Achilles Tendon Ruptures - Presentation of a Case and Review of Treatment
(Author - Kristy M. Farmer)
A 29 year old Olympic athlete presents after feeling a pop in his heel while exercising. On examination, there is loss of normal plantarflexion (downward motion) of the foot, a defect in the Achilles tendon, and a positive Thomas test. The diagnosis of acute Achilles rupture (tear) is made.
The Achilles tendon connects the calf muscle to the heel. The tendon is named after the Greek myth in which Achilles’ mother held him by his foot and dipped him in the Styx river to prevent him from harm. By holding him by his foot she left his achilles vulnerable.
An achilles rupture can occur during basketball, tennis, soccer, and running, during a moment of eccentric stretching, the active elongation phase of the tendon. Men between the ages of 30 and 50 and unconditioned individuals are at highest risk. Achilles rupture often feels like a popping or snapping sensation followed by immediate pain and possible swelling and bruising. Walking is painful but possible. A partial rupture usually results in less pain/swelling. Achilles ruptures are relatively easy to diagnose but some differential diagnoses that could be made include acute achilles tendon peritendinitis, tennis leg, calf muscle strain or rupture, posterior tibialis stress syndrome, ligament injuries, and peroneal injuries.
Radiological and Examination Findings
Diagnosis of an achilles rupture can occur right in the doctor’s office without the use of MRIs, CT scan, X-rays or ultrasounds. The Thomas test performed with the patient lying in the prone position (on their stomach) with their feet hanging off the end of the table. The doctor then squeezes the calf, if the tendon is intact then the foot will plantarflex. A palpable gap in the tendon is further affirmation that there is a complete tear in the tendon.
Nonsurgical treatment are available and consist of placing the patient in a specialized boot in which the pressure and tension is taken off of the muscle and tendon. Nonsurgical treatments may result in a higher incidence of re-rupture. Surgery is generally favored if the rupture is complete, and/or if the patient has had multiple ruptures. Surgery appears to offer a more rapid return of mobility and strength to the tendon. The decision to perform surgery will likely depend on the severity of the tear, the activity level of the patient, and other factors. In open surgery, the surgeon makes one large incision in the back of the leg to make the repair, whereas in the percutaneous type of surgery, several small incisions are made. Percutaneous surgeries have a slightly increased risk of reprupture and of nerve damage while the open surgery has a higher incidence of infection.
Synopsis of Outcome
After surgery the patient is non-weightbearing for about 10 days after which the patient begins walking in a removable boot. At that point, the patient can begin full weight bearing, although some surgeons may delay weightbearing longer. Physical therapy can be helpful for recovery whether surgery has taken place or not, and ofter begins about two weeks after treatment. The goal is to increase the range of motion and strength of the tendon. Patients can expect to return to their former activity level in about 4-6 months. Conditioned individuals (mostly athletes) are likely to return sooner.
Follow-up on the patient:
At three months, the athlete was participating in gentle sports, and was scheduled to return to Olympic training and competition at 6 months.