At a glance......
- 1 Anatomy
- 2 The Function of Achilles Tendon Rupture
- 3 Epidemiology of Achilles tendon rupture
- 4 Risk factors of Achilles tendon rupture
- 5 Sports Risk Assessment
- 6 Ground Sports Risk Assessment
- 7 What Causes an Achilles Tendon Rupture?
- 8 Symptoms of Achilles tendon rupture
- 9 Diagnosis of Achilles tendon rupture
- 10 Treatments of Achilles tendon rupture
- 11 Management of Achilles tendon rupture
- 12 Over-the-counter painkillers for Achilles tendon rupture
- 13 Surgery for Achilles tendon rupture
- 14 The benefits of percutaneous repair
- 15 Surgical Technique
- 16 Complications
- 17 References
Achilles tendon rupture is when the Achilles tendon, at the back of the ankle, breaks. Symptoms include the sudden onset of sharp pain in the heel. A snapping sound may be heard as the tendon breaks and walking becomes difficult. Rupture typically occurs as a result of a sudden bending up of the foot when the calf muscle is engaged, direct trauma, or long-standing tendonitis. Other risk factors include the use of fluoroquinolones, a sig
Achilles tendon rupture is the most common tendon rupture in the lower extremity. The injury most commonly occurs in adults in their third to the fifth decade of life. [rx] Acute ruptures often present with sudden onset of pain associated with a “snapping” or audible “pop” heard at the site of injury. Patients can describe the sensation of being kicked in the lower leg. The injury causes significant pain and disability in patient populations.
Achilles tendon injuries typically occur in individuals who are only active intermittently (i.e., the “weekend warrior” athletes). The injury is reportedly misdiagnosed as an ankle sprain in 20% to 25% of patients. Moreover, patients in their third to the fifth decade of life are most commonly affected as 10% report a history of prodromal symptoms, and known risk factors include prior intratendinous degeneration (i.e., tendinosis), fluoroquinolone use, steroid injections, and inflammatory arthritides.[rx][rx][rx][rx]
The Achilles tendon is composed of tendinous fibers contributed by the gastrocnemius and soleus muscles. These fibers then coalesce and insert on the calcaneal tuberosity. The blood supply to the Achilles tendon has three principal sources: the musculotendinous junction, the osseous insertion, and multiple vessels in the mesotenon [rx]. Injection studies using computer-assisted imaging show a reduction in the number and the mean relative area of mesotenal vessels in the mid-section of the tendon. Similarly, the number of intratendinous vessels is fewest 4 cm from the calcaneal insertion [rx].
The tendon receives equal contributions from both the gastrocnemius and soleus muscle and tendinous fibers. These fibers converge approximately 15 cm from the insertion point. As the tendon courses inferiorly in the posterior aspect of the leg, the fibers twist approximately 120° internally (counter-clockwise on the right leg) before its insertion point on the calcaneal tuberosity [rx]. The Achilles tendon lacks a true synovial sheath. Rather, the tendon is enveloped within a paratenon. The paratenon permits gliding of the tendon between the skin and surrounding posterior soft tissues of the leg. In addition, the paratenon is responsible for a significant portion of the tendon’s blood supply through a highly vascularized areolar tissue on its anterior aspect. A recent angiographic study showed that a dense net of small arteries inserts into the paratenon of the Achilles tendon in its lower 20 cm and seems to provide ample blood supply [rx]. The Achilles’ remaining blood supply is derived from the musculotendinous junction proximally, and from the osseous insertion, distally. The pattern of blood supply leaves the Achilles tendon vulnerable to injury in a watershed area approximately 2–6 cm from its insertion on the posterior calcaneus. Rupture occurs in this watershed area approximately 75 % of the time. Furthermore, ruptures can occur at the distal insertion (10 %–20 %) and the myotendinous junction (5 %–15 %) as well [rx].
The Achilles’ main purpose is to provide ankle plantarflexion. Other functions include acting as a checkrein during eccentric contraction to prevent excessive ankle dorsiflexion and forward lurching during ambulation. Unique viscoelastic properties of the Achilles allow the tendon to undergo plastic deformation as the gastrocnemius-soleus complex contracts. These viscoelastic properties also cause the tendon to become stiffer as rapidly increasing loading forces are applied [rx, rx].
The Function of Achilles Tendon Rupture
The Achilles tendon is the largest and strongest tendon in the human body. The Achilles tendon connects the heel bone (calcaneus) to the muscles at the back of the calf (using gastrocnemius and soleus muscles). The synchronous function of the tendon and calf muscles is critical for activities like jumping, running, standing on the toe, and climbing stairs. When climbing stairs or running, the forces within the tendon have been measured and indicate that the structure is able to withstand at least 10 times the body weight of the individual.
The function of the Achilles tendon is to help raise your heel as you walk. The tendon also assists in pushing up the toes and lifting the rear of the heel. Without an intact Achilles tendon, almost any motion with the ankle (for example, walking or running) is difficult.
Epidemiology of Achilles tendon rupture
- Achilles tendinopathy typically affects athletes; long-distance runners have a lifetime risk of 52%.
- It has an annual incidence of 2.35 per 1,000 adults registered with a GP.
- It has been thought to be more common in men than in women and it has been proposed that estrogen protects tendons; however, in a study of athletes aged over 40, there was no gender difference. Similarly, there was no gender difference identified in a GP-based cohort study.
Risk factors of Achilles tendon rupture
The Achilles tendon can experience forces of up to 12.5 times body weight during running.
Activities such as running, jumping, dancing, and tennis, where the tendon is susceptible to chronic overloading, are the likeliest associations. The main risk factors are
- The rapid increase in the amount of time spent on the activity.
- Change in footwear or training surface, such as going from running on a treadmill to running on the road.
- The poor running technique, such as excessive pronation of the foot or forefoot, which may contribute.
- Poorly fitting footwear. Particularly, compression from the firm or high heel tab on shoes may precipitate problems.
- Family history (increases risk 5x).
- Familial hypercholesterolemia may present with Achilles tendon pain.
- Insertional tendinopathy may be due to an enthesitis; ankylosing spondylitis, reactive arthritis, and psoriatic arthritis should be considered.
- Quinolone antibiotics (eg, ciprofloxacin, ofloxacin) can cause inflammation of tendons and predispose them to rupture.
- Chronic renal failure
- Collagen deficiency
- Diabetes mellitus
- Parathyroid disorders
- Thyroid disorders
Foot problems that increase the risk of Achilles tendon injuries include the following
- Cavus foot
- Insufficient gastrocsoleus flexibility and strength
- limited ability to perform ankle dorsiflexion
- Tibia vara
- Varus alignment with functional hyperpronation
It has been observed that Achilles tendon rupture is often more common in people with blood group O. Further anyone with a family history is also at high risk of developing Achilles tendon rupture at some point in their life.
Sports Risk Assessment
There are multiple risk factors to consider when determining the risk of AT rupture in an aerial sport athlete.
- For gymnasts, the carpeted floor underlined with plywood and foam is softened with 4-in spring coils affording gymnasts more airtime. Reducing the stiffness of the spring floor decreases floor stability and increases the horizontal distance of tumbling flight trajectories altering the joint torques.[rx]
- Modeling studies show that the gymnast-floor interface produces forces at the feet and ankles ranging from 5- to 17.5-times bodyweight.[rx] Gymnasts who consistently land short on tumbling landings increase their risk for anterior ankle impingement.
- They stretch and load across the gastrosoleus complex through the AT, which can accelerate degeneration of the tendon.[rx] In practice, athletes are more protected by preventing repetitious hard impact through the use of foam pits, soft mats, belts, and bungee devices.[rx]
- Preseason is a high-risk period when new skills are attempted in preparation for competition if physical conditioning is poor and fatigue occurs from training intensity.[rx]
- There is a significant increase in injuries during seasonal competition likely due to higher levels of fatigue while performing full routines.[rx]
- The International Gymnastics Federation’s scoring code rewards gymnasts for difficult aerial maneuvers. Gymnasts attempt greater heights and riskier maneuvers that enhance scoring and gain bonus points with judges. Unfortunately, this also increases the potential for greater ground reaction forces upon landing.[rx]
- Loads on the ankle, AT, and the spine are highly dependent on the posture of the gymnast during the landing impact.[rx] Gymnasts often underrotate a landing (land “short”) forcing dorsiflexion at the ankle with a violent stretch of the AT.
Lack of Footwear
- Traditional footwear is not used by aerial athletes because of their weight and distortion of body lines. Gymnasts have a forefoot strike when running and perform in constant plantarflexion with toe pointing in most skills until landing. Shoe wear would make this difficult. Without shoes, there is no support to limit pathologic foot pronation, which can strain the AT complex on unstable surfaces.[rx]
- The aerial athlete’s age, weight, body proportions (fat), rapid growth, strength, experience, and tendon health may put an individual at risk.[rx] Older gymnasts may be more at risk because of more complex and difficult skills and accumulated training.[rx] Gymnasts of an atypical body type lost the most time from training due to injury.[rx]
Lack of Concentration
- Lack of concentration correlates to injury risk in jumping athletes because of the need for coordination.[rx]Anxiety, time pressure, and physical or emotional fatigue are related to the number and severity of injuries in the nonelite athlete.[rx] In a Swedish team study, 53% of injuries occurred while the gymnasts were in a negative mood, 32% felt “as usual,” and only 12% were in a positive mood.[rx]
Ground Sports Risk Assessment
- Intrinsic factors play a larger role for ground athletes because of the shoe-surface interaction. Preexisting degenerative tendon, cavus foot, tibia vara, or underdeveloped hamstrings may increase the risk of AT ruptures.[rx]
- Over- or underpronating is linked with poor shock absorption and may increase stress on the AT.[rx] Increased femoral anteversion, leg length discrepancy, muscle weakness, increased body mass index, and aging increase the intrinsic risk of AT rupture in running athletes.[rx]
- Sudden increases in interval training, solitary intense runs, increases in terrain elevation, uneven or density differing surfaces, or an increase in eccentric loading may increase the risk of injury.[rx] Asphalt running decreases midportion Achilles tendinopathy by nearly one-half, while sand running increased this pathology nearly tenfold.[rx]
Lack of Stretching/Fatigue
- In the fatigued or a poorly trained athlete, injury occurs after 30 minutes of activity.[rx] As distances increase, muscle fatigue results in tendon elongation and micro-tearing.[rx] This damage can occur within the tendon’s physiologic limits if the time for repair is not adequate.[rx]
- In athletes of all ages, morning stiffness correlates to the severity of Achilles tendinopathy.[rx]Proper initiation of an athletic and consistent stretching regimen to prevent injury are vital in the ground sports athletic population.
What Causes an Achilles Tendon Rupture?
Repeated stress from a variety of causes is often the cause of Achilles tendon injury. The stress may occur from any of the following:
- Excessive activity or overuse
- Flat feet
- Poorly fitting or inadequate shoes
- Inadequate warm-up or proper conditioning
- Jogging or running on hard surfaces
- Older recreational athlete
- Previous Achilles tendon injury (tendonitis/rupture)
- Repeated steroid injections
- Sudden changes in the intensity of exercise
- Use of fluoroquinolone antibiotics (especially in children)
- Trauma to the ankle
- Tense calf muscles prior to exercise
- Weak calf muscles
Symptoms of Achilles tendon rupture
- You hear a snap, crack or popping sound when pushing off with your leg, often accompanied by a sharp pain in the back of your leg or ankle
- Trouble moving your foot to walk or go upstairs. You’re unable to stand on your toes (“tippy-toe”)
- Pain, bruising and swelling at the back of your leg or heel
- Chronic, recurrent calf or Achilles tendon ̶ area pain
- Previous rupture of the affected tendon
- Loss of plantar flexion power in the foot
- Swelling of the calf
- The recent increase in physical activity/training volume
- Recent use of fluoroquinolones, corticosteroids, or corticosteroid injections
Severity – Partial Rupture or Complete Tear
The physician will perform further testing by visible soft tissue depression like the Thompson test, visual observation, and possible image testing such an MRI or ultrasound.
Note: a partial Achilles tear is not as recognizable as a complete Achilles rupture and you might not notice the injury when it occurs. Partial tears often don’t reveal themselves until after you cool down from your activity, at which point
- The middle section of your Achilles will be tender to touch and swollen. This will likely subside after a few daYour
- Achilles tendon could be painful and stiff, especially after a long period of inactivity
If the tear is partial you may still be able to walk, but you will have a limp, often accompanied by severe pain when you push off with your toes or touch down on your heel (heel strike).
Complete Tear/Total Rupture
More severe than a partial tear, a total Achilles rupture will be more obvious, and you will likely notice it at the moment that the injury occurs:
- Acute pain often described as being struck by a sharp object in the Achilles area
- A loud snap or pop can be heard at the time of your injury
- Flexing and pointing your foot will be difficult
- Occasionally a small gap will be visible or a palpable depression can be felt in the area of the tendon where the injury occurred in the back of the calf.
If any of these symptoms are present, it’s highly likely you have an Achilles rupture. You will want to have your injury assessed and verified by a physician right away to avoid more damage and give yourself the optimal opportunity for recovery.
Diagnosis of Achilles tendon rupture
- increased resting ankle dorsiflexion in a prone position with knees bent
- calf atrophy may be apparent in chronic cases
- palpable gap
- weakness to ankle plantar flexion
- increased passive dorsiflexion
- Thompson test lack of plantar flexion when the calf is squeezed
- indications may be useful to determine complete vs. partial ruptures
- indications, equivocal physical exam findings, chronic ruptures
- findings will show acute rupture with retracted tendon edges
Treatments of Achilles tendon rupture
- Rest – Stay off the injured foot and ankle, since walking can cause pain or further damage.
- Ice – Apply a bag of ice covered with a thin towel to reduce swelling and pain. Do not put ice directly against the skin.
- Compression – Wrap the foot and ankle in an elastic bandage to prevent further swelling.
- Elevation – Keep the leg elevated to reduce the swelling. It should be even with or slightly above heart level.
Management of Achilles tendon rupture
- Immediate relief of symptoms of acute Achilles tendinopathy includes rest, application of ice and analgesics, including non-steroidal anti-inflammatory drugs (NSAIDs), and heel lifts (orthotic devices – used on both sides to prevent a gait imbalance).
- Gentle stretching of the front and back of the lower leg.
- The patient will need to alter their activities, at least in the short term; they may benefit from advice from a physiotherapist.
If there is no improvement after 7-10 days of rest and gentle stretching, eccentric heel-drop exercises, first described by Alfredson, are the best treatment for Achilles tendinopathy
- This involves pushing up on to the toes of both feet then lowering over the edge of a step on the affected foot.
- There are two exercises, one is done with the knee straight and the second with the knee in flexion.
- Alfredson’s research dictated three sets of 15 repeats of both exercises twice a day. This may be difficult for people to adhere to but they need to do as close to this many as they can of both exercises, twice a day.
- Eccentric loading may be painful.
- These exercises should be done daily for three months, with increasing load, and may need to be continued for much longer.
- There are many potential explanations as to why eccentric loading is effective, the likeliest being changes in neuromuscular control that reduce the tendon load.[Rx]
- A Cochrane review of injection therapies concluded that there is insufficient evidence, possibly due to the poor quality of the available research, to support the routine use of injection therapies and that more research is needed in this area, particularly in the older non-athletic population.]There is a risk of tendon atrophy and rupture with steroid injection. In the UK the National Institute for Health and Care Excellence (NICE) does not approve steroid injections into or around the Achilles tendon.
- There is some evidence that combining eccentric loading with extracorporeal shock-wave therapy (ESWT) is an effective treatment in recalcitrant Achilles tendinopathy.
- Autologous blood injection, using either whole blood or platelet-rich plasma, that contains growth factors, is safe but the efficacy is uncertain.
- NICE advises that ESWT and autologous blood injection should only be used with special arrangements for clinical governance, consent, and audit but encourages further research into both approaches.ESWT can be painful.
- Topical glyceryl trinitrate used for six months may be effective but possibly no more so than a formal exercise program. It is not licensed for this use in the UK.
- Casting is an option for resistant Achilles tendinopathy.
- Surgery is sometimes used for resistant Achilles tendinopathy but usually as a last resort. Open surgery involves excision of fibrous adhesions and regenerative nodules. Minimally invasive operative treatments include tendon stripping or percutaneous tenotomy.
Over-the-counter painkillers for Achilles tendon rupture
If you have mild-to-moderate pain, start by taking a non-opiate painkiller, such as paracetamol or an NSAID, such as ibuprofen. Take it regularly and up to the largest recommended amount. If that doesn’t work and you still have pain, then try a weak opiate medicine such as codeine. If that doesn’t work, talk to your GP.
You can buy over-the-counter (OTC) painkillers in several different forms, including:
Sometimes the Achilles tendon is weak, making it more prone to rupture. Factors that weaken the Achilles tendon are:
- Corticosteroid medication (such as prednisolone) – mainly if it is used as long-term treatment rather than a short course.
- Corticosteroid injection near the Achilles tendon.
- Certain rare medical conditions, such as Cushing’s syndrome, where the body makes too much of its own corticosteroid hormones.
- Tendinopathy of the Achilles tendon.
- Other medical conditions which can make the tendon more prone to rupture; for example, rheumatoid arthritis, gout and systemic lupus erythematosus.
- Certain antibiotic medicines may slightly increase the risk of having an Achilles tendon rupture. These are the quinolone antibiotics such as ciprofloxacin and ofloxacin. The risk of having an Achilles tendon rupture with these antibiotics is actually very low and mainly applies if you are also taking corticosteroid medication.
- Tablets, caplets (longer tablets that are rounded at each end that may be easier to swallow) or capsules that you swallow
- A powder or tablet to dissolve in water
- A liquid or syrup
- Suppositories, which are soft, shaped tablets which you put into your back passage
- Gels or sprays that you put directly onto your skin
- Patches that you place on your skin
How much to take
The table below shows the recommended amount of the main over-the-counter medicines that an adult should take.
Some other medicines also contain painkillers such as paracetamol. So, if you need to take a painkiller, be sure to check the labels carefully on other medicines. Ask your pharmacist for advice if you’re not sure.
Always read the patient information leaflet that comes with your medicine, and if you have any questions, ask your pharmacist for advice.
Surgery for Achilles tendon rupture
Open end-to-end Achilles tendon repair
- Indications for acute ruptures (approximately <6 weeks)
- Outcomes decreased the rate of re-rupture compared to non-operative management
- New Level 1 evidence has suggested no difference in re-rupture rates
- Increased plantar flexion strength compared to non-operative management new Level 1 evidence has suggested no significant difference in plantar flexion strength
Percutaneous Achilles tendon repair
- Indications for concerns over cosmesis of traditional scar
- Outcomes of higher risk of sural nerve damage, lesser risk of wound complications/infection compared with open repair
Reconstruction with VY advancement
- Indications for chronic ruptures with defect < 3cm
Flexor hallucis longus transfer +/- VY advancement of the gastrocnemius
- Indications for chronic ruptures with defect < 3cm
- Chronic ruptures with defect > 3cm
- Requires a functioning tibial nerve
Functional bracing/casting in resting equinus
- Technique cast/brace in 20 degrees of plantar flexion early functional rehab for those treated without a cast
End-to-end Achilles tendon repair
Approach make an incision just medial to Achilles tendon to avoid sural nerve
- Incise paratenon
- Expose tendon edges
- Repair with heavy non-absorbable suture
- Immobilize in 20° of plantar flexion to decrease tension on the skin and protect tendon repair for 4-6 weeks
Percutaneous Achilles tendon repair
Reconstruction with VY advancement
- Make V cut with the apex at the musculotendinous junction with limbs divergent to exit the tendon
- V is incised through only the superficial tendinous portion leaving the muscle fibers intact
Flexor hallucis longus transfer ± VY advancement of the gastrocnemius
- Excise degenerative tendon edges
- Release FHL tendon at the Knot of Henry and transfer through the calcaneus
Peroneus Brevis Tendon Transfer
- The peroneus brevis tendon transfer is an effective technique to repair a chronic Achilles tendon rupture when the gap between the two tendon stumps is smaller than 6 cm.
- The patient is placed prone under general anesthesia, with the ankles clear of the operating table. A tourniquet is applied to the limb to be operated. The limb is exsanguinated, and the tourniquet is inflated to 250 mm Hg. Three longitudinal surgical approaches are made. The first incision is made medially the proximal tendon stump. It is about 5 cm long and it begins 2 cm proximal to the palpable end of the residual tendon.
- The second incision is lateral to the distal end of the tendon rupture, and it is about 3 cm long. Care is taken to prevent damage to the sural nerve by making the incision as close as possible to the anterior aspect of the lateral border of the Achilles tendon. The third incision is a 2 cm longitudinal incision at the base of the fifth metatarsal
Ipsilateral Free Semitendinosus Tendon Graft
- If the gap between the proximal and distal stumps is greater than 6 cm despite maximal plantar flexion of the ankle and traction on the tendon stumps, an ipsilateral semitendinosus tendon graft is indicated. The first two longitudinal incisions are the same performed for the peroneus brevis tendon transfer. One incision is medial to the proximal Achilles tendon end, and the second is just lateral to the distal stump, taking care to prevent damage to the sural nerve.
- Through the proximal incision, the peritendinous adhesions are gently dissected and partial resection of the proximal tendon stump is performed to expose the healthy portion of the tendon. The free tendon edge is sutured with a #1 Vicryl locking suture to prevent separation of the bundles. The soft tissues anterior to the soleus and gastrocnemius are released to better mobilize the proximal stump of the tendon and minimize the gap. The distal stump is mobilized too.
- A loop of polyglyconate is used in a Krakow configuration to impose adequate traction on the proximal stump of the tendon. Moderate traction to the proximal stump is applied taking care to maintain the ankle in maximal plantar flexion.
- The ipsilateral semitendinosus tendon is harvested through a 2 cm longitudinal incision over the anteromedial aspect of the tibia over the pes anserinus [Rx]. In the original technique, the semitendinosus was harvested with the patient supine, but it was technically demanding, as the patient was upside down, and the anatomy is obviously ‘the other way round’ [rx] . Currently, the authors harvest the tendon of semitendinosus with the patient prone, using a 2 cm transverse incision over the palpable tendon of the semitendinosus in the popliteal fossa.
The benefits of percutaneous repair
- No full incision
- Reduced risk of infection
- Less scarring
- Less pain
- No general anesthetic required
- Shorter surgery
- The tendon sheath, holding the blood clot that forms at the time of the tendon rupture is kept intact, permitting rapid healing of the tendon.
- The rehabilitation program is accelerated
- Full return to sports is expected
The proximal portion of the tendon, as identified by palpation and MRI, is captured with a #1 Tevdek suture placed transversely through the skin and the tendon and out the opposite side. This suture is then crisscrossed through the tendon, the gap at the rupture site, and finally through the distal portion of the tendon just above the calcaneus, through the skin punctures. A second stitch is placed after the first one and is tied with the foot in plantar flexion. A dressing is applied and the foot is placed in a plantarflexed pre-formed padded splint.
While newer level 1 evidence has reported no difference in re-rupture rates, prior studies have suggested a 10% to 40% re-rupture rate with nonoperative management (compared to 1% to 2% rate of re-rupture after surgery) Lantto et al. recently demonstrated in a randomized controlled trial of 60 patients from 2009 to 2013 at 18-month follow-up: [rx]
- Similar Achilles tendon performance scores
- Slightly increased calf muscle strength differences favoring the operative cohort (10% to 18% strength difference) at 18-month follow-up
- Slightly better health-related quality of life scores in the domains of physical functioning and bodily pain favoring the operative cohort
Wound Healing Complications
- Overall, a 5-10% risk following surgery
- Risk factors for postoperative wound complications include – Smoking, (most common and most significant risk factor), Female gender, Steroid use, Open technique (vs percutaneous procedures)
Sural Nerve Injury
- Increased rate of injury associated with the percutaneous procedure (compared to open technique)
Postoperative and Rehabilitation Care
No matter which method is used to treat the tendon rupture, participating in an exercise program is vital. One may swim, cycle, jog or walk to increase muscle strength and range of motion.
Deterrence and Patient Education
While active patients and recreational athletes often return to baseline activity levels and work following both nonoperative and operative management of these injuries, high-level professional athletes most often report inferior results and return to play regardless of the chosen management plan.
A 2017 study from the American Journal of Sports Medicine reported professional athletes followup performance (NBA, NFL, MLB, and NHL) at 1- and 2-year follow-up after surgery performed between 1989 and 2013: [rx]
- >30% failure to return to play
Athletes returning noted (at 1-year followup):
- Fewer games played, overall
- Less playing time, overall
- Suboptimal performance level, overall
Athletes able to return to play, by 2-year followup:
- No statistically significant difference in performance level
Thus, athletes demonstrating the ability to return to play by 1-year should expect to achieve continued improvement to baseline performance by the ensuing season.