The Achilles tendon is the body's single strongest tendon. Its primary function is to transmit force from the upper leg and calf to the foot, enabling walking and running. An Achilles tendon rupture can be partial or complete. A partial rupture can be a micro or longitudinal rupture often referred to as a tear. A partial or complete rupture of the Achilles tendon is an injury that requires prompt medical attention.
Partial Achilles Tendon Rupture
Insidious or abrupt onset with pain and swelling 2 to 3 centimeters proximal to the insertion of the Achilles tendon on the back of the heel.
Pain is most pronounced with the onset of use i.e. getting out of bed in the morning or walking after a brief period of rest.
Swelling is described as fusiform or tubular, often surrounding the entire body of the tendon.
Erythema (redness) and bruising are not common.
Most patients with a partial rupture of the Achilles tendon cannot describe an injury or single event that initiated the onset of pain. Often patients experience sharp pain at the beginning of an activity, but the pain may decrease for a time. The pain may return at the end of the activity. For instance a runner may experience pain at the beginning of a run. The pain may subside during the run but return at the end of a normal running distance.
Complete Achilles Tendon Rupture
Audible pop or snap in the back of the ankle.
Unable to rise up on toes or push off at the toe-off phase of gait.
Smaller, partial tears of the Achilles tendon are called micro tears. Micro tears measure a millimeter to several millimeters and can be single or multiple in number. Micro tears can propagate into a larger, longitudinal tear over time. Longitudinal tears can be as small as a centimeter or as large as several centimeters. They dissect the length of the Achilles tendon, paralleling the fibers of the tendon. An MRI is used to determine the presence of a tear and whether it is a micro tear or a longitudinal tear.
A complete rupture of the Achilles tendon can be debilitating. Most complete ruptures occur 2 to 4 centimeters proximal to the insertion of the tendon into the calcaneus (heel bone). A Thompson test is used to evaluate a suspected torn Achilles tendon. With the patient lying prone the calf is squeezed. If the patient has an in-tact Achilles tendon the foot will plantarflex. This is called a negative Thompson sign. If the calf is squeezed and the foot does not plantarflex, this indicates a positive Thompson's sign and complete rupture of the Achilles tendon.
Many patients describe a long period of chronic Achilles tendinitis leading up to a complete rupture. Other factors include the use of steroids (oral and injectable), the use of fluoroquinolone antibiotics (Levaquine, Cipro) and advanced age.
The differential diagnosis of an Achilles tendon rupture includes;
Calcaneal stress fracture
Posterior tibial tendon dysfunction
Posterior shin splints
Conservative care of partial and complete Achilles tendon ruptures includes 10 to 12 weeks of casting in a slightly plantar-flexed position. Plantarflexion is the position that occurs as the toes move away from the shin. This position removes tension from the Achilles tendon allowing for healing while casted. Casting can be performed in a serial manner, with less plantarflexion in each cast as the tendon heals. Follow-up in a walking cast with an elevated heel is common. Physical therapy often is recommended after casting to help the patient regain strength and flexibility.
Numerous articles in the literature compare the merits of conservative and surgical care of partial and complete Achilles tendon ruptures. Surgery traditionally is performed with open techniques rather than small incisions or endoscopic techniques. Surgical repair of the Achilles tendon is performed under general anesthesia with the patient in the prone position. The damaged margins of the tear are debrided to healthy tissue. A special stitch called a Bunnell suture is used to reappose the margins of the torn tendon. A Bunnell suture includes a criss-cross of stitches to prevent tear-out of the suture. Graft tendons are often used supplement repair. Synthetic grafting material may also be used to supplement defects in the length of the tendon. Surgical repair of the Achilles tendon may also be performed with a combination of percutaneus and open techniques. Surgical correction always is followed with non-weight-bearing casting for six to eight weeks. Unfortunately re-rupture is common regardless of the method of correction.
The disability following Achilles tendon surgery can be prolonged. Weakness and atrophy of the calf muscle are common and can be challenging for the patient and physical therapy team. One study reported 2 centimeters of atrophy two years after surgery. Additional studies found persistent weakness in the calf after surgery regardless of the method of correction. Early weight-bearing and range-of-motion play important roles in how quickly a patient returns to activity. Other variables that are important include age, physical well-being prior to surgery and smoking. Return to weight-bearing usually is initiated with the use of a heel lift bilaterally. The height of the lift is reduced in the weeks after the discontinuation of casting as strength returns to the injured Achilles tendon.
Symptoms of partial or complete rupture of the Achilles tendon should be promptly evaluated by your podiatrist or orthopedist.
References are pending.
This article was written by Myfootshop.com chief medical officer, Jeffrey A. Oster, DPM.
Competing Interests - None
Peer Reviewed - This article is peer reviewed by an open source editorial board. Your comments and suggestions to improve this paper are appreciated.
Cite this article as - Oster, Jeffrey. Achilles tendon ruptures. http://www.myfootshop.com/article/achilles-tendon-rupture
Most recent article update - December 28, 2015.
Achilles Tendon Rupture by Myfootshop.com is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License.
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