What is the Achilles?
The Achilles tendon is the largest and strongest tendon in the human body. However, despite this it is the most commonly ruptured tendon in the body. The Achilles tendon runs from the back of your calf muscle to one of the bones at the heel.
Research has revealed predisposing factors to ruptures which include: an ageing population, increasing obesity prevalence, recreational sports, tendon degeneration, prescription-based medications such as steroids. Altered biomechanics such flat feet and poor running mechanics also increase the chance of injury. The peak age for rupture is 30 to 40 years for both men and women, with a rupture being 2-12 times more common in males than females. Over 80 percent of ruptures occur during recreational sports are most often seen in “weekend warriors”—typically, middle-aged people participating in sports in their spare time.
Tendon rupture occurs when sudden forces are exerted upon the Achilles tendon during strenuous physical activities that involve sudden pivoting on a foot or rapid acceleration (eg, stop-and-go sports such as tennis, soccer or basketball). The most likely causes of injury include:
- Taking off during a sprint, running or jumping.
- Sudden dorsi flexion (bending upwards) of the ankle
- Weak tendon often due to long term Achilles tendinopathy
Typical signs and symptoms:
Many feel as if they have been struck violently in the back of the foot. Some hear a “pop” and experience severe, acute pain. Large swelling around the heel and ankle and difficulty walking are often noticed. Often a gap may be felt over the area and it is difficult to perform a heel raise.
Controversy has surrounded the best way to treat Achilles tendon ruptures. There are 2 main approaches which include surgery or no surgery (i.e. conservative management using physiotherapy). Historically, surgical intervention was preferred due to high re-rupture rates in early conservative study treatments that used long term cast immobilisation. More recently evidence suggests conservative management using accelerated functional rehabilitation program has had similar results in regard to potential re-ruptures rates. A functional accelerated rehabilitation protocol essentially is a fancy term for ensuring weightbearing and range of motion is completed early on. Those who wish to return to demanding sport involving sprinting and jumping opt for surgical repair but evidence suggests non operative management that includes a rehabilitation program with early mobilisation has very good outcomes. Management for both surgical and conservative management involves a protocol which are very similar in nature. These protocols with vary slightly based on the orthopaedic surgeon or physiotherapist you see.
So what’s the evidence for surgery vs non-surgical treatment?
A systematic review by Ochen et al. published in 2019 looked at studies focusing on re-rupture rates in surgical vs conservative management using a functional/accelerated rehabilitation protocol. Focusing on re-rupture rates when using accelerated functional rehabilitation, out of the 6 studies included, there was no significant difference between operative and nonoperative treatment regarding re-rupture rate. This tells us that not having surgery has the same level of re-rupture, than if you went and had surgery. Considering the potential complications with surgery such as infection and DVTs, I think I know which option I’d choose!
A second meta-analysis of 10 RCTs evaluated the effects of surgical versus nonsurgical treatment in acute Achilles tendon ruptures. If a functional/accelerated rehabilitation protocol with early range of motion was employed after an Achilles tendon rupture, re-rupture rates were equal for surgical and non-surgical. If a functional rehabilitation program was not employed and included prolonged immobilisation there was a significant reduction in re-rupture in the surgical intervention. Moreover, complications showed a statistically significant increase in patients who underwent surgical repair.
So what to do when you rupture your Achilles?
You should seek medical assistance where you will be fitted with a CAM boot and crutches. A boot will often be fitted with wedges to keep to foot pointing down to allow healing of the tendon and prevent over stretching. A review from an orthopedic surgeon should be completed within the first few weeks after a rupture. Here the surgeon will determine whether surgery will be required or conservative (non-surgical) management. Depending on the surgeon’s clinical judgement, physiotherapy rehabilitation will be involved no matter whether you opt for a surgical or a conservative pathway. Whilst often Achilles ruptures involve a long rehabilitation process, physiotherapy aims to restore range of motion in early phases, with later stages focusing on strength and balance, with aim focusing on return to activity or sport depending on your requirements.
Ruptured Achilles? We’d love to help out.
Written by William Lewis (Physiotherapist)