Achilles tendon ruptures most often occur in athletes and active people between the ages of 30 and 55. This age group is at risk because these patients are still quite active, but over time their tendons tend to become stiffer and gradually weaken.
As a rule, this occurs when performing actions that require sudden acceleration or a change in direction of movement (for example, basketball, tennis, etc.). Patients usually describe a sharp pain in the heel area, as if they had been “struck with a stick in the Achilles tendon area.” Acute rupture of the Achilles tendon is diagnosed upon examination of the patient; radiography in this case is of little effectiveness.
The Achilles tendon is the largest and strongest tendon in the body (Figure 1). It can withstand a load of 2-3 times your body weight during normal walking, so restoring normal function of the Achilles tendon is extremely important.
An Achilles tendon rupture can be successfully treated either non-surgically or surgically. In both cases, this must be treatment in compliance with all rules and regulations. Recent studies show that non-surgical and surgical treatments for Achilles tendon ruptures produce similar results.
Surgery may result in a slightly faster recovery and a lower rate of re-rupture. However, surgery can be associated with very serious complications, such as infection or problems with postoperative wound healing.
Therefore, conservative treatment may be preferable for people suffering from diabetes and vascular diseases, as well as heavy smokers.
Figure 1: Achilles tendon
Mechanism of injury and clinical picture
Tears typically occur when an athlete puts stress on the Achilles tendon in preparation for a push-off. This can happen when there is a sudden change in direction, when starting to run or preparing to jump (Figure 2).
Tears occur because the calf muscles create enormous forces through the Achilles tendon as the body moves. At the time of injury, patients feel a sharp pain in the back of the leg or foot, many describe this feeling as if they were hit from behind with a stick, often a clicking sound is heard.
After an injury, an area of retraction or deformation appears along the Achilles tendon, swelling, and hematoma. Patients walk with a limp on the injured limb and cannot stand on their toes. Partial rupture of the Achilles tendon is not common.
Painful tendinitis (inflammation) of the Achilles tendon or a partial tear of the calf (calf) muscles as they attach to the Achilles tendon can also cause pain in this area. The pain of an Achilles tendon rupture may subside quickly, and the injury may be considered a sprain upon initial evaluation in the emergency room.
Rice. 2. Mechanism of injury - sudden change in direction of movement to maximum load of the Achilles tendon Figure 3: Maximum load during walking - heel lift
Achilles bursitis and posterior calcaneal bursitis
In the heel area there are two synovial bursae in which an inflammatory process can develop. The first is located between the heel bone and the Achilles tendon and is called the calcaneal tendon bursa, the second is between the Achilles tendon and the skin and is called the posterior calcaneal bursa. In the latter case, bursitis usually develops from friction from poorly fitting shoes and is especially common in women who wear high-heeled shoes. The bursa is usually distended with fluid and inflamed. In chronic cases, the bursa is thickened along with the overlying skin; There is pain and swelling at the back of the heel where the shoe rubs. With Achilles bursitis, the patient complains of pain when moving; palpation reveals localized tenderness just anterior to the Achilles tendon.
Treatment for Achilles bursitis includes rest, warmth, and elevation of the limb. Patients with posterior calcaneal bursitis need to choose suitable low-heeled shoes. In acute cases, the heel of the shoe can be cut out. Puncture of the bursa and administration of hydrocortisone lead to rapid subsidence of symptoms.
Clinical examination
An Achilles tendon rupture can be diagnosed quite easily during an examination by a specialist. The most common location of ruptures is 2.0-5.0 cm above the site of attachment of the tendon to the heel bone. The main way to determine the presence or absence of an Achilles tendon rupture is to perform the Thompson test .
The patient is placed on his stomach so that his feet hang freely over the edge of the couch, after which the doctor squeezes the calf muscles. If the integrity of the tendon is not compromised, the foot will rise [plantarflexion]. If there is a tendon rupture, there will be no movement.
Often patients mistakenly believe that their tendon is working normally if they can move their foot up and down. However, this is only possible in a sitting position because the adjacent muscles and tendons are not damaged.
When you try to lift your leg up in a standing position and transfer your body weight to the injured limb, pain and weakness will appear. If an Achilles tendon rupture occurs, it will be incredibly difficult for the patient to stand on their toes for any length of time - this is called the STAMP test . Sensitivity and blood circulation in the foot and ankle are usually not affected.
Anatomy
The Achilles tendon is the largest tendon, formed by tendon fibers of the soleus and gastrocnemius muscles. It lifts the heel when a person takes a step and lowers the front of the foot to the ground after the heel contacts the support. Without this tendon, a person cannot run, stand on tiptoes or climb stairs.
In its lower part, the tendon is attached to the tubercle of the heel bone. Between the tendon and the heel bone there is a mucous bursa, which reduces the friction of the tendon fibers on the bone during movements.
Research methods
In acute tendon rupture, a clinical examination is often sufficient to make a diagnosis. Radiography can be useful only if there is a suspicion of an avulsion fracture of the calcaneus (a situation in which the Achilles tendon is torn from the heel bone with its fragment).
The rupture can be seen on ultrasound or MRI. However, these studies are not needed for acute ruptures unless there is some uncertainty about the diagnosis. These examination methods are very useful for old ruptures or chronic diseases of the Achilles tendon.
Treatment
A ruptured Achilles tendon can be treated either non-surgically or surgically. Both treatment methods have their advantages and disadvantages. Recent studies have shown that non-surgical and surgical treatment of Achilles tendon ruptures provide equivalent results.
The choice of treatment method depends on the individual case and patient. It is important to understand that Achilles tendon ruptures must be treated. Neglected (ignored) rupture of the Achilles tendon leads to negative consequences, such as chronic pain syndrome, lameness, and dysfunction of the injured limb. In addition, old ruptures are much more difficult to treat, and the treatment results are worse, and the rehabilitation period also increases.
The doctor only helps nature restore the integrity of the Achilles tendon; his task is to create comfortable conditions for the regeneration process, namely, to bring the torn ends of the tendon closer together and, for the time necessary for recovery, immobilize them. With a conservative method of treatment, the doctor seeks to bring the ends of the tendon closer together by positioning the foot; with an operative method, the doctor sews the ends of the tendon together with threads.
Rules for massage
Physical therapy exercises after an Achilles tendon rupture must be accompanied by either self-massage or seeking help from specialists. For self-massage, you will need to slowly rub your shin with your hands using smooth movements. Next, you need to place the ball under your foot and roll it with light circular movements until warmth appears.
The first weeks of rehabilitation are especially difficult. Patients often complain of swelling. To get rid of it, a professional massage is prescribed. It helps disperse blood and lymph, helps cope with tumors. Massage is performed using several methods:
- soft bilateral kneading with two hands;
- light stroking;
- circular impact with the pad of the thumb;
- by mechanical vibration.
Important
! The procedure must be carried out from the bottom up. Movements should be smooth and not cause sharp pain or discomfort. If necessary, it is recommended to use special massage oil.
Non-surgical treatment
With this method of treatment, the foot is brought out and fixed in the equinus position (the foot is in the position of maximum plantar flexion). In this position of the foot, the free ends of the Achilles tendon are brought together as closely as possible. For this, a plaster (polymer) bandage or a rigid articulated section for the ankle joint with the ability to adjust the angle and a heel pad can be used.
With conservative treatment, rehabilitation can be more aggressive - patients are allowed partial weight-bearing on the injured limb from the first day, but full weight-bearing is allowed only 6 weeks after the injury. Modern rehabilitation protocols aim to mobilize patients as early as possible while protecting the injured tendon from significant stress that could cause the healing tendon to rupture or sprain.
It is extremely important that with this approach it is possible to preserve the function of the lower leg muscles. It is necessary to monitor the condition of the tendon throughout the entire period of non-surgical treatment. This can be done through clinical examination and/or ultrasound. If there is evidence of tendon end dehiscence or nonunion, surgical treatment should be considered.
The main advantage of non-surgical treatment is the absence of incisions and punctures in this area, therefore, there can be no problems with wound healing or infection. Wound infection after Achilles tendon surgery can lead to serious complications, so for many patients, especially those with diabetes, vascular disease, and patients who smoke for a long period of time, non-surgical treatment should be considered.
The main disadvantage of non-surgical treatment is that recovery may be a little slower. Full recovery occurs 2-4 weeks later than with surgical treatment. In addition, with conservative treatment, the risk of recurrent tendon ruptures increases. Recurrent ruptures usually occur 8-18 months after the initial injury.
Rehabilitation
The duration of the rehabilitation period depends on the severity of the injury and the speed of recovery of the torn tendon. Doctors allow full weight bearing on the injured leg after 2-3 months. At the beginning of rehabilitation, patients are advised to take antibiotics to prevent tissue infection and NSAIDs to reduce pain. After a few days, systemic medications begin to be gradually replaced with ointments with an analgesic and (or) warming effect.
After removing the plaster splint, it is necessary to wear rigid, semi-rigid orthoses with a gradual decrease in the degree of fixation. The patient is also advised to walk with the help of a cane or crutches. During the recovery period, to speed up recovery, sessions of physiotherapeutic procedures are prescribed: magnetic therapy, UHF therapy, balneological treatment.
Sometimes, with an incomplete tendon rupture, the victim does not appreciate the seriousness of his situation and does not seek medical help. The result is improper fusion of fibers, causing gradual atrophy of the ankle muscles. Its characteristic external sign is a decrease in size of the damaged leg. The sooner the victim is hospitalized for treatment, the faster he can return to an active lifestyle.
Open Achilles tendon repair
Achilles tendon repair is most often performed through a skin incision made in the projection of the tendon rupture along the back of the leg. The site of the Achilles tendon rupture is reached, then the unfibered ends are sparingly trimmed, cleaned and prepared for stitching.
The foot is brought to the position of maximum plantar flexion so that the tension on the tendon is minimal and the torn ends of the tendon are brought together as close as possible, after which suturing occurs.
After suturing the ends of the tendon, the wound is thoroughly washed, bleeding is controlled, the skin is sutured, aseptic dressing, elastic compression and immobilization using a plaster splint or a rigid cut. Cold locally. (see Fig. 1).
A possible disadvantage of open Achilles tendon repair is the problem of wound healing, which can lead to a deep infection that is difficult to resolve or a painful post-operative scar.
Figure 1: Open repair of an Achilles tendon rupture
Minimally invasive method for Achilles tendon reconstruction
Another method of Achilles tendon repair is through a “mini” skin incision. In this case, a small horizontal incision 1.5-2.0 cm long is made in the projection of the tendon rupture. The free ends of the tendon are mobilized and brought out into the wound, the dislocated ends are sparingly trimmed, cleaned and prepared for stitching.
Through skin punctures, the ends of the tendon are stitched at a distance of 2.0 - 4.0 cm from the rupture site, the foot is brought to the position of maximum plantar flexion so that the tension on the tendon is minimal, and the torn ends of the tendon are brought together as closely as possible, then stitching occurs.
After suturing the ends of the tendon, the wound is thoroughly washed, bleeding is controlled, the skin is sutured, aseptic dressing, elastic compression and immobilization using a plaster splint or a rigid cut. Cold locally.
Advantages of this technique include less soft tissue damage, less scar tissue, and better cosmesis.
Disadvantages include a higher risk of injury to the sural nerve because, unlike open surgery, sutures are placed without exposing the entire length of the tendon, making it difficult to see whether the nerve is in the surgical site.
The nerve that is potentially damaged will cause numbness along the outer surface of the dorsum of the foot, near the little toe. It is possible that the tendon suture itself may not be as strong as with the open technique, which may lead to faster re-rupture. (see Fig. 2)
Figure 2: Minimally invasive method for Achilles tendon repair
The benefits of Achilles tendon surgery include the following:
- faster recovery
- possibility of early range of motion in the lower leg muscles, therefore the rehabilitation program can be more aggressive
- lower percentage of re-rupture (percentage of re-rupture is significantly lower in patients after surgery (2-5%) than in those who underwent conservative treatment (8-12%)
Possible complications of surgical and conservative treatment
- asymmetrical gait (leading to pain in other areas)
- deep vein thrombosis of the lower extremities
- pulmonary embolism
- Achilles tendon nonunion
- repeated ruptures
results
When analyzing the results of treatment of patients in the control group ( n
=21), which performed plastic surgery of the Achilles tendon defect zone (according to Chernavsky, Krasnov, V-Y-plasty), we noted that the strength of the plantar flexor muscles of the feet (according to the Lovvet scale) on the damaged side averaged 3.43 points, in main group - 4.63. Muscle strength of 5 points in the main group was in 62.5% of patients, and in the control group in 14.3%.
When analyzing podometric indicators, we studied such time characteristics of the step as the duration of the double step, the time of transfer of the foot, the duration of single and double support, the sequence of contact of the parts of the foot with the support. The comparison was carried out on different limbs according to the asymmetry coefficient of the subject’s gait, which was defined as the ratio of the larger period of support to the smaller one minus one and multiplied by 100%. Based on this indicator, gait asymmetry of up to 5% is normal; from 5 to 10% - hidden lameness; more than 10% - obvious lameness
Gait asymmetry up to 5° in the main group was 81.25%, and in the control group - 14.3%. Gait asymmetry of 5-10% in the main group was 18.75%, in the control group - 71.43%. Asymmetry of more than 10% was not detected in the main group, but in the control group it was 14.27%.
The data obtained indicate that the best gait indicators were in the main group.
As can be seen from the obtained functional indicators, patients in the control group showed a significant decrease in the strength of the plantar flexor muscles of the feet on the injured side and persistent gait asymmetry in the late postoperative period. This is evidence that even high-quality replacement (plasty) of the Achilles tendon defect with severe hypotrophy of the triceps muscle cannot fully compensate for the function of proper active flexion in the ankle joint, and was the basis for the development of a new method.
Complications after surgical treatment
Non-healing of wounds
Although usually a common complication for most surgeries, complications in wound healing are especially problematic in Achilles tendon repairs. Because in the area of the Achilles tendon there is little surrounding soft tissue, and this area of skin has a notoriously poor blood supply.
Therefore, any kind of wound healing problem can easily affect the tendon itself. For most patients, there is approximately a 2-5% risk of developing a wound healing problem. However, this risk increases significantly in smokers and patients with diabetes.
Infection
Deep infection after Achilles tendon repair can be a huge problem. Often an infection occurs if there is a wound healing problem that allows bacteria from the outside world to infect the repaired Achilles tendon.
Treatment may require not only antibiotics, but also the possible removal of all suture materials and, in some cases, removal of the tendon. Smokers and diabetics are at increased risk of serious wound infection after Achilles tendon repair surgery.
Nerve damage/neuritis
Numbness of the skin in the area of the postoperative scar is a fairly common complication. A more serious problem is damage to the nerve that controls muscle function or sensory control. This can happen when a nerve is involved in a suture or damaged by an instrument during surgery.
Damage to one of the nerves in the foot often results in neuritis (painful inflammation of the nerve). The initial injury to the nerve may be relatively minor, such as: a nerve that is stretched when soft tissue is retracted during surgery; or a nerve that becomes entangled in scar tissue that forms in response to post-operative bleeding.
This type of nerve irritation creates symptoms such as numbness and/or a burning sensation along the nerve. Localized nerve damage is often associated with a surgical incision, and pressing on the area of nerve damage can cause sharp pain or discomfort along the path of the nerve.
Rehabilitation after Achilles tendon rupture
Standard recovery
For the first 6-8 weeks, the leg is immobilized in a cast or brace to allow the tendons and surrounding tissue to heal properly. In addition, the tendon needs to be protected because the healing Achilles tendon may still be too weak to withstand the stress of normal walking.
After 6-8 weeks, the patient's foot is placed in a replacement boot, often with a slight heel lift, to take some of the pressure off the Achilles tendon.
From this point on, the patient can begin to walk, but at a slow pace. Physiotherapy and physical therapy aimed at developing movements and strengthening the tone of the lower leg muscles usually begins 6-8 weeks after surgery.
The heel lift is gradually removed over several weeks, returning the foot to a neutral position. In the case of standard recovery, the patient can wear regular shoes again 9-14 weeks after surgery.
More aggressive sports rehabilitation after Achilles tendon rupture is indicated for young patients and professional athletes, provided they are disciplined.
Below is an approximate step-by-step rehabilitation plan that will help you recover faster and more effectively after an Achilles tendon rupture.
Ideally, rehabilitation is most effectively carried out in specialized centers under the guidance of professional rehabilitation specialists.
Week 0-2
The shin is fixed at an angle of 20 degrees of plantar flexion (or a heel pad with a 2 cm rise is placed under the heel in the orthosis). Axial load on the leg is prohibited. Walking within the apartment with the help of crutches. In case of surgery, dressings are performed during this period. Prevention of thrombosis.
Week 2-4
The tibia is still in plantar flexion. The exercises begin, several times a day without a splint. The exercises involve gentle rocking movements (up and down) of the ankle joint, trying to keep the Achilles tendon in a neutral position (90 degrees).
In addition, inversion and eversion of the foot and lower leg are performed with slight plantar flexion. Axial load on the leg is prohibited. Walking with crutches. Prevention of thrombosis.
Week 4-6
It is allowed to increase the load on the leg. Walking with a measured load on the operated limb. Continue to do the exercises mentioned above and also wear the splint day and night. Prevention of thrombosis.
Week 6-8
Remove the instep under the heel and continue to wear the splint. The exercises progress: slowly stretching the tendon 90 degrees. Resistance exercises are added to strengthen the lower leg muscles. Prevention of thrombosis.
Week 8-12
Gradually wean off the splint and use crutches as needed. Range of motion, stability and proprioception are gradually optimized. Exercises on a balance pad are added.
It is important to understand that in order to return to your previous activity, you must wait for the Achilles tendon to fully heal.
Preventing Achilles Tendon Injury
Following these simple steps will help you significantly reduce the risk of Achilles tendon injury.
- warm up before starting your workout
- use sports warming ointments before training
- exercise in specialized shoes
- use custom orthopedic insoles
- Balance your level of physical activity with your age and fitness level
- After training, be sure to stretch
- use cold after stretching
- If you experience discomfort during or after physical activity, consult a doctor
First aid to the victim
Prompt provision of first aid will help avoid complications and shorten the recovery period after surgery. The victim must be laid down, calmed down, and shoes and outerwear removed. To relieve swelling, the injured leg should be elevated by 40-50 cm. You can use a pillow, cushion or folded clothing. What should be done to improve a person’s condition:
- apply something cold to the injured area. This could be an ice pack, frozen meat or mixed vegetables. It must first be wrapped in thick cloth to prevent frostbite. If the rupture occurs while hiking or on a picnic, a towel soaked in cold water is suitable for cooling. A cold compress is applied for 10-15 minutes, then a half-hour break is necessary;
- Give the victim any painkiller. The best option is a non-steroidal anti-inflammatory drug (Ibuprofen, Nise, Ketorol, Diclofenac, Celecoxib). If there are no NSAIDs in the home medicine cabinet, an injured person can take Paracetamol, Analgin, Spazgan, Spazmalgon.
Next, the victim must be taken to a traumatology department. When transporting yourself, you should always keep your leg elevated.
It is advisable to fix the leg.