Working With Achilles Tendon Ruptures

Overview

Achilles Tendonitis

The Achilles tendon is the confluence of the independent tendons of the gastrocnemius and soleus, which fuse to become the Achilles tendon approximately 5 to 6 cm proximal to its insertion on the posterior surface of the calcaneus. The gastrocnemius and soleus muscles, via the Achilles tendon, function as the chief plantarflexors of the ankle joint. This musculotendinous unit provides the primary propulsive force for walking, running, and jumping. The normal Achilles tendon can withstand repetitive loads near its ultimate tensile strength, which approach 6 to 8 times body weight.




Causes

Achilles tendon rupture occurs in people that engage in strenuous activity, who are usually sedentary and have weakened tendons, or in people who have had previous chronic injury to their Achilles tendons. Previous injury to the tendon can be caused by overuse, improper stretching habits, worn-out or improperly fitting shoes, or poor biomechanics (flat-feet). The risk of tendon rupture is also increased with the use of quinolone antibiotics (e.g. ciprofloxacin, Levaquin).




Symptoms

When the Achilles tendon ruptures a loud bang or popping sound may be heard. The person may feel that they have been hit or kicked in the back of the lower leg and often they will look over their shoulder to see who or what has hit them. This is quickly followed by the sudden onset of sharp pain in the tendon and a loss of strength and function. If a complete rupture has occurred it may not be possible to lift the heel off the ground or point the toes. Often the degree of pain experienced, or lack of it, can be inversely proportional to the extent of the injury, ie a partial rupture may in fact be more painful than a complete rupture.




Diagnosis

Your caregiver will ask what you were doing at the time of your injury. You may need any of the following. A calf-squeeze test is used to check for movement. You will lie on your stomach on a table or bed with your feet hanging over the edge. Your caregiver will squeeze the lower part of each calf. If your foot or ankle do not move, the tendon is torn. An x-ray will show swelling or any broken bones. An ultrasound uses sound waves to show pictures of your tendon on a monitor. An ultrasound may show a tear in the tendon. An MRI takes pictures of your tendon to show damage. You may be given dye to help the tendon show up better. Tell the caregiver if you have ever had an allergic reaction to contrast dye. Do not enter the MRI room with anything metal. Metal can cause serious injury. Tell the caregiver if you have any metal in or on your body.




Non Surgical Treatment

Your doctor will advise you exactly when to start your home physical therapy program, what exercises to do, how much, and for how long to continue them. Alphabet Range of Motion exercises. Typically, the first exercise to be started (once out of a non-removable cast). While holding your knee and leg still (or cross your leg), you simply write the letters of the alphabet in an imaginary fashion while moving your foot and ankle (pretend that the tip of your toe is the tip of a pencil). Motion the capital letter A, then B, then C, all the way through Z. Do this exercise three times per day (or as your doctor advises). Freeze a paper cup with water, and then use the ice to massage the tendon area as deeply as tolerated. The massage helps to reduce the residual inflammation and helps to reduce the scarring and bulkiness of the tendon at the injury site. Do the ice massage for 15-20 minutes, three times per day (or as your doctor advises). Calf Strength exercises. This exercise is typically delayed and not used in the initial stages of rehabilitation, begin only when your doctor advises. This exercise is typically done while standing on just the foot of the injured side. Sometimes, the doctor will advise you to start with standing on both feet. Stand on a step with your forefoot on the step and your heel off the step. The heel and forefoot should be level (neither on your tip toes nor with your heel down). Lower your heel very slowly as low as it will go, then rise back up to the level starting position, again very slowly. This is not a fast exercise. Repeat the exercise as tolerated. The number of repetitions may be very limited at first. Progress the number of repetitions as tolerated. Do this exercise one to two times per day (or as your doctor advises).

Achilles Tendinitis




Surgical Treatment

The goal of surgery is to realign the two ends of the ruptured tendon to allow healing. There are multiple techniques to accomplish this goal that will vary from surgeon to surgeon. Recovery from this injury is usually very successful with return to full function in approximately 6 months. Post operatively casting is required with the use of crutches or other means to remain non-weightbearing for 4-8 weeks. This is followed by a course of physical therapy. Partial rupture may or may not require surgical intervention depending on the extent of injury but cast immobilization is a common requirement.




Prevention

Achilles tendon rupture can be prevented by avoiding chronic injury to the Achilles tendon (i.e. tendonitis), as well as being careful to warm up and stretch properly before physical activity. Additionally, be sure to use properly fitting equipment (e.g. running shoes) and correct training techniques to avoid this problem!

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