Anatomy of the Achilles Tendon
The Achilles tendon runs along the rear of the ankle, a resilient band of fibrous material that serves as the connector between the calf muscle and the heel. The two muscles of the gastroc-soleus muscle group make up the calf: the “gastrocnemius” on the outer side and the “soleus” that lies beneath. When you move your feet, the Achilles tendons in each leg contract to let you control the movement. When you point your feet down, for example, the Achilles tendons are pulled to cause this action (this is crucial to running, climbing, jumping, etc.)
Ruptures of the Achilles tendon are common amongst athletes, but they are actually seen the most in people between the ages of 30 and 50, primarily those who engage in intense activity on weekends. The exact cause of Achilles tendon ruptures is still not known, but they are thought to be a result of pre-existing swelling and deterioration (which may or may not have caused symptoms).
While pre-existing conditions may not have caused noticeable symptoms, an Achilles tendon rupture itself is impossible to miss. People who have it have described the feeling as being on par to getting kicked violently in their calf muscle, and they are often unable to point their feet or rise up on their toes after the injury. There may also be swelling. Sometimes there is even an audible “snap” when the tendon ruptures.
Middle-aged athletes or “weekend warriors” are at risk of rupturing the Achilles tendon when they put too much stress on it. Tendonitis (inflammation of the tendon) may occur before the rupture, weakening the tendon so it is more vulnerable.
While non-surgical treatments are usually desired in most muscoskeletal injuries, it is actually considered controversial when it comes to the Achilles tendon. Placing the leg and ankle in a cast will indeed help the injury heal on its own, but not taking surgical measures will greatly increase the risk of the rupture happening again, and the strength of the tendon is diminished. Especially when it comes to young, athletic people, most experts on these ruptures believe it is best to go ahead with surgical repair.
Surgery to repair an Achilles tendon rupture begins (typically) with a small incision on the ankle, over the Achilles. The ends on either side of the rupture are then stitched carefully together again (there are some other methods, but this is the most common). Over the years, there have also been new methods developed to ensure that the incision made is as small as possible.
Surgical complications arise from the location and design of the tendon itself. The tissue is thin here, and there is no great blood supply to assist with speedy healing and to ward off infection. In fact, surgery to repair Achilles tendon ruptures has gotten more precise over time, but historically the complexity of the procedure caused physicians to recommend it only as a last resort (though we now know that it is the preferred way to heal the injury). Fortunately, surgical advances and increased knowledge of the area have decreased the rate of complications.
While it is still not recommended in most cases, non-surgical treatment of an Achilles tendon rupture is still considered for some patients (like the elderly or those who are not very active in their everyday life). Typically, the injury is placed in a cast for about eight weeks, with the foot put in a downward position (this forces the torn ends to the Achilles tendon to come together). Because of the foot’s position, a large orthopedic lift is usually worn under the heel to help the patient walk with less of an imbalance. Complications may include muscular atrophy, stiffness and blood clots.
Once surgery is completed, the complications are similar to those seen in non-surgical treatment due to the ankle having to be in a splint (though infection is also a risk). Many orthopedic surgeons will start their patients on gentle physical therapy right after surgery to help prevent this complication. Splints can be removed to perform these PT exercises, though most patients need crutches for a while to get around. Strength and conditioning movements during this time help patients heal faster while maintaining their strength and flexibility in the ankle. Once a splint no longer has to be worn, patients will typically wear a shoe with high heel lift to keep their foot pointed downward for about eight additional weeks. It is at this point that more in-depth physical therapy can begin.
Every patient’s case will vary, but in general physicians may recommend therapy for four to five months following the injury. This will include massaging to strengthen and help further heal the tendon, along with plenty of ice and even whirlpool treatments to help decrease pain and inflammation.
As the patient’s strength improves and symptoms become minimized, more advanced forms of physical therapy can be taken on. Athletes, for example, will be able to start jumping, cutting and running drill exercises at about four months following surgery. However, they may not be able to return to their preferred sport until about six months.
The purpose of therapy following initial treatment is to maintain strength and range of motion, as well as keeping inflammation and pain to a minimum. Ultimately, it helps patients regain their normal movements and walking patterns.