Achilles Tendon Rupture Management and Physiotherapy
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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 Achilles tendon consists of the tendons from the two main calf muscles, the gastrocnemius and the soleus, coming together into one about 15cm above the upper edge of the heel bone. Tendons have ideal properties to transmit force from muscles to bones, being stiff but resilient, having a high tensile strength and able to stretch up to 4% before any damage occurs. Over 8% of stretch to the tendon and rupture of the fibres occurs. About 2-6cm up from the heel bone the blood supply is less good and in this area most of the degeneration and eventual rupture occurs.
Achilles tendon tears occur mostly in the left leg where the poor blood supply is, perhaps because most people are right handed and push off more with their left leg. Common injuries are on sudden foot push off, an unexpected forcing up of the ankle and an upward force on the ankle when pushed down. Direct trauma and general degeneration of the tendon without trauma can also occur. People at risk include those exerting themselves when they are unfit, relatively older people, steroid users and those who exert themselves in extreme ways.
Achilles tendon forces in running can be very high and have been measured at six to eight times bodyweight. The patient typically reports a sudden snap or blow to the rear of the lower calf, a sudden strong pain, an ability to walk but not to run or climb stairs. On examination there may be a swollen or bruised calf, a palpable gap in the tendon and an inability to stand on tiptoe. A history of treatment with steroids, previous tendon rupture or an unusually high activity level (e.g. weekend warrior) can also be important findings.
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 physio will begin the rehabilitation with exercises to increase the ankle movements and gently stress the tendon, instruction in good gait and use of a heel raise to reduce stretching forces on the tendon. Static bicycling and swimming are useful non weight-bearing exercises, steadily progressing to exercises in weight bearing, muscle strength work and then to advanced work such as running, jumping and balance training. Four months after surgery a patient may be able to start back to normal activity.
The prognosis for Achilles tendon sufferers is mostly excellent or good and most sportsmen and women can get back to their sport. In surgical care the re-rupture rate is zero to five percent but in conservative care it can be as high as forty percent. Physio education helps the patient to train and stretch properly and to choose the right footwear to reduce the risks of rupturing again.
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