres above the calcaneum. Tendons transmit forces from muscles to bones and to do this they have high resilience and sufficient stiffness, good tensile strength and allow 4 percent stretch before damage. Damage and rupture to the fibres can occur when the stretch reaches 8 percent. Most of the tendon rupture and degeneration occurs where the blood supply is poorest, about 2-6 centimetres up from the heel bone.

The left leg is the commonest site for tendon rupture in the area deprived of good blood supply described previously. Most people are right footed so push off forcefully with their left leg in acceleration manoeuvres. The tendon can be damaged in sudden acceleration, if the ankle is pushed up forcefully by surprise and if there is upward pressure as the foot is being pushed down. Tendon degeneration over time without trauma and direct accidents can both lead to rupture. Rupture is more likely in relatively older people (30-50), patients on corticosteroids, in extreme activities and in unfit people who exert themselves suddenly.

Running can impose high levels of force through the Achilles tendon, around six to eight times our body weight. The commonest report is a sudden blow or snap in the posterior ankle area, a severe immediate pain and difficulty pushing off or standing on tiptoe. Examination can show a bruised and swollen calf, a gap in the Achilles tendon, an ability to walk but not to climb stairs or run. Precipitating factors for rupture are having a rupture before, exerting oneself unusually strongly when unfit and taking medication such as steroids over some time.

Doctors choose conservative or surgical management, operation having a higher risk of complications and conservative treatment a higher risk of re-rupture. Non-operative treatment is suitable for sedentary people, diabetics, older people and those with medical problems or poor skin integrity. Impaired blood supply, diabetes and other illnesses make wound breakdown, tendon separation and infections more likely. A calf or thigh length plaster may be used with the ankle flexed down, moving it up regularly over six to ten weeks. The patient is allowed to weight bear and given an orthotic as the tendon heals.

The surgical options are percutaneous or open operation with the leg put into a plaster or a brace with the ankle flexed downwards, the patient routinely returning for the ankle to be re-immobilized in a more neutral position. The ankle is in the brace or cast for four to six weeks and shorter periods of tendon immobilization seem to be more effective than longer ones. Surgical management shows reduced rates of re-rupture, faster return to normal activity, improved calf strength and endurance when compared to conservative management.

The physiotherapy rehabilitation starts with ankle range of movement exercises without body weight loading, encouraging a good walking pattern and a heel raise to reduce the upward force on the tendon in gait. Static cycling and swimming are good starting activities, moving onto weight bearing exercises, muscle strengthening and onto more vigorous activities such as jogging, jumping and balance practice. Normal activity may be resumed by four months from surgery but this varies.

Achilles tendon rupture usually turns out with good or excellent results with most athletes getting back to their chosen sports. Surgical management has a re-rupture rate of 0-5 percent and conservative treatment up to 40 percent, so patient education by the physio in training and stretching performance and the best choice of footwear is important for the long term.