What is the Achilles tendon?
The Achilles tendon is the biggest tendon in the human body. It attaches above the knee to the femur and inserts into the tuberosity of the calcaneum (heel bone) in the foot. A tendon is the strong fibrous tissue attaching muscle to bone. The Achilles tendon allows the gastrocnemius and soleus muscles (calf muscles) to function and plantarflex the foot to allow you to stand on your toes.
What causes the Achilles tendon to rupture?
The Achilles tendon often ruptures after a sudden push-off during activity. It is commonly related to a tendon that has been chronically damaged and is a bimodal distribution of injuries with an initial peak incidence between the ages of 25–40 yrs and a further increase in incidence in those over the age of 60 yrs.
What are the symptoms?
Patients often describe hearing an audible popping noise and feel as if someone has just hit them in the calf from behind. This is associated with localised swelling and bruising. Patients will struggle to walk and will be unable to stand on their toes. It is important to seek medical treatment promptly as a delay to presentation can mean that you are not eligible for non-operative management of the Achilles tendon rupture.
How is it diagnosed?
It is diagnosed based on the history of the symptoms described above and an examination that identifies a defect in the Achilles tendon. The doctor will get you to lie on your front or kneel on the bed and will then squeeze the calf muscle. If there is no movement of the foot it indicates that the muscle is no longer carrying out its function and therefore the tendon has ruptured. If there is any question over whether the tendon is ruptured your doctor will organise an ultrasound scan to assess the tendon.
Calf squeeze test for Achilles tendon rupture
What is non-surgical management?
The management of the rupture initially involves positioning the foot in a position where the foot and toes are pointing down (equinus position) (picture of this position). This allows the Achilles tendon to shorten down and therefore brings the ruptured ends of the tendon into contact. The foot must be immobilised in this position as soon as possible after the injury. The benefits of treating it without an operation are that you avoid an anaesthetic and the risks of surgery. The main risks of surgery are wound infection and wound breakdown as well as damage to the sural nerve that can lead to areas of foot numbness and occasionally chronic pain. The risks of non-operative treatment are that the tendon can lengthen slightly leading to reduced push-off strength. There is also a slightly increased risk of re-rupture after non-operative management.
The rehabilitation is largely the same whether it is treated surgically or non surgically. The first 2 weeks are spent in plaster with the foot maximally plantar flexed. You will then go into a boot with a 3cm heel wedge and then gradually build up to weight-bearing and range of movement for the next 6weeks, aiming to remove the boot between 8–12 weeks after the initial injury.
When is surgery considered?
Surgery is considered in patients who are extremely active and trying to get back to high-level sporting activity. The surgery has been shown to increase push-off strength which is not noticeable in everyday activities but might increase acceleration required in particular sports. Patients may also choose to have surgery due to the slightly reduced risks of re-rupture. Occasionally surgery is required when patients present late (after 72 hrs) and therefore the initial scar tissue would have stretched out too much to manage without an operation.
Achilles tendon rupture rehabilitation
Initially, you will be placed in plaster with your foot plantar flexed (toes pointing down like a ballet dancer en pointe) (add picture).
Time frame
Activity
0–2 weeks
- Posterior slab/splint in equinus
- Non-weight-bearing with crutches (immediate post-op in surgical group, after injury in non-op group)
- Complete straight leg raise exercises and elevate limb when sitting
- Intrinsic toe exercises
2–4 weeks
- *† Walking boot with 3cm heel lift
- Protect weight bearing with crutches
- Active platarflexion and dorsiflexion to neutral
- Inversion/eversion below neutral
- Intrinsic foot exercises
- Modalities to control swelling
- Incision mobilisation modalities
- Knee/hip exercises with no ankle involvement
- Non weight-bearing fitness/cardiovascular exercise e.g static bicycling with one leg, deep water running
4–6 weeks
- *† Weightbearing as tolerated in a walking boot
- Continue 2–4 week protocol
- Removing heel raises at weekly intervals guided by your physio
6–8 weeks
- Weightbearing as tolerated in walking boot
- Dorsiflexion stretching, slowly
- Graduated resistance exercises ( open and closed kinetic chain as well as functional activities)
- Proprioceptive and gait retraining
- Incision mobilisation
- Fitness/cardiovascular exercises to include weight bearing as tolerated e.g bicycling, walking, elliptical machine
8–12 weeks
- Wean out of the boot
- Return to crutches or cane as necessary and gradually wean off
- Continue to progress a range of motion, strength, proprioception
> 12 weeks
- Continue to progress range of motion, strength, proprioception
- Retrain strength, power and endurance
- Increase dynamic weight-bearing exercise, include plyometric training and sport specific retraining
* Patients were required to wear the boot while sleeping.
† Patients could remove the boot for bathing, dressing and physio but are required to adhere to the weight-bearing restrictions according to the rehabilitation protocol.
When can I return to work?
This is always dependent on the type of work you do and the recovery period can be extremely varied for individuals.
2 weeks
- Desk work
8–10 weeks
- Standing work
12 weeks or more
- Heavy lifting work
When can I drive?
Some postoperative pain medicines can affect your concentration, mood, coordination and reactions thereby reducing your ability to drive safely. You mustn’t return to driving whilst still taking any of these medications. Please check this link for further information https://www.vicroads.vic.gov.au/safety-and-road-rules/driver-safety/drugs-and-alcohol/medicines-and-road-safety
You can not return to driving when any foot involved in driving the car is restricted by an orthotic (post-op shoe, walking boot or plaster cast).
Car type
Operated foot
Automatic
Right—8–10 weeks. When you are fully weight-bearing in normal shoes
Left—Restrictions related to post anaesthetic and pain medications
Manual
Right/Left—8–10 weeks. When you are fully weight-bearing in normal shoes
When can I run?
This is extremely variable and you should be guided by your physiotherapist. You would have to have 90% calf strength and proprioception in order to return to light jogging. Often when you can carry out 20 or more single leg calf raises or can hop on the spot then you are in a position to return to running. It would also be a staged return, starting with a light jog for a minute or two then gradually building up distance and speed over time.
When can I return to sport?
This depends on the sport but it may take 6–9 months to get back to some activities and again this would be guided by your physiotherapist and your ability to build up your level of running and match fitness.