Achilles tendon break: Achilles tendon rupture – Symptoms and causes
Achilles Tendon Rupture – Foot Health Facts
Javascript is required to view the content on this page. Please enable Javascript in your browser.
What Is the Achilles Tendon?
A tendon is a band of tissue that connects a muscle to a bone. The Achilles tendon runs down the back of the lower leg and connects the calf muscle to the heel bone. Also called the heel cord, the Achilles tendon facilitates walking by helping to raise the heel off the ground.
What Is an Achilles Tendon Rupture?
An Achilles tendon rupture is a complete or partial tear that occurs when the tendon is stretched beyond its capacity. Forceful jumping or pivoting, or sudden accelerations of running, can overstretch the tendon and cause a tear. An injury to the tendon can also result from falling or tripping.
Achilles tendon ruptures are most often seen in “weekend warriors”—typically, middle-aged people participating in sports in their spare time.
Less commonly, illness or medications, such as steroids or certain antibiotics, may weaken the tendon and contribute to ruptures.
Signs & Symptoms
A person with a ruptured Achilles tendon may experience one or more of the following:
- Sudden pain (which feels like a kick or a stab) in the back of the ankle or calf—often subsiding into a dull ache
- A popping or snapping sensation
- Swelling on the back of the leg between the heel and the calf
- Difficulty walking (especially upstairs or uphill) and difficulty rising up on the toes
These symptoms require prompt medical attention to prevent further damage. Until the patient is able to see a doctor, the RICE method should be used. This involves:
- Rest. Stay off the injured foot and ankle, since walking can cause pain or further damage.
- Ice. Apply a bag of ice covered with a thin towel to reduce swelling and pain.
Do not put ice directly against the skin. - Compression. Wrap the foot and ankle in an elastic bandage to prevent further swelling.
- Elevation. Keep the leg elevated to reduce the swelling. It should be even with or slightly above heart level.
Do not put ice directly against the skin.
Diagnosis
In diagnosing an Achilles tendon rupture, the foot and ankle surgeon will ask questions about how and when the injury occurred and whether the patient has previously injured the tendon or experienced similar symptoms. The surgeon will examine the foot and ankle, feeling for a defect in the tendon that suggests a tear. Range of motion and muscle strength will be evaluated and compared to the uninjured foot and ankle. If the Achilles tendon is ruptured, the patient will have less strength in pushing down (as on a gas pedal) and will have difficulty rising on the toes.
The diagnosis of an Achilles tendon rupture is typically straightforward and can be made through this type of examination.
In some cases, however, the surgeon may order an MRI or other advanced imaging tests.
Treatment
Treatment options for an Achilles tendon rupture include surgical and nonsurgical approaches. The decision of whether to proceed with surgery or nonsurgical treatment is based on the severity of the rupture and the patient’s health status and activity level.
Nonsurgical Treatment
Nonsurgical treatment, which is generally associated with a higher rate of rerupture, is selected for minor ruptures, less active patients and those with medical conditions that prevent them from undergoing surgery. Nonsurgical treatment involves use of a cast, walking boot or brace to restrict motion and allow the torn tendon to heal.
Surgery
Surgery offers important potential benefits. Besides decreasing the likelihood of rerupturing the Achilles tendon, surgery often increases the patient’s push-off strength and improves muscle function and movement of the ankle.
Various surgical techniques are available to repair the rupture. The surgeon will select the procedure best suited to the patient.
Following surgery, the foot and ankle are initially immobilized in a cast or walking boot. The surgeon will determine when the patient can begin weightbearing.
Complications such as incision-healing difficulties, rerupture of the tendon or nerve pain can arise after surgery.
Physical Therapy
Whether an Achilles tendon rupture is treated surgically or nonsurgically, physical therapy is an important component of the healing process. Physical therapy involves exercises that strengthen the muscles and improve range of motion in the foot and ankle.
What Is It, Symptoms & Treatment
Overview
What is an Achilles tendon rupture?
The Achilles tendon attaches the calf muscle to the heel bone. This thick band of tissue is very strong. In fact the Achilles tendon is the largest and strongest tendon in the body.
The Achilles tendon gives your leg strength to walk, run and jump.
An Achilles tendon rupture is a full or partial tear of the Achilles tendon. This acute (sudden) injury occurs when the tendon stretches to its breaking point. It happens most frequently while playing sports. Tripping, falling or twisting your ankle can also cause an Achilles tear.
How common are ruptured Achilles tendons?
Achilles tendon ruptures are very common sports injuries. They occur most frequently in people ages 30 to 40 and are more common in men than in women.
People who are “weekend warriors” (usually adults who don’t train regularly, then exercise at a high intensity) are more likely to tear an Achilles tendon than younger, well-trained athletes.
Symptoms and Causes
What causes an Achilles tendon rupture?
Sudden movement that puts stress on the Achilles tendon can lead to a rupture. Typically, people tear the Achilles tendon while playing sports. The biggest culprits are sports with sudden stops, starts and pivots — such as soccer, football, basketball, tennis or squash.
Achilles tendon tears aren’t always a sports injury. You can tear your Achilles tendon by tripping, missing a step when going downstairs or accidentally stepping into a hole and twisting your ankle. Some medications — including certain antibiotics and steroid injections in the area — can weaken the Achilles tendon. This can put you at a higher risk for a tear.
What are the symptoms of a torn Achilles tendon?
The classic sign of a ruptured Achilles tendon is feeling (and sometimes hearing) a pop or snap at the back of your ankle. People often mistakenly think something has hit them, but they’re actually feeling the tendon snap.
Other common symptoms include:
- Sharp, sudden pain in the back of the ankle near the heel.
- Swelling and bruising in the back of the ankle.
- Pain when walking, especially upstairs or uphill.
- Tenderness in the spot where the tendon is torn.
What are the complications of an Achilles tendon rupture?
A torn Achilles tendon is a traumatic injury that requires medical attention.
Without treatment, an Achilles tendon rupture may not heal properly. This can increase your risk of rupturing it again.
Diagnosis and Tests
How is a ruptured Achilles tendon diagnosed?
Your healthcare provider will physically examine your foot and ankle. They’ll check your ability to move it in various directions and see how you react to pressure on the area. They will also feel for a gap in the tendon that suggests it’s torn.
Your provider may also use imaging tests — such as ultrasound or MRI — to determine the extent of the Achilles tear.
Management and Treatment
How is a ruptured Achilles tendon treated?
Even before you seek medical help, you can reduce pain and swelling to the injured tendon by following the RICE (Rest, Ice, Compression, Elevation) method:
- Rest, by staying off the injured leg.
- Apply ice to the injured area.
- Wrap your ankle to compress the injured area and prevent more swelling.
- Elevate your leg at or above the level of your heart to reduce swelling.
Full healing of a torn Achilles tendon typically takes about four to six months. Medical treatment for a ruptured Achilles tendon may include:
- Brace or walking cast: Nonsurgical treatment for a torn Achilles tendon requires immobilizing the injured foot and ankle. Your provider will place your foot, ankle and calf in a brace or walking cast. Your foot and ankle flex downward so that the Achilles tendon can heal.
- Surgery: Most providers recommend surgical repair of a torn Achilles tendon in people who are active and middle-aged or younger. During surgery, a surgeon stitches the two ends of the torn tendon back together. After surgery, you’ll need a cast on your lower leg to immobilize the tendon while it heals.
- Physical therapy: You will need physical therapy to regain strength and mobility in your Achilles tendon, whether or not you had surgery.
Prevention
How can I prevent a torn Achilles tendon?
You can’t always prevent an accidental injury like tearing your Achilles tendon. But you can take steps to reduce the risk of an Achilles tendon rupture, including:
- Doing warmup exercises before a workout or game.
- Increasing the intensity of workouts gradually.
- Regularly stretching your calf muscles and Achilles tendons.
Outlook / Prognosis
What is the prognosis (outlook) for people with an Achilles tendon rupture?
With proper treatment, most Achilles tendon ruptures fully heal within four to six months.
Having surgery to repair a torn Achilles tendon is usually the best option for younger, active people. After surgical repair, you can regain your Achilles tendon’s full strength and function.
Living With
When should I call the doctor?
You should call your healthcare provider if you experience:
- A snap or pop at the back of your ankle during activity.
- Sudden sharp pain at the back of your ankle.
- Difficulty walking after an injury.
What questions should I ask my doctor?
You may want to ask your healthcare provider:
- Do I need surgery to repair my Achilles tendon?
- How long will I need to wear a brace or cast?
- When can I start exercising or playing sports again?
- Am I at risk of tearing my Achilles again after it heals?
A note from Cleveland Clinic
An Achilles tendon rupture is a common sports injury. People who play sports that involve running, frequent stopping and starting, and changing directions are most at risk. You can also tear your Achilles tendon by tripping, missing a step going down the stairs or twisting your ankle. With proper treatment, most torn Achilles tendon injuries heal in four to six months.
Achilles Tendon Rupture Treatment | Johns Hopkins Department of Orthopaedic Surgery
The Achilles tendon is a band of thick, fibrous tissue connecting the calf muscles to the heel bone.
If the tendon fibers break completely or partially, it is called an Achilles tendon rupture or torn Achilles and may need immediate medical attention.
Torn Achilles Treatment: Why Choose Johns Hopkins
- Our foot and ankle specialists have treated patients with a wide range of complications and performed numerous surgeries for foot and ankle injuries.
- They are experienced in nonsurgical treatments and can provide an evaluation and a second opinion if you are looking for nonsurgical options.
- Whenever possible, our surgeons use minimally invasive surgery instead of the traditional open surgery to help you get back on your feet faster after an Achilles tendon rupture.
- Our foot and ankle team provides excellent coordination of care, seamlessly guiding you toward recovery, from the orthopaedic consultation to treatment and physical therapy.
Achilles Tendon Rupture Treatment Options
Surgical Treatment
Some patients may benefit from surgery to repair a fully ruptured Achilles tendon.
The goal of the surgery is to stitch the tendon back together. However, in some cases, the damaged part (or the entire tendon) may need to be removed and replaced with tissues taken from another area of your foot.
Nonsurgical Options
For other patients, it may be best to avoid surgery. Nonsurgical treatment for Achilles tendon rupture focuses on allowing the tendon to heal naturally while it’s immobilized in a boot. Early functional weight-bearing is a key part of Achilles tendon rehabilitation for surgical and nonsurgical management.
Consult an orthopaedic surgeon to determine which treatment approach will work best for you, based on your age, activity level and other factors.
Our Achilles Repair Specialists
You can rely on the expertise of our orthopaedic specialists to help you manage your Achilles tendon rupture.
General Foot and Ankle Specialists
Pediatric Specialists
Sports Medicine Specialists
Achilles Tendon Problems | Michigan Medicine
Topic Overview
What is the Achilles tendon?
The Achilles tendon connects the calf muscle to the heel bone.
It lets you rise up on your toes and push off when you walk or run.
What are common Achilles tendon problems?
The two main problems are:
- Achilles tendinopathy. This refers to tiny tears (microtears) in the tissue in and around the tendon. These tears are caused by overuse. Achilles tendinopathy is also often called Achilles tendinitis.
- Achilles tendon tear or rupture. An Achilles tendon also can partially tear or completely tear (rupture). A partial tear may cause mild or no symptoms. But a complete rupture causes pain and sudden loss of strength and movement.
Problems with the Achilles tendon may seem to happen suddenly. But usually they are the result of many tiny tears in the tendon that have happened over time.
Achilles tendinopathy is likely to occur in men older than 30. Most Achilles tendon ruptures occur in people 30 to 50 years old who are recreational athletes (“weekend warriors”).
Ruptures can also happen in older adults.
What causes Achilles tendon problems?
Achilles tendinopathy is most often caused by overuse or repeated movements during sports, work, or other activities. For example, if you do a lot of pushing off or stop-and-go motions when you play sports, you can get microtears in the tendon.
Achilles tendon rupture is most often caused by a sudden, forceful motion that stresses the calf muscle. This can happen during an intense athletic activity or even during simple running or jumping. Middle-aged adults are especially likely to get this kind of injury.
What are the symptoms?
Symptoms of Achilles tendinopathy include swelling in the ankle area and mild or severe pain. The pain may come on gradually or may only occur when you walk or run. You may have less strength and range of movement in the ankle.
Symptoms of an Achilles tendon rupture may include a sudden, sharp pain.
Most people feel or hear a pop at the same time. Swelling and bruising may occur. You may not be able to point your foot down or stand on your toes.
How are Achilles tendon problems diagnosed?
Your doctor can tell if you have an Achilles tendon problem by asking questions about your past health and checking the back of your leg for pain and swelling.
If your symptoms are severe or don’t improve with treatment, your doctor may want you to get an X-ray, ultrasound scan, or MRI.
How are they treated?
Treatment for mild Achilles tendon problems includes rest, over-the-counter pain medicine, and stretching exercises. You may need to wear well-cushioned shoes and change the way you play sports so that you reduce stress on the tendon. Early treatment works best and can help prevent more injury. Orthotic shoe devices can also help reduce stress on the tendon.
Even in mild cases, it can take weeks to months of rest for the tendon to repair itself.
It’s important to be patient and not return too soon to sports and activities that stress the tendon.
Treatment for severe problems, such as a torn or ruptured tendon, may include surgery or a cast, splint, brace, walking boot, or other device that keeps the lower leg and ankle from moving. Exercise, either in physical therapy or in a rehab program, can help the lower leg and ankle get strong and flexible again. The tendon will take weeks to months to heal.
Although treatment for Achilles tendon problems takes time, it usually works. Most people can return to sports and other activities.
Cause
Achilles tendinopathy is most often caused by:
- Overuse or repeated movements during sports, work, or other activities. In sports, a change in how long, intensely, or often you exercise can cause microtears in the tendon. These tears are unable to heal quickly and will eventually cause pain. A change in your environment, such as going from a flat surface to a hill or from a dirt road to a paved road, can also cause these tears.
- Injury from repeated push-offs or a stop-and-go motion. These injuries are common in such activities as running, basketball, tennis, or ballet dancing.
A change in your environment, such as going from a flat surface to a hill or from a dirt road to a paved road, can also cause these tears.Achilles tendon rupture is most often caused by:
- Sudden, forceful motion that stresses the calf muscle. This can happen during an intense athletic activity or even during simple running or jumping, especially in middle-aged adults. A rupture most often occurs in sports such as basketball, racquet sports (including tennis), soccer, and softball.
- Overstretching the tendon during any activity when the tendon is already damaged because of Achilles tendinopathy or another condition.
Symptoms
Symptoms of Achilles tendinopathy may include:
- Pain in the back of the heel, in the Achilles tendon area. Pain may be mild or severe. Swelling may occur.
- Tenderness in the Achilles tendon area. Tenderness may be more noticeable in the morning.
- Stiffness that goes away as the tendon warms up with use.
- Decreased strength and movement, or a feeling of sluggishness in the leg.
Pain may be mild or severe. Swelling may occur.Symptoms of an Achilles tendon rupture may include:
- A sudden, sharp pain that feels like a direct hit to the Achilles tendon. There may be a pop when the rupture occurs. This may be followed by swelling and bruising.
- Heel pain. (It may be severe.)
- Not being able to go on tiptoe with the hurt leg.
If you have a partial rupture (tear) of the Achilles tendon, you may have near-normal strength and less pain after the initial injury, compared to what you would have after a complete rupture.
What Happens
Achilles tendinopathy
Achilles tendinopathy starts with repeated small tears in the tendon.
These tears may cause no obvious symptoms. Or they may cause mild to severe pain during movement. As the tearing continues, the leg may weaken and the tendon pain may become constant. Abnormal growths (nodules) may form in the tendon, and it may thicken.
Without rest and treatment of Achilles tendinopathy, you may develop long-lasting (chronic) pain.
Achilles tendon tear or rupture
An Achilles tendon can partially tear or completely tear (rupture). A tear usually occurs in the tendon about 1.5 in. (3.8 cm) to 2.5 in. (6.4 cm) above where it attaches to the heel bone. Some doctors believe that this area is most likely to tear or rupture because of a limited blood supply.
If you don’t treat an Achilles rupture, you will feel weakness in your first steps when you walk. It may feel like walking in the sand. Over time, walking will become difficult.
Other Achilles tendon problems
Other conditions can affect the Achilles tendon area.
These other conditions are caused by inflammation. They include:
What Increases Your Risk
Things that increase your risk for Achilles tendinopathy or rupture include:
- Sports and physical activity. Overuse and repeated movements can cause injury and weaken the Achilles tendon. Playing sports increases the risk of an injury. Activities at work (such as in construction) and at home (such as gardening) may also increase your risk.
- Sports training errors. Not warming up before running or other activities or suddenly changing your training program can increase your risk for injury. Increasing your distance, running uphill more often, or changing your ground surfaces too quickly can increase your risk. Decreased flexibility may also increase the risk of tendon problems.
- Age. Most cases of Achilles tendinopathy or rupture occur in people older than 30.
- Weight. If you are very heavy, you have a greater risk.
- Being male. Men are more likely than women to have an Achilles tendon injury.
- Footwear. You may increase your risk if you wear shoes that are worn out, that do not support your feet, or that do not cushion your heel.
Other risk factors for an Achilles tendon rupture include:
- A previous injury or rupture to the Achilles tendon.
- Corticosteroid injections in the Achilles tendon. They can weaken the tendon.
- Long-term use of quinolone antibiotics. Quinolones include ciprofloxacin and ofloxacin.
- Having osteoarthritis, gout, or rheumatoid arthritis.
When should you call your doctor?
Call your doctor right away if you think you have an Achilles tendon problem (at or above the back of your ankle) and:
- The back of your heel and ankle are very painful.
- You felt a sharp pain like a direct hit to the Achilles tendon.
- You heard a pop in your Achilles tendon when you were injured.
- You aren’t able to walk comfortably.
- Your Achilles tendon area has begun to swell.
- You have signs of damage to the nerves or blood vessels. Signs include numbness, tingling, a pins-and-needles feeling in your foot, and pale or bluish skin.
If you have had an Achilles tendon injury in the past and you have reinjured your Achilles tendon, call your doctor to find out what you need to do. Rest your lower leg and foot until treatment begins.
Watchful waiting
Watchful waiting is a period of time during which you and your doctor observe your symptoms or condition without using medical treatment. Watchful waiting is not a good idea if you have severe pain in the Achilles tendon area. If you think you have injured your Achilles tendon, call your doctor.
Early treatment is most effective.
If you think you have Achilles tendinopathy and you have mild symptoms, rest your lower leg and foot for a couple of days. Follow the other steps in Home Treatment. If you have weakness, cramping, or constant pain in your Achilles tendon, call your doctor.
Who to see
Health professionals who can diagnosis and treat an Achilles tendon problem include:
You may be referred to a physical therapist for exercises to rebuild strength in your Achilles tendon and leg muscles.
Exams and Tests
Most doctors diagnose an Achilles tendon problem through a medical history and physical exam. This includes checking for tenderness, watching how you walk and stand, and comparing the range of motion of your two legs.
Other tests may be done to clarify a diagnosis or to prepare for surgery. These tests include:
- Ultrasound. It may be used to check whether there is a rupture of the tendon or signs of tendinopathy.
- X-rays, to check the heel bone.
- MRI scan to check the tendon for signs of tendinopathy or a tendon rupture. An MRI is also used to evaluate the heel bone.
Treatment Overview
Early treatment usually results in better healing.
Achilles tendinopathy
To treat Achilles tendinopathy:
- Use home treatment. This includes resting your lower leg and foot, stretching the area, wearing cushioned shoes or other orthotics, and switching sports or modifying how you do sports that may have caused the problem.
- Reduce pain by using ice or taking over-the-counter pain relievers, such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), as directed. Be safe with medicines. Read and follow all instructions on the label.
- Follow any physical therapy that your doctor has prescribed. This may include stretching and strengthening exercises, deep massage, heat, or ultrasound.
If your Achilles tendon shortens and stiffens while you sleep, your doctor may suggest that you wear a night brace to keep your foot in a neutral position (not pointing up or down).
If you keep having pain or stiffness in the ankle area, your doctor may prescribe a walking boot or other device for 4 to 6 weeks. This keeps your lower leg and ankle from moving. It allows the tendon to heal.
If you still have Achilles tendon pain after more than 6 months of consistent treatment and rest, you might need to consider surgery.
Achilles tendon rupture
Treatment for an Achilles tendon rupture includes:
- Surgery followed by rehabilitation (rehab). This is the most common treatment for younger adults.
- Immobilizing your leg, followed by rehab. This prevents movement of the lower leg and ankle. It allows the ends of the Achilles tendon to reattach and heal.
What to think about
Don’t smoke or use other tobacco products.
Smoking slows healing, because it decreases blood supply and delays tissue repair.
If you have an Achilles tendon rupture, your decision about whether to have surgery will depend in part on your:
- Age and activity level. For example, if you are an older adult who doesn’t do activities that may cause another rupture and who doesn’t want the added risk of surgery, you may choose to use a cast or similar device.
- Medical condition. If you have another medical condition—such as diabetes or heart or lung disease—that raises the risks associated with surgery, you may choose to use a cast or similar device.
- Time since injury. Over time, the torn ends of the tendon shorten and pull away from each other. If they are too far apart, the surgery is less likely to work. If surgery is chosen, many surgeons will wait a few days for the swelling to go down, then do the surgery as soon as possible. Surgery is usually done within 4 to 6 weeks.
Prevention
Most Achilles tendon injuries occur during sports. If you had an Achilles tendon problem in the past, it is especially important to try to prevent another injury. To help prevent injury, try to:
- Warm up. Before any sport or intense activity, gradually warm up your body by doing 5 to 10 minutes of walking or biking.
- Cool down and stretch. After intense activity, gradually cool down with about 5 minutes of easy jogging, walking, or biking, and 5 minutes of stretches.
- Avoid any sport or intense activity that you are not in condition to do.
- Wear shoes that cushion your heel during sports or any strenuous activity.
- Wear heel pads or other orthotics that are designed to reduce stress on the Achilles tendon.
Home Treatment
Home treatment is often used for Achilles tendinopathy as part of physical therapy or rehabilitation (rehab) after an Achilles tendon rupture.
Achilles tendinopathy
Follow these steps to rest, heal, and strengthen your Achilles tendon and prevent further injury:
- Rest your Achilles tendon. Avoid all activities that strain the tendon, such as stair climbing or running. Try other activities, such as swimming, while you give your tendon the days, weeks, or months it needs to heal. Your doctor will tell you what you can and cannot do.
- Reduce pain by icing your Achilles tendon and taking nonprescription pain relievers such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) as directed. Be safe with medicines. Read and follow all instructions on the label.
- Follow your physical therapy program if one has been prescribed for you. Do gentle stretching and strengthening exercises. Focus on calf stretches.
- Don’t smoke or use other tobacco products. Smoking slows healing, because it decreases blood supply and delays tissue repair.
- Wear footwear that protects the tendon while it heals.
- Quality athletic shoes that support your arches and cushion your heels can make a big difference in your comfort and healing. If needed, talk to your physical therapist or podiatrist about heel pads or orthotics.
- A bandage that keeps your foot in a neutral position (not pointing up or down) can restrict the motion of the Achilles tendon.
- A silicone sleeve or pad can distribute pressure on the Achilles tendon.
If your Achilles tendon shortens and stiffens while you sleep, your doctor may suggest that you wear a night brace to keep your foot in a neutral position.
Achilles tendon rupture
No matter how you treat an Achilles tendon rupture, after treatment it’s important to follow your rehab program. This program helps your tendon heal and helps prevent further injury.
Medications
You can use medicine to relieve pain from Achilles tendinopathy or an Achilles tendon rupture.
The medicine may be prescription or nonprescription. Be safe with medicines. Read and follow all instructions on the label.
- Acetaminophen (such as Tylenol) can relieve pain.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) are also often used to treat pain. But most tendon problems don’t involve inflammation, so NSAIDs usually aren’t needed. These drugs include ibuprofen (such as Advil and Motrin) and naproxen (such as Aleve).
Corticosteroid injections, which sometimes are injected around tendons or into joints to reduce pain and inflammation, aren’t used to treat Achilles tendinopathy. They may increase the risk of a tendon rupture.
Surgery
Achilles tendinopathy
Surgery usually isn’t needed to treat Achilles tendinopathy. But in rare cases, someone might consider surgery when rubbing between the tendon and the tissue covering the tendon (tendon sheath) causes the sheath to become thick and fibrous.
Surgery can be done to remove the fibrous tissue and repair any small tendon tears. This may also help prevent an Achilles tendon rupture.
Achilles tendon rupture
Surgery is often used to reattach the ends of a ruptured Achilles tendon. It may provide a better chance of preventing the tendon from rupturing again compared to using a cast or other device that will keep your lower leg and ankle from moving ( immobilization).footnote 1
Surgery works best when you have surgery soon after your injury. Recovering from surgery may take months. Most surgeons will wait a few days for swelling to go down, then do the surgery as soon as possible. Surgery is usually done within 4 to 6 weeks. You will also need a rehabilitation (rehab) program to help heal and strengthen the tendon.
Surgery choices
Surgery for an Achilles tendon rupture can be done with a single large incision, which is called open surgery.
Or it can be done with several small incisions. This is called percutaneous surgery.
What to think about
The differences in age and activity levels of people who get surgery can make it hard to know if Achilles tendon surgery is effective. The success of your surgery can depend on:
- Your surgeon’s experience.
- The type of surgery you have.
- How damaged the tendon is.
- How soon after rupture the surgery is done.
- How soon you start your rehab program after surgery.
- How well you follow your rehab program.
Talk to your surgeon about his or her surgical experience. Ask about his or her success rate with the technique that would best treat your condition.
Other Treatment
Other treatments are often used for Achilles tendinopathy or rupture. Before using other treatments, you most likely will try rest and medicine to reduce pain and swelling.
Achilles tendon rupture
A cast or similar device can be used to prevent the lower leg and ankle from moving (immobilization). This type of treatment may take as long as 6 months to completely heal a tendon. This is usually followed by a rehabilitation (rehab) program that helps you regain strength and flexibility in the tendon and leg. The rehab program may include physical therapy.
Achilles tendinopathy
Common physical therapy treatments include:
If other treatment doesn’t reduce your pain, your doctor may recommend using a cast or other device for 4 to 6 weeks. These devices can prevent your lower leg and ankle from moving and allow the tendon to heal. This is then followed by physical therapy and changes in your activities.
Experimental treatment
Medical researchers continue to study new ways to treat tendon injuries. Talk to your doctor if you are interested in experimental treatments.
Some of the treatments being studied include:
- Nitric oxide and glyceryl trinitrate, applied topically (to the skin) over the injury.
- Ultrasonic, or shock, waves directed at the injured tendon (shock wave therapy) for pain caused by calcific tendinitis (calcium built up in the tendons). For more information, see the topic Calcium Deposits and Tendinitis (Calcific Tendinitis).
- Platelet-rich plasma (PRP). In this procedure, blood is drawn from the person and spun at high speeds to separate out the blood cells called platelets. Then the platelets are injected back into the body at the injury site.
References
Citations
- Khan RJK, Smith RLC (2010). Surgical interventions for treating acute Achilles tendon ruptures. Cochrane Database of Systematic Reviews (9).
Credits
Current as of:
November 16, 2020
Author: Healthwise Staff
Medical Review:
Anne C.
Poinier MD – Internal Medicine
E. Gregory Thompson MD – Internal Medicine
Adam Husney MD – Family Medicine
Kathleen Romito MD – Family Medicine
David Bardana MD, FRCSC – Orthopedic Surgery, Sports Medicine
Current as of: November 16, 2020
Author:
Healthwise Staff
Medical Review:Anne C. Poinier MD – Internal Medicine & E. Gregory Thompson MD – Internal Medicine & Adam Husney MD – Family Medicine & Kathleen Romito MD – Family Medicine & David Bardana MD, FRCSC – Orthopedic Surgery, Sports Medicine
Acute Achilles tendon rupture | The BMJ
- Dishan Singh, consultant orthopaedic surgeon
- 1Foot and Ankle Unit, Royal National Orthopaedic Hospital, Stanmore, UK
- dishan.singh{at}rnoh.nhs.uk
What you need to know
Patients with an Achilles tendon rupture often report feeling a blow to the heel and sometimes an audible snap while playing sports or running
Patients may still be able to walk on tiptoes and plantarflex against resistance because the other ankle plantarflexors are intact
The Simmonds’ triad of altered angle of declination (the foot of the injured leg rests in a more dorsiflexed position than the other side when the patient lies prone), palpable gap, and lack of plantarflexion on calf squeeze test will detect a rupture in nearly all cases
Imaging is rarely necessary
While playing tennis, a healthy 35 year old man felt as though he had been hit on the back of the lower leg by his opponent’s racquet.
He couldn’t keep playing but could walk. He presents the next day with mild bruising, swelling, and weakness while walking. He can walk on tip toes but Simmonds’ triad (calf squeeze, altered angle of declination, and palpable gap) confirms the diagnosis of a ruptured Achilles tendon.
What is an Achilles tendon rupture?
A rupture of the Achilles tendon (fig 1⇓) is a disruption in the conjoined tendon of the gastrocnemius and soleus muscles, usually about 2-6 cm proximal to the tendon insertion into the calcaneus.1 Risk factors include increasing age, Achilles tendonopathy, systemic corticosteroids, previous steroid injections into or around the Achilles tendon, and use of quinolone antibiotics.1 2
Fig 1 On opening the paratenon at surgery, the two ends of a complete transverse rupture of the Achilles tendon, with an intervening gap (arrow), are seen. The plantaris tendon is intact (arrowhead)
How common is acute Achilles tendon rupture?
An acute rupture is commonly seen in squash, tennis, football, running, and other sports that require repetitive abrupt jumping or bursts of sprinting2
Injury may also occur from a fall or missing a step or a deep laceration …
Achilles Tendon Rupture – StatPearls
Continuing Education Activity
Achilles tendon rupture is the most common tendon rupture in the lower extremity.
The injury most commonly occurs in adults in their third to fifth decade of life. Acute ruptures often present with sudden onset of pain associated with a “snapping” or audible “pop” heard at the site of injury. Patients may describe a sensation similar to being kicked in the lower leg. Achilles tendon rupture causes significant pain and disability. This activity reviews the etiology, presentation, evaluation, and management of achilles tendon rupture and reviews the role of the interprofessional team in managing it.
Objectives:
Describe risk factors associated with achilles tendon rupture.
Explain how the Thompson test is performed and what a positive test suggests.
Describe the factors that should be considered when deciding whether to treat with operative versus nonoperative management.
Describe how an optimally functioning interprofessional team would coordinate care to enhance outcomes for patients with achilles tendon rupture.
Access free multiple choice questions on this topic.
Introduction
Achilles tendon rupture is the most common tendon rupture in the lower extremity. The injury most commonly occurs in adults in their third to fifth decade of life. [1] Acute ruptures often present with sudden onset of pain associated with a “snapping” or audible “pop” heard at the site of injury. Patients can describe the sensation of being kicked in the lower leg. The injury is causes significant pain and disability in patient populations.
Achilles tendon injuries typically occur in individuals who are only active intermittently (i.e., the “weekend warrior” athletes). The injury is reportedly misdiagnosed as an ankle sprain in 20% to 25% of patients. Moreover, patients in their third to the fifth decade of life are most commonly affected as 10% report a history of prodromal symptoms, and known risk factors include prior intratendinous degeneration (i.e., tendinosis), fluoroquinolone use, steroid injections, and inflammatory arthritides.
[2][3][4][5]
Etiology
Causes of Achilles tendon rupture include sudden forced plantar flexion of the foot, direct trauma, and long-standing tendinopathy or intratendinous degenerative conditions. Sports that are often associated with Achilles tendon rupture include diving, tennis, basketball, and track. Risk factors for a rupture of the Achilles tendon include poor conditioning before exercise, prolonged use of corticosteroids, overexertion, and the use of quinolone antibiotics. The Achilles tendon rupture usually tends to occur about two to four cm above the calcaneal insertion of the tendon. In individuals who are right-handed, the left Achilles tendon is most likely to rupture and vice versa.[6][7][8]
The exact cause of Achilles tendon injury appears to be multifactorial. The injury is most common in cyclists, runners, volleyball players, and gymnasts. When the ankle is subject to extreme pronation, it places enormous stress on the tendon, leading to injury. In cyclists, the combination of low saddle height and extreme dorsiflexion during pedaling may also be a factor in an overuse injury.
Systemic Factors
Systemic diseases that may be associated with Achilles tendon injuries include the following:
Chronic renal failure
Collagen deficiency
Diabetes mellitus
Gout
Infections
Lupus
Parathyroid disorders
Rheumatoid arthritis
Thyroid disorders
Foot problems that increase the risk of Achilles tendon injuries include the following:
Cavus foot
Insufficient gastrocsoleus flexibility and strength
limited ability to perform ankle dorsiflexion
Tibia vara
Varus alignment with functional hyperpronation
It has been observed that Achilles tendon rupture is often more common in people with blood group O. Further anyone with a family history is also at a high risk of developing Achilles tendon rupture at some point in their life.
Epidemiology
The incidence rates of Achilles tendon ruptures varies in the literature, with recent studies reporting a rate of 18 patients per 100,000 patient population annually.
In regard to athletic populations, the incidence rate of achilles tendon injuries ranges from 6% to 18%, and football players are the least likely to develop this problem compared to gymnasts and tennis players. It is believed that about a million athletes suffer from Achilles tendon injuries each year.
The true incidence of Achilles tendinosis is unknown, although reported incidence rates are 7% to 18% in runners, 9% in dancers, 5% in gymnasts, 2% in tennis players, and less than 1% in American football players. It is estimated that Achilles disorders affect approximately 1 million athletes per year.[9]
The incidence of Achilles tendon injuries is on the increase in the USA because of more participation of people into sporting activities. Outside the USA, the exact incidence of Achilles tendon injuries are not known, but studies from Denmark and Scotland reveal 6-37 cases per 100,000 persons.
Achilles tendon injuries appear to be more common in males, and this is probably related to greater participation in sports activities.
Most injuries are seen in between the third and fifth decade of life. Many of these individuals are only active intermittently and rarely warm up.
Pathophysiology
Achilles tendonitis is often not associated with primary prostaglandin-mediated inflammation. It appears there is a neurogenic inflammation with the presence of calcitonin gene-related peptide and substance P present. Histopathological studies reveal thickening and fibrin adhesions of the tendon with the occasional disarray of the fibers.
Neurovascularization is frequently seen in the degenerating tendon, which is also associated with pain. Tendon rupture is usually the terminal event during the degeneration process. After rupture, type 111 collagen appears to be the major collagen manufactured, suggesting that the repair process is incomplete. Animal studies show that if there is more than 8% stretching of their original length, tendon rupture is most likely.
The proximal segment of the tendon receives its blood from the muscle bellies connected to the tendon.
Blood supply to the distal segment of the tendon is via the tendon-bone interface.
History and Physical
Patients often present with acute, sharp pain in the region of the Achilles tendon. On physical exam, patients with Achilles tendon rupture are unable to stand on their toes or have very weak plantar flexion of the ankle. Palpation may reveal a tendon discontinuity or signs of bruising around the posterior ankle.
The Thompson test is performed by the examiner to assess for achilles tendon continuity in the setting of suspected rupture. The examiner places the patient in the prone position with the ipsilateral knee flexed to about 90 degrees. The foot/ankle are in the resting position. Upon squeezing the calf, the examiner notes for the presence and degree of plantarflexion at the foot/ankle. This should be compared to the contralateral side. A positive (abnormal) test is strongly associated with achilles rupture.
Evaluation
In the setting of trauma to the lower leg, radiographs are obtained to rule out the presence of a fracture.
Based on clinical suspicion following the physical examination, the diagnosis can be confirmed with ultrasound or MRI. [10]
Treatment / Management
Operative Versus Nonoperative Management
The initial management of Achilles tendon rupture is rest, elevation, pain control, and functional bracing. There is still debate surrounding the potential benefits versus risks of surgical intervention. Studies have demonstrated good functional results and patient satisfaction with both operative and nonoperative modalities.
Healing rates with serial casting/functional bracing are no different compared to surgical anastomosis of the tendon, but return to work may be slightly prolonged in patients treated medically. All patients require physical and orthotic therapy to help strengthen the muscles and improve range of motion of the ankle.[11][4][12]
Rehabilitation is critical to regaining maximal ankle function. While the debate remains regarding the optimal treatment modality, the general consensus includes the following:
- Patients with significant medical comorbidities or those with relatively sedentary lifestyles are often recommended for nonoperative management
- The patient/surgeon discussion should include a detailed discussion with respect to the current literature reporting satisfactory outcomes with both treatment plans, specifically
Possiblity of quicker return to work with operative intervention
Equivalent plantar flexion strength at long-term followup
Possibility of an increased risk of re-rupture and/or re-injury with nonoperative management (compared to operative management)
Lower complication rates for nonoperative treatment compared to operative management
There are several techniques for Achilles tendon repair, but all involve reapproximation of the torn ends.
Sometimes the repair is reinforced by the plantaris tendon or the gastrocsoleus aponeurosis.
Overall, the healing rates between casting and surgical repair are similar. The debate about an early return to activity after surgery is now being questioned. If a cast is used, it should remain for at least 6-12 weeks. Benefits of a non-surgical approach include no hospital admission costs, no wound complications and no risk of anesthesia. The biggest disadvantage is a risk of re-rupture which is as high as 40%.
Differential Diagnosis
Achilles bursitis
Ankle fracture
Ankle impingement syndrome
Ankle osteoarthritis
Ankle sprain
Calf injuries
Calcaneofibular ligament injury
Calcaneus fractures
Deep venous thrombosis (DVT)
Exertional Compartment Syndrome
Fascial tears
Gastrocsoleus muscle strain or rupture
Haglund deformity
Plantaris tendon tear
Psoriatic arthritis
Reiter syndrome
Retrocalcaneal bursitis
Ruptured Baker cyst
Syndesmosis
Talofibular Ligament Injury
Prognosis
For most patients with Achilles tendon rupture, the prognosis is excellent.
But in some non-athletes, there may be some residual deficits like a reduced range of motion.The majority of athletes are able to resume their previous sporting activity without any limitations. However, it is important to be aware that non-surgical treatment has a re-rupture rate of nearly 40% compared to only 0.5% for those treated surgically.
Complications
Re-rupture
- While newer level 1 evidence has reported no difference in re-rupture rates, prior studies have suggested a 10% to 40% re-rupture rate with nonoperative management (compared to 1% to 2% rate of re-rupture after surgery)
- Lantto et al. recently demonstrated in a randomized controlled trial of 60 patients from 2009 to 2013 at 18-month follow-up: [13]
Similar achilles tendon performance scores
Slightly increased calf muscle strength differences favoring the operative cohort (10% to 18% strength difference) at 18-month follow-up
Slightly better health-related quality of life scores in the domains of physical functioning and bodily pain favoring the operative cohort
- Lantto et al. recently demonstrated in a randomized controlled trial of 60 patients from 2009 to 2013 at 18-month follow-up: [13]
Wound Healing Complications
Sural Nerve Injury
Postoperative and Rehabilitation Care
No matter which method is used to treat the tendon rupture, participating in an exercise program is vital.
One may swim, cycle, jog or walk to increase muscle strength and range of motion.
Deterrence and Patient Education
While active patients and recreational athletes often return to baseline activity levels and work following both nonoperative and operative management of these injuries, high-level professional athletes most often report inferior results and return to play regardless of the chosen management plan.
A 2017 study from the American Journal of Sports Medicine reported professional athletes followup performance (NBA, NFL, MLB, and NHL) at 1- and 2-year followup after surgery performed between 1989 and 2013: [14]
Thus, athletes demonstrating the ability to return to play by 1-year should expect to achieve continued improvement to baseline performance by the ensuing season.
Pearls and Other Issues
To prevent rupture of the Achilles tendon, adequate warming and stretching before physical activity is recommended.
Enhancing Healthcare Team Outcomes
Even though there are several treatments for Achilles tendon rupture, there is no consensus on which one to undertake.
There is a wide variation in the management of Achilles tendon injury between orthopedic surgeons and sports physicians. Further, there is no uniformity in postoperative rehabilitation. Experts recommend that an interprofessional approach may help achieve better outcomes. [10][15] (Level V) The team should include a trauma surgeon, orthopedic surgeon, rehabilitation specialist, and a sports physician. It is important that the pharmacist ensure that the patient is not on any medications that can affect the healing process. The nurse should educate the patient on the importance of stretching prior to any exercise and participating in a regular exercise program after repair.
Outcomes
Conservative treatment is usually preferred for non-athletes, but the risk of re-rupture is high. While surgery offers a lower risk of re-rupture, it is also associated with post-surgical complications that may delay recovery. Overall, the outcomes for Achilles tendon rupture are good to excellent after treatment.
[16][17][18] (Level V)
Figure
achilles tendon rupture. Image courtesy S Bhimji MD
Figure
Achilles tendon rupture. Image courtesy S Bhimji MD
Figure
Achilles Tendon Rupture
T2 MRI demonstrating a full-thickness Achilles rupture with gapping at the classing “watershed” area. Contributed by Mark A. Dreyer, DPM, FACFAS
References
- 1.
- Järvinen TA, Kannus P, Maffulli N, Khan KM. Achilles tendon disorders: etiology and epidemiology. Foot Ankle Clin. 2005 Jun;10(2):255-66. [PubMed: 15922917]
- 2.
- Carmont MR. Achilles tendon rupture: the evaluation and outcome of percutaneous and minimally invasive repair. Br J Sports Med. 2018 Oct;52(19):1281-1282. [PubMed: 29936431]
- 3.
- Noback PC, Freibott CE, Tantigate D, Jang E, Greisberg JK, Wong T, Vosseller JT. Prevalence of Asymptomatic Achilles Tendinosis. Foot Ankle Int. 2018 Oct;39(10):1205-1209. [PubMed: 29855207]
- 4.
- Haapasalo H, Peltoniemi U, Laine HJ, Kannus P, Mattila VM. Treatment of acute Achilles tendon rupture with a standardised protocol. Arch Orthop Trauma Surg. 2018 Aug;138(8):1089-1096. [PubMed: 29725765]
- 5.
- Yasui Y, Tonogai I, Rosenbaum AJ, Shimozono Y, Kawano H, Kennedy JG. The Risk of Achilles Tendon Rupture in the Patients with Achilles Tendinopathy: Healthcare Database Analysis in the United States. Biomed Res Int. 2017;2017:7021862. [PMC free article: PMC5429922] [PubMed: 28540301]
- 6.
- Alušík Š, Paluch Z. [Drug induced tendon injury]. Vnitr Lek. 2018 Winter;63(12):967-971. [PubMed: 29334747]
- 7.
- Ahmad J, Jones K. The Effect of Obesity on Surgical Treatment of Achilles Tendon Ruptures. J Am Acad Orthop Surg. 2017 Nov;25(11):773-779. [PubMed: 28957986]
- 8.
- Egger AC, Berkowitz MJ. Achilles tendon injuries. Curr Rev Musculoskelet Med. 2017 Mar;10(1):72-80. [PMC free article: PMC5344857] [PubMed: 28194638]
- 9.
- Maffulli N, Via AG, Oliva F. Chronic Achilles Tendon Rupture. Open Orthop J. 2017;11:660-669. [PMC free article: PMC5633724] [PubMed: 29081863]
- 10.
- Dams OC, van den Akker-Scheek I, Diercks RL, Wendt KW, Zwerver J, Reininga IHF. Surveying the management of Achilles tendon ruptures in the Netherlands: lack of consensus and need for treatment guidelines. Knee Surg Sports Traumatol Arthrosc. 2019 Sep;27(9):2754-2764. [PMC free article: PMC6706364] [PubMed: 29971520]
- 11.
- Kanchanatawan W, Densiri-Aksorn W, Maneesrisajja T, Suppauksorn S, Arirachakaran A, Rungchamrussopa P, Boonma P. Hybrid Achilles Tendon Repair. Arthrosc Tech. 2018 Jun;7(6):e639-e644. [PMC free article: PMC6019910] [PubMed: 30013904]
- 12.
- Westin O, Svensson M, Nilsson Helander K, Samuelsson K, Grävare Silbernagel K, Olsson N, Karlsson J, Hansson Olofsson E. Cost-effectiveness analysis of surgical versus non-surgical management of acute Achilles tendon ruptures. Knee Surg Sports Traumatol Arthrosc. 2018 Oct;26(10):3074-3082. [PMC free article: PMC6154020] [PubMed: 29696317]
- 13.
- Lantto I, Heikkinen J, Flinkkila T, Ohtonen P, Siira P, Laine V, Leppilahti J. A Prospective Randomized Trial Comparing Surgical and Nonsurgical Treatments of Acute Achilles Tendon Ruptures. Am J Sports Med. 2016 Sep;44(9):2406-14. [PubMed: 27307495]
- 14.
- 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 Oct;45(12):2864-2871. [PubMed: 28644678]
- 15.
- Hertel G, Götz J, Grifka J, Willers J. [Achilles tendon rupture : Current diagnostic and therapeutic standards]. Orthopade. 2016 Aug;45(8):709-20. [PubMed: 27405457]
- 16.
- Song YJ, Chen G, Jia SH, Xu WB, Hua YH. Good outcomes at mid-term following the reconstruction of chronic Achilles tendon rupture with semitendinosus allograft. Knee Surg Sports Traumatol Arthrosc. 2020 May;28(5):1619-1624. [PubMed: 30128686]
- 17.
- Westin O, Nilsson Helander K, Grävare Silbernagel K, Samuelsson K, Brorsson A, Karlsson J. Patients with an Achilles tendon re-rupture have long-term functional deficits and worse patient-reported outcome than primary ruptures. Knee Surg Sports Traumatol Arthrosc. 2018 Oct;26(10):3063-3072. [PMC free article: PMC6154022] [PubMed: 29691618]
- 18.
- Becher C, Donner S, Brucker J, Daniilidis K, Thermann H. Outcome after operative treatment for chronic versus acute Achilles tendon rupture – A comparative analysis. Foot Ankle Surg. 2018 Apr;24(2):110-114. [PubMed: 29409231]
Treatment of acute Achilles tendon rupture with a standardised protocol. Arch Orthop Trauma Surg. 2018 Aug;138(8):1089-1096. [PubMed: 29725765]
Open Orthop J. 2017;11:660-669. [PMC free article: PMC5633724] [PubMed: 29081863]
Patients with an Achilles tendon re-rupture have long-term functional deficits and worse patient-reported outcome than primary ruptures. Knee Surg Sports Traumatol Arthrosc. 2018 Oct;26(10):3063-3072. [PMC free article: PMC6154022] [PubMed: 29691618]how to avoid missing the diagnosis
Br J Gen Pract. 2015 Dec; 65(641): 668–669.
Robert PR Boyd, BM, BSc, MRCS, ST6
Trauma & Orthopaedics, Ashford & St Peter’s Hospital, Chertsey.
Matthew C Solan, FRCS (Orth), Consultant orthopaedic surgeon (foot & ankle)
Royal Surrey County Hospital, Egerton Road, Guildford, Surrey.
Edward Porter, MBBS, GP
North Baddesley Surgery, Norton Welch Close, Fleming Avenue, North Baddesley, Hampshire.
Address for correspondence ST6 Trauma & Orthopaedics, Ashford & St Peter’s Hospital, Chertsey, KT16 0PZ, UK.
E-mail: ku.gro.srotcod@dyobtrebor
Received 2015 May 6; Accepted 2015 Aug 25.
Copyright © British Journal of General Practice 2015This article has been cited by other articles in PMC.
INTRODUCTION
Over recent months, the authors of this paper have seen an increase in the number of patients with a delayed or missed diagnosis of ruptured Achilles tendon presenting to their orthopaedic clinics. Many subscribe to the view that any delay in diagnosis of more than 24 hours is a relative indication for surgery. In a recent review of negligence claims in foot and ankle surgery, it was shown that delayed or missed diagnosis of ruptured Achilles tendon represented the third highest claim, with an average of £56 900 per case.1
Rupture of the Achilles tendon is a common injury, with approximately 4500 patients seeking medical help every year in the UK.2–4 Most cases of Achilles tendon rupture are traumatic sports injuries. The typical age of patients is 29–40 years with a male-to-female ratio of nearly 20:1.
HISTORY
A sudden pain in the back of the leg, with an audible snap, is the classic story in Achilles tendon rupture. Patients will often think that they have been hit directly in the calf; it is very rare for there to be prior symptoms from the tendon.
EXAMINATION
Look
Swelling and bruising are variable and not reliable.
Feel
Tenderness is very likely but may not be at the precise level that is expected. A gap in the tendon is frequently not evident (local swelling masking this).
Move
Because several other tendons (long toe flexors, tibialis posterior, peronei, plantaris) pass from the calf to the foot, some active plantar movement of the ankle is usually still possible. Passive movement is affected by pain but not actually limited. Active dorsiflexion is unaffected.
Points to remember
Patients with rupture of the Achilles tendon can still walk.
Patients with rupture of the Achilles tendon can still actively move the ankle up and down.
Patients with an Achilles tendon rupture may even manage to stand on tiptoes (on both feet together — though not on the injured limb alone).
Patients with an Achilles tendon rupture will not always have a palpable gap in the tendon.
Special tests
Clinicians will never be falsely reassured by these history and examination findings if they remember to assess for Achilles tendon rupture specifically with the Simmonds’ calf squeeze test.
Simmonds’ test, first described in 19575 by Franklin ‘Sam’ Simmonds, and subsequently by Thompson in 1962,6 should be understood and remembered by all medical and physiotherapy practitioners. It is an excellent test, perhaps the closest that there is to ‘the perfect clinical test’.
Technique
The Simmonds’ calf squeeze test is best performed with the patient kneeling on a chair or bench, or lying prone on an examination couch. In either position, both feet and ankles must be free and dangling unsupported ().
Gently squeezing the normal leg, over the bulky part of the calf muscle, will make the foot move into plantar flexion (). When the test is repeated on the injured side the foot will not move if there is a fresh rupture of the Achilles tendon. This is because the calf muscle (gastrocnemius-soleus complex) is no longer connected to the foot.
Pre- and post-calf squeeze.
Documentation of result
The test is positive if, on the injured side, the foot does not move when the calf is squeezed. To avoid confusion it is best to document the result in longhand: ‘the foot does not move when calf is squeezed (Achilles rupture)’ or ‘symmetrical left = right foot movement on calf squeeze test (no Achilles rupture)’.
Imaging studies
In the acute setting there is no need for any imaging at all for the purpose of establishing the diagnosis; scans may even serve to confuse and falsely reassure. A radiological report of a ‘partial tear’ should be an assumed complete Achilles tendon rupture, if this fits with the clinical history.
Like all rules, there are of course (very rare) exceptions, but by far the best and safest approach is to assume the worst and refer the patient for further assessment.
Caveats
Exceptionally rare situations where there may be a false-negative result to the Simmonds’ calf squeeze test do exist.
A patient who has had joint fusion surgery to the hind foot, or has a very stiff ankle from arthritis or trauma, will have a false-negative result on performing the calf squeeze test. Severe calf muscle wasting from neurological causes has the potential to produce the same error. Prior surgery, such as an Achilles tendon lengthening (for example, with treatment for club-foot), presents a further possible exception to the rule.
More relevant is the question of a delay after injury. A neglected tendon rupture will heal, albeit at an elongated length, giving rise to long-term weakness. There is no evidence to clarify the time interval between injury and the return of (some, though reduced) foot movement when Simmonds’ test is performed.
Simmonds’ test cannot be relied upon in chronic cases, though an excellent test for ‘chronic rupture’ is the hyper-dorsiflexion test. If the Achilles tendon has healed without any treatment then it will be elongated, and the affected ankle exhibits a greater range of passive dorsiflexion than the normal ankle (where the Achilles tension limits motion before the bony anatomy does).
LEARNING SUMMARY
The calf squeeze (Simmonds’ test) should be performed, and the findings clearly documented, in all ankle injuries and ‘calf sprains’.
‘There is no such thing as a partial tear.’
Imaging studies are not required to make the diagnosis in the acute situation, and frequently offer false reassurance.
Patients with an acute rupture of the Achilles tendon can still walk and move the ankle, using other parts of the calf muscle complex.
Although the debate regarding operative versus non-operative treatment is unresolved, the need for prompt recognition of this injury is paramount.
Notes
Provenance
Freely submitted; not externally peer reviewed.
Competing interests
The authors have declared no competing interests.
REFERENCES
1. Ring J, Talbot CL, Clough TM. Clinical negligence in foot and ankle surgery: a 17-year review of claims to the NHS Litigation Authority. Bone Joint J. 2014;96-B(11):1510–1514. [PubMed] [Google Scholar]2. Leppilahti J, Puranen J, Orava S. Incidence of Achilles tendon rupture. Acta Orthop Scand. 1996;67(3):277–279. [PubMed] [Google Scholar]3. Suchak AA, Bostick G, Reid D, et al. The incidence of Achilles tendon ruptures in Edmonton, Canada. Foot Ankle Int. 2005;26(11):932–936. [PubMed] [Google Scholar]4. Maffulli N, Waterston S, Squair J, et al. Changing incidence of Achilles tendon rupture in Scotland: a 15-year study. Clin J Sport Med. 1999;9(3):157–160. [PubMed] [Google Scholar]5. Simmonds FA. The diagnosis of the ruptured Achilles tendon. Practioner. 1957;179(1069):56–58. [PubMed] [Google Scholar]6.
Thompson TC. A test for rupture of the tendo achillis. Acta Orthop Scand. 1962;32:461–465. [PubMed] [Google Scholar]
Achilles tendon rupture
Achilles tendon – the most powerful tendon in the human body
The Achilles tendon transmits force from the triceps muscle of the lower leg to the foot and plays a very important role in the rolling of the foot. When you run, a force equal to eight times your body weight acts on the Achilles tendon. This fact indicates that the Achilles tendon is under tremendous stress.A healthy tendon is able to withstand such loads and perform its stabilizing function. However, constant overload, especially against the background of a genetically determined weakness of the connective tissue, can lead to disease.
Causes of rupture of the Achilles tendon
Sports injuries are the most common cause of ruptured Achilles tendon.
Symptoms of ruptured Achilles tendon
Characteristic symptoms of rupture of the Achilles tendon
- The patient feels that something has “burst” or there has been a “sharp blow” to the leg.
- After a rupture, dorsiflexion of the foot is impossible.
- Walking on toes is not possible, but there is no sharp pain.
- On palpation, a gap or thinning along the tendon is determined.
- The Achilles tendon reflex is not invoked.
Operate or not?
It is believed that the best effect of the operation is achieved when it is performed in the first hours after the injury.After surgery, the foot is immobilized for several weeks in a dorsiflexion position. After about four to six weeks, the patient begins physiotherapy exercises with a gradual return to the physiological position of the foot.
A low heel should be used to temporarily relieve tension on the Achilles tendon.
Achilles tendon rupture can be treated conservatively. The disadvantage of this method is the shortening of the tendon, which changes the biomechanics of the foot and gait. Therefore, doctors usually recommend surgical treatment.
Postoperative rehabilitation
After surgery, the ankle is immobilized for four to six weeks.
Then they begin to perform therapeutic exercises in order to gradually restore the length of the tendon. In many cases, heel pads are used to relieve pain in the Achilles tendon.
Ankle support
medi products for ankle joint
An alternative is the so-called postoperative functional treatment with special shoes.
The medi support ROM Walker from medi helps to quickly get the patient back on his feet. The boot provides circular compression. Its special rockade outsole even provides a physiological gait. medi ROM Walker can be used in cases of severe edema and the need for quick access to the postoperative wound.
In addition, the orthosis can be used as an adjunct to conservative treatment.
Find out more about medi ankle braces and braces.
Sources:
Klein, Dr. med. Christoph (2014): Orthopädie für Patienten. Medizin verstehen. Remagen: Verlag Michels-Klein
Human body
Ligament damage often occurs during sports.
Tendons and ligaments
Healthy lifestyle
Find out which sport suits you best
Sports and recreation
| International Specialized Center for Orthopedic Surgery, Arabellastr. Tel: +49. 89.92 333 94-0 Diese E-Mail-Adresse ist gegen Spam-Bots geschützt, Sie müssen Javascript aktivieren, damit Sie sie sehen können. DEPARTMENT FOR WORKING WITH PATIENTS FROM RUSSIA: Mail: Diese E-Mail-Address ist gegen Spam-Bots geschützt, Sie müssen Javascript aktivieren, damit Sie sie sehen können. Dr. Erich. H. Rembeck >> to the photo gallery | |||||
medicine Erich H. Rembeck
The advantage of orthoses is that they allow you to adjust the angle at which the foot is immobilized, which greatly facilitates rehabilitation.
In the treatment of chronic tendon ruptures, surgical treatment becomes necessary in any case. When choosing a method of intervention or a questionable clinical picture of damage, MRI of the Achilles tendon can be successfully applied. This examination allows a clear assessment of the level of rupture and the degree of divergence of the ends of the tendon. In combination with the clinical examination method, this makes it possible to determine the specific direction of the surgical intervention.
There is, however, another method of surgery, in which a closed percutaneous suture is performed.In this case, the skin is not cut and the tendon is not opened. This method of operation gives a better cosmetic effect, however, it has one drawback, since the damaged ends of the tendon cannot be 100% stitched end-to-end. For this reason, a closed percutaneous suture is used only in selected cases. Surgical treatment with this method is not used for tendon ruptures in professional athletes or ambitious amateur athletes.
Two, sometimes four weeks after the operation, the position of the foot is changed up to 0 °. Depending on the degree of damage to the tendon and at the discretion of the surgeon, it is possible to switch from wearing a plaster cast to wearing a removable orthosis (Vacoped boots), with which an increase in physical activity with partial load is allowed.
17 
Often, these injuries are found in athletes, and this does not necessarily have to be about professional sports.
In other cases, about 6 months.
If the patient again loads the injured leg and the ankle in particular, it is not uncommon for ruptures to result in new injuries against the background of an incompletely healed defect. Failure to follow medical advice often leads to the development of inflammation at the site of injury, called tendinitis.
The terms of immobilization are 6-8 weeks.
Its role is extremely important. The heel tendon actively participates in the walking process, absorbs traumatic movements. The damage in this area is often complete, that is, a rupture occurs.
Leninsky prospect, st. Fotieva, 10
Diagnostic methods include: examination by a doctor, feeling, studying all the nuances and signs. It is important for the doctor to know the cause of the rupture. Also, the patient should undergo an X-ray.
