Achilles Tendon Rupture

Introduction

You have torn the Achilles tendon at the back of your ankle. The following information is to ensure that you make an optimal recovery and return to full activities as soon as possible.

What is an Achilles Tendon Rupture (tear)?

The Achilles tendon is the largest tendon in the body. It connects the calf muscles to the heel bone. It is made up of bundles of a very strong material called collagen. The Achilles tendon’s function is to help bend the foot downwards at the ankle (this movement is called plantarflexion). An example of this is going up on to your tiptoes. It also helps to propel us forwards when walking or running. A complete tear of the Achilles tendon is known as a rupture (Figure 1).

Occasionally, the tear may be partial and usually occurs where the tendon joins the calf muscle. This injury is managed slightly differently and usually involves resting the ankle in a boot for a few weeks.

What are the symptoms?

These vary from person to person. People may experience a sudden pain in their heel or calf. The pain may then settle to a dull ache or go completely. This can be associated with a snapping or popping sound during injury.

Patients often describe the feeling as if someone has hit or ‘shot’ them in the back of the leg, only to turn around and find no one is there. After the rupture of your Achilles tendon, there may be some swelling and bruising in your calf. Walking is usually difficult, with only a flat-footed type of walking being possible.

It is commonly difficult to push off the ground properly on the affected side. You may be unable to stand on tiptoes or climb stairs.

What are the causes?

An Achilles tendon rupture occurs when the tendon quality is reduced due to tendinopathy (wear and repair changes within the tendon) and is then loaded beyond its capacity. Forceful jumping, pivoting, or sudden accelerations of running can overload the tendon and cause it to rupture. An injury to the tendon can also result from falling or tripping.

Sometimes, the Achilles tendon can be weak, making it more prone to rupture. This could be due to specific medical conditions, such as rheumatological conditions, or medication combinations, such as long-term steroid or some types of antibiotic use.

Diagnosis

It is usually possible to detect a complete rupture of the Achilles tendon based on the symptoms, the history of the injury and a healthcare professional’s examination. A gap may be able to be felt in the tendon, usually 4 to 5 cm above the heel bone. This is the normal site of the injury and is called an intra-substance tear. The tear can occur higher up, about 10cm above the insertion into the heel, at the site where the muscles join the tendon, known as a musculo-tendinous tear.

A special calf squeeze test will be performed. Usually, if the Achilles tendon is intact, this causes the foot to point downwards, but if it is ruptured, it causes no movement. If there is uncertainty about the diagnosis or the exact site of the rupture, it may, on occasion, be necessary to perform an ultrasound scan.

Treatment options

There are two treatment options available for acute Achilles tendon ruptures. These are:

1. non-operative (conservative) and
2. operative (surgical).

In NHS Fife, we employ conservative treatment (functional bracing) in the majority of patients. The evidence suggests similar results to surgery without the associated complications. Occasionally, surgery may be considered, especially in cases of delayed presentation or atypical ruptures.

The Orthopaedic Team will review you in the Orthopaedic Outpatient Department. The Team will review your case and discuss the best management option for your particular presentation and circumstances.

Conservative treatment (functional bracing)

Conservative treatment (functional bracing uses a specialised boot that holds your leg in a set position to allow healing of the tendon while allowing you to function as normal. With conservative treatment, you will follow a set regime that involves initially being non-weight bearing for two weeks in a below-knee plaster cast with the foot held in a fully bent downwards (equinus) position. Most patients will be placed in a specialised boot (VACOped®) after two weeks. This boot is from the knee down to the toes secured with Velcro straps (Figure 2).

The plaster cast or boot should be worn at all times, including in bed, to ensure that your tendon is protected throughout the healing process. After two weeks, you will be advised on the degree of weight bearing you should take through your foot. Usually, after two weeks, while wearing the specialist boot (VACOped), you are able to partially bear weight through the foot using elbow crutches.

As you will be less mobile than previously, you will have a risk assessment for deep venous thromboembolism (VTE), sometimes also called a DVT (blood clot in the leg). If you are felt to be at risk, you will be prescribed blood thinning medication (anticoagulants such as Rivaroxaban) for eight weeks from the date of your injury. You will be referred to the Orthopaedic Service and advised on how to progress to rehabilitation when ready. During these visits, the boot will be adjusted to allow your foot to come up into a more neutral position. The total treatment time with the boot will be approximately ten weeks. You will be referred for physiotherapy to start towards the end of your boot treatment. It may take 4 to 6 months for your symptoms to completely settle and your function to improve. Continued improvements, however, can be expected up to 12 to 18 months post-injury.

Surgical treatment

This is not usually the preferred treatment option, as the risks of complications may outweigh the benefits. Surgery, however, may be considered for certain patient presentations, these being:

• Delayed presentation/treatment (more than 2 to 3 weeks following injury).
• Re-ruptures of Achilles tendon, avulsion injuries or fat within tendon gap.
• Younger, more physically active patients with no other health conditions, as the tendon quality is more amenable to surgical repair and healing.

Patients undergoing surgery will be booked in to have surgery within a week or two following clinic review. On the day of surgery, you will be admitted to the ward. Your surgeon will remind you of the surgical process and possible complications and will ask you to sign a consent form. The anaesthetist will also meet you and discuss any queries. During the morning or afternoon, you will be escorted to theatre.

Once in the theatre, you will be given a general anaesthetic. The procedure lasts about 45 to 60 minutes. It involves making an incision over the Achilles tendon and repairing the tendon with sutures (stitches). After the procedure, you will have a below-knee back slab (half plaster with the foot pointing down) applied.

As you will be less mobile than previously, you will have a risk assessment for deep venous thromboembolism (VTE), sometimes also called a DVT (blood clot in the leg). If you are felt to be at risk, you will be prescribed blood thinning medication (anticoagulants such as Rivaroxaban) for eight weeks post-surgery.

You will be shown how to use crutches as you should not weight bear on the cast or boot (VACOped) for two weeks. Most patients should be able to go home the same day after surgery (day case).

Understandably, you will be unable to drive. You should be accompanied home by a responsible adult to take you home and look after you, especially on the night after your surgery. You will be advised of your follow-up appointment date on the day or by letter in the post. Your stitches will be removed at 10 to 14 days following surgery in outpatients. You will then go through functional bracing (see above) like conservatively managed patients using the specialised boot (VACOped®).

Risks of conservative treatment:

• Risk of re-rupture
• Decreased calf strength
• Risk of clot in leg veins (deep vein thrombosis)/lungs (pulmonary embolus)

Risks of surgical treatment:

• Risk of re-rupture
• Decreased calf strength
• Risk of clot in leg veins (deep vein thrombosis) less than 1 in 100
• Risk of clot in lungs (pulmonary embolus) 1 in 500
• Risk of Infection 1 in 100
• Risk of delayed wound healing
•  Risk of numbness around incision

Patients therefore have to consider potential complications of surgical intervention (all risks increase of around 10% to 16%) compared to conservative treatment).

General management of Achilles tendon in NHS Fife

The following outlines the general course of the journey post injury.

Should you suffer from any of the following symptoms, please seek urgent medical advice:

• Sudden cramp-like pain in calf, thigh or groin 
• Pain in the chest or shortness of breath (A&E) 
• Sudden increase in swelling, numbness or pins and needles 
• Wound concerns (post-surgery if applicable) 

The following video outlines how to apply the boot should this be required.

This usually starts towards the end of your boot treatment. A physiotherapy referral request should have been made at the beginning of your treatment and you should have been contacted by the relevant Physiotherapy team with an appointment date or advice to contact them when ready to commence physiotherapy. If not, please contact the service on 01592 647199.

Preventing recurrence

You have been wearing a VACOped boot to protect your healing ruptured Achilles tendon. During the first six weeks after removal of the boot, there is a risk that the tendon could rupture again. We advise that you avoid sudden stretching of the tendon during this timeframe.

Protecting the tendon

You can protect the tendon from further injury by wearing shoes with a heel, no less than 2.5 centimetres and both shoes should be of the same height. A lace up shoe may be beneficial as it can be adjusted to any swelling and does not slip around the ankles.

• Make sure you take care when walking on rough, soft or uneven ground, as the ground could suddenly force your ankle upwards.
• Make sure your foot is flat on stairs, steps or kerbs with your heel on the step to prevent it from jerking backwards/downwards. 

General return to activities of daily living

Please note that these timescales should only be used for guidance, and all individuals must discuss them with their consultant or physiotherapist.

Guidance for return to work

Timescales for returning to work will depend on the type of work you do, with desk-based employment being sooner than more manual forms of work. It is advised that you return to work when you feel confident that you can safely perform the tasks expected of you. It is recommended that you communicate regularly with your employer to facilitate support for returning to work.

Note: Timescales are for guidance only and will vary depending on when immobilisation/surgery was commenced/undertaken and the extent and nature of the Achilles tendon tear.

Worries or concerns

For non-urgent issues or concerns

For non-urgent issues or concerns please contact your Consultant’s Secretary through the NHS Fife Hospital Switchboard 01592 643355.

For urgent issues or concerns

If you have any urgent concerns regarding your condition, please contact the Physiotherapy Service on 01592 647199.

Urgent advice for patients between 8am to 7.30pm Monday to Sunday, contact the National Treatment Centre - Fife Orthopaedics on 01592 643355 Extension 22685.

Urgent out of the hours advice

For an urgent problem out of hours, please contact NHS 24 on 111 or attend Accident and Emergency.

Emergency advice

For emergency advice, attend Accident and Emergency or call 999.