The Achilles tendon is one of the largest tendons that anchor muscle to bone and certainly one of the most vulnerable. The Achilles tendon attaches proximally (closest to the head) to the end of the calf muscles and distally (furthest from the head) to the calcaneous or tip of the heel bone. Movement of the foot from pointing to flexion requires the use of the calf muscles and therefore the use of the Achilles tendon. If you have a ruptured Achilles tendon or would like to know how to prevent it from happening, keep reading.
The tendon was named after a mighty Greek warrior and one of the hero’s in Homer’s Illiad. In an attempt to make her boy immortal she held him by his heel and dipped him in the river Styx. Everything the water touched was invulnerable but what remained dry was not. Later references to an Achilles Heel refers to literally the weakest link in the chain.
Ruptured Achilles Tendon Diagnosis
The Achilles tendon bears the brunt of the force of pushing off against the ground in running and jumping, or pushing against the pedals in biking. But you do rely on this tendon every time you move your foot. The tendon is most often ruptured or torn during an explosive action requiring eccentric force – such as when jumping or starting to sprint.
First there is a pop, or a snap and then comes a sharp pain in the lower leg and heel that makes it impossible to walk. In fact it is impossible to walk if the rupture is complete because the calf muscle is no longer attached to the heel and can’t move the foot. There will be weakness, pain, calf swelling, and an inability to appropriately move the foot into dorsiflexion (toes flexed toward the head). The patient will report an inability to walk up and down stairs.
There also may have been a prior diagnosis of a sprained ankle because they continue to have active plantar flexion or the ability to point their toes. Presenting late for treatment and rehabilitation affects the long-term outcome of the recovery negatively.
People who have had a prior Achilles tendon rupture that was treated conservatively without surgery have a high rate of recurrence. Weekend warriors, or those older athletes who only workout on the weekends also have a higher rate of injury due to decreased flexibility and increased weakness of the calf muscle. During physical examination the doctor will feel the entire calf area to find swelling, tendon defects and tenderness. When there is a complete rupture there will be a gap in the tendon that is palpable approximately 1-2 inches above the site of insertion at the heel. Physicians will note that there is an inability to stand on the toes.
Several physical tests may be performed to confirm the diagnosis of an Achilles tendon rupture. The hyperdorsiflexion sign is done while the patient is lying on their stomach with both knees flexed to 90 degrees. The doctor manually flexes the feet and compares the results side by side. In the Thompson test the patient is again on their stomach and the affected leg is extended. The doctor will squeeze the calf muscle to indirectly point the toe. A positive test results if the foot doesn’t point and helps to confirm the diagnosis of a rupture. See below for an example of how this test is performed:
Common Risk Factors
There are several common risk factors of an Achilles tendon rupture that include:
- Weekend warrior or recreational athlete who doesn’t know their limitations
- Older athlete between 30 and 50 years
- Prior Achilles tendon injury, tendonitis or rupture
- Prior injections to the tendon or use of fluoroquinolone
- Abrupt change in training or activity level
- Starting a new activity
- Weakened calf muscles
- Poor flexibility in the Achilles tendon or calf muscles
Although an x-ray won’t reveal a ruptured Achilles tendon the physician may be looking for an injury to the calcaneal bone where the Achilles tendon attaches. During some injuries the Achilles tendon doesn’t rupture but rather pulls part of the calcaneous off of the heel. The end result of lack of use of the ankle is the same but the treatment is entirely different.
Ruptured Achilles Tendon – Treatment, Surgery, Therapy, Recovery
Treatment of a ruptured Achilles tendon can be conservative or surgical in nature. A conservative approach places the patient in a cast for 8 weeks with the foot in plantar flexion, or toes pointed, to help the tendon reconnect. This type of treatment may work for those who aren’t interested in becoming very active again once the treatment has been completed. Unfortunately the conservative approach has a high incidence of repeat injuries following recovery. Some of the reasons that physicians and patients may choose a more conservative approach is because the patient is a poor candidate for anesthesia due to cardiac or pulmonary problems, poor circulation, advanced diabetes leading to poor circulation and poor healing, presence of skin problems at the site of the injury, increased age or sedentary lifestyle. The use of a conservative approach to treatment and casting only also usually increases the time needed for healing. Although the standard time for casting is 8 weeks the healing time is variable and for some people complete recovery comes after 6 months.
The second, and more likely approach, is a surgical repair to the tendon. During surgery the doctor will sew the tendon together to allow greater healing or reattach the tendon to the heel if it were avulsed instead of torn. After surgery patients are also placed in a cast to rest the foot and allow the tendon to heal. To keep the heel from stretching the cast is initially placed with the toes slightly pointed and gradually moved to the toes being in neutral position. Casting after surgery can also be between 6 and 12 weeks depending upon the type of repair needed.
After either a conservative approach or surgical intervention there will be a period of rehabilitation involving physical therapy exercises to strengthen the leg muscles. Most people will return to normal activities within 4 to 6 months. The amount of recovery is dependent upon the quality of physical therapy and the commitment to the program on a daily basis.
Tips on Preventing Ruptured Achilles Tendons
Before starting any physical activity, gently stretch the tendon and calf muscles and warm them up. Stretch slowly and not to the point of pain. You should feel a gentle pull but not pain. Never bounce during a stretch since you’re increasing the risk of rupturing or tearing the tendon. Avoid excessive stress on the Achilles tendon such as hill running or jumping. If you notice pain while doing physical activities stop and rest. Alternate high impact sports such as running with lower impact sports such as walking, biking or swimming. Do strengthening exercises for the calf muscle and stretch the muscles and tendons regularly.
A ruptured Achilles tendon will sideline you from your physical activities for up to 6 months but the rehabilitation and recovery is well worth the process. Physical activity improves your emotional and mental states, decreases your risk of stroke, heart attack and immune mediated illnesses such as arthritis and lupus as well as improving your circulation. To continue to reap the benefits and rewards of a strong exercise program continue to work through the rehabilitation to return to your normal activities. If you are looking for more information on ruptured achilles tendons, have a look at the additional resources section below.
BTW -- If you are an avid runnner or play sports that require a lot of stop and go, you may want to check out the following articles: “Symptoms of a Torn Hamstring” and “How to Tell If You Have Plantar Fasciitis”
Disclaimer – I am not a doctor and I am not qualified to provide medical advice. The information above on treatment options for ruptured achilles tendon was posted for informational purposes only and should not be interpreted as medical advice.
MayoClinic: Achilles Tendon Rupture
American Academy of Orthopedic Surgeons: Diagnosis and treatment of Acute Achilles Tendon Rupture