Achilles Tendon Rupture Management and Physiotherapy

By: Jonathan Blood-Smyth

The Achilles tendon is the biggest and the strongest tendon in the body, located in the back of the lower calf. Healthy men roughly between 30 and 50 years old are typical sufferers and they often have no previous history of injury or difficulties with the leg. It is common in people who are usually not very active and who unexpectedly perform physical activities or play football at weekends, so-called "weekend warriors".
The Achilles tendon consists of the tendons from the two main calf muscles, the gastrocnemius and the soleus, coming together into one about 15cm above the upper edge of the heel bone. Tendons have ideal properties to transmit force from muscles to bones, being stiff but resilient, having a high tensile strength and able to stretch up to 4% before any damage occurs. Over 8% of stretch to the tendon and rupture of the fibres occurs. About 2-6cm up from the heel bone the blood supply is less good and in this area most of the degeneration and eventual rupture occurs.
Achilles tendon tears occur mostly in the left leg where the poor blood supply is, perhaps because most people are right handed and push off more with their left leg. Common injuries are on sudden foot push off, an unexpected forcing up of the ankle and an upward force on the ankle when pushed down. Direct trauma and general degeneration of the tendon without trauma can also occur. People at risk include those exerting themselves when they are unfit, relatively older people, steroid users and those who exert themselves in extreme ways.
Achilles tendon forces in running can be very high and have been measured at six to eight times bodyweight. The patient typically reports a sudden snap or blow to the rear of the lower calf, a sudden strong pain, an ability to walk but not to run or climb stairs. On examination there may be a swollen or bruised calf, a palpable gap in the tendon and an inability to stand on tiptoe. A history of treatment with steroids, previous tendon rupture or an unusually high activity level (e.g. weekend warrior) can also be important findings.
Doctors choose conservative or surgical management, operation having a higher risk of complications and conservative treatment a higher risk of re-rupture. Non-operative treatment is suitable for sedentary people, diabetics, older people and those with medical problems or poor skin integrity. Impaired blood supply, diabetes and other illnesses make wound breakdown, tendon separation and infections more likely. A calf or thigh length plaster may be used with the ankle flexed down, moving it up regularly over six to ten weeks. The patient is allowed to weight bear and given an orthotic as the tendon heals.
Surgery can be open or percutaneous and after surgery the ankle is kept plantar flexed in a plaster of Paris or a rigid orthosis, with the patient coming back for the ankle to be repositioned upwards as the tendon heals, until the ankle is freed from the splint four to six weeks after the repair. Shorter periods of immobilization appear to be more successful than longer. Overall surgical repair may have lower re-rupture rates, faster return to normality and better strength and endurance as compared to conservative treatment.
The physiotherapy rehabilitation starts with ankle range of movement exercises without body weight loading, encouraging a good walking pattern and a heel raise to reduce the upward force on the tendon in gait. Static cycling and swimming are good starting activities, moving onto weight bearing exercises, muscle strengthening and onto more vigorous activities such as jogging, jumping and balance practice. Normal activity may be resumed by four months from surgery but this varies.
Achilles tendon rupture usually turns out with good or excellent results with most athletes getting back to their chosen sports. Surgical management has a re-rupture rate of 0-5 percent and conservative treatment up to 40 percent, so patient education by the physio in training and stretching performance and the best choice of footwear is important for the long term.

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Jonathan Blood Smyth is a Superintendent Physiotherapist at an NHS hospital in the South-West of the UK. He specialises in orthopaedic conditions and looking after joint replacements as well as managing chronic pain. Visit the website he edits if you are looking for physiotherapists in Oxford.

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