The Achilles tendon is the largest and strongest tendon in the human body and derives its name from the legendary hero of Homer's Iliad who as a child was dipped into the river Styx conferring invulnerability on all but his heel. Ruptures of this tendon most commonly occur in individuals engaged in competitive sports, but can occur with slips or falls. The injury generally occurs in males in their 30's and 40's.
Insufficient preparation, sporadic conditioning and explosive push-off forces are associated with disruption of this important structure. Other reported risk factors include corticosteroids such as prednisone, performance enhancing steroids and fluoroquinolone antibiotics such as Cipro. Most patients report that they felt as if the had been struck or kicked at the posterior aspect of the involved calf. Remarkably, many patients do not have significant pain with this injury and often delay treatment or evaluation. Case reviews reported in the orthopedic literature also report that even with immediate evaluation the injury can be missed by primary physicians 23% of the time.
After the injury significant swelling and loss of function, (inability to stand on tip toes, run or push-off), may be seen. Physical exam reveals swelling and discoloration, or bruising. There is generally a palpable gap or defect between the retracted ends of the tendon. A simple test performed by your physician, the Thompson test, is used to determine whether the tendon is intact. With the patient in the kneeling position or lying on his or her stomach the calf muscle is squeezed. If the foot plantar flexes, (points down), the tendon is intact. Lack of flexion confirms the rupture. An MRI scan or an ultrasound examination may be used to confirm or document the tear; however additional tests are generally unnecessary.
The goal of treatment is to restore the normal length and tension, thereby optimizing the ultimate strength and function, of the Achilles tendon. There continues, however, to be a controversy as to whether operative or non-operative treatment best achieves these goals without unnecessary risk to the patient. While careful operative technique can minimize surgical risks there is a real and significantly greater risk of complications such as infection, skin slough or necrosis, and nerve damage associated with a surgical procedure in this area of the body.
Proponents of surgery quote a lower rate of rerupture after surgery. Although argument exists, rerupture rates of 0-5% have been reported after surgical repair vs. a rate of 6-10% with non-operative treatment. Increased strength and push-off power have been also used as indications for surgery, especially in the high level athlete. Another relative indication would be the patient who presents with a delay between injury and evaluation.
In the recreational athlete, as well as those “crafty veterans” who have already lost their athletic ‘edge' or prowess, a non-operative treatment is usually recommended. Regardless of whether surgery is performed or not there is a risk of blood clots (Deep Vein Thrombosis) which form in the injured calf, with either treatment, and can result in pulmonary emboli and rarely death. Shortness of breath should trigger an emergency transfer to the hospital.
Non-operative treatment: With the non-surgical approach patients are initially placed in a cast with the foot flexed or pointing down. Depending on physician preference, as well as time of presentation (acute or delayed), a long or a short leg cast may be applied. This allows the tendon ends to come closer together to allow a more predictable healing. The exact type and duration of casting varies from physician to physician with casting sometimes being replaced by a removable fracture brace which is similar in size to a ski boot. After approximately 2-3 months patients are allowed to resume normal footwear with a heel lift. It is during this early stage that most re-ruptures occur and therefore caution is essential.
Operative treatment: To understand surgery the patient should think of the Achilles tendon as a rope which has ruptured and the ends are frayed like the ends of a mop. Large sutures are placed into the intact portions of the tendon drawing the mop ends together, followed by smaller sutures to approximate the smaller strands of tendon. It is for this reason the surgical repairs are mobilized only slightly sooner than the non-surgical cases. Additionally, some physicians also reinforce the repair with other tendons that bridge the repair for additional strength.
Regardless of treatment, it takes one-year for the healed tendon to mature and strengthen back to its' normal tensile strength. Therapy is occasionally recommended; however, biologic healing takes so long that most patients are slowly progressed with a self directed home exercise program until the later stage of treatment when the individual begins to ease back into athletics.