Treatment and Physiotherapy Management of Torn Achilles Tendon

Published: 24th November 2008
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Treatment and Physiotherapy Management of Torn Achilles Tendon

by Jonathan Blood-Smyth

The biggest and strongest of the body's tendinous structures is the Achilles tendon in the lower part of the posterior calf. The main patients who suffer from Achilles tendon rupture are men in the 30 to 50 year group and they have often no history of similar events or difficulties with the leg. Tendon rupture occurs in a group of men who are not continually active and who perform sporadic or irregular sporting activities such as weekend football, people often referred to as "weekend warriors".

The tendons from the two major calf muscles, the gastrocnemius and the soleus, merge into the single Achilles tendon about fifteen centimetres above the top of the calcaneus. Tendons have high tensile strength, stiffness coupled with resilience and the ability to stretch four percent without damage, making them ideal to perform force transmission between muscle and bones. Rupture of fibres will occur if eight percent stretch is applied. Poor blood supply occurs about two to six centimetres up from the heel and most degenerative change and rupture occurs here.

Achilles tendon tears occur mostly in the left leg where the poor blood supply is, perhaps because most people are right handed and push off more with their left leg. Common injuries are on sudden foot push off, an unexpected forcing up of the ankle and an upward force on the ankle when pushed down. Direct trauma and general degeneration of the tendon without trauma can also occur. People at risk include those exerting themselves when they are unfit, relatively older people, steroid users and those who exert themselves in extreme ways.

Running can impose high levels of force through the Achilles tendon, around six to eight times our body weight. The commonest report is a sudden blow or snap in the posterior ankle area, a severe immediate pain and difficulty pushing off or standing on tiptoe. Examination can show a bruised and swollen calf, a gap in the Achilles tendon, an ability to walk but not to climb stairs or run. Precipitating factors for rupture are having a rupture before, exerting oneself unusually strongly when unfit and taking medication such as steroids over some time.

Conservative or surgical management is used, with a greater number of re-ruptures without operation. Old people, sedentary persons, those with poor skin healing and some medical conditions are more appropriate for conservative treatment. Infections, wound or repair breakdown and other complications are more common in diabetes, peripheral vascular disease and other conditions which impair healing. A short or long leg cast may be applied in plantar flexion, gradually moving the ankle up over a period of six to ten weeks. Once the foot is fairly flat, weight bearing can be allowed and the patient put into an adjustable orthotic.

The surgical options are percutaneous or open operation with the leg put into a plaster or a brace with the ankle flexed downwards, the patient routinely returning for the ankle to be re-immobilized in a more neutral position. The ankle is in the brace or cast for four to six weeks and shorter periods of tendon immobilization seem to be more effective than longer ones. Surgical management shows reduced rates of re-rupture, faster return to normal activity, improved calf strength and endurance when compared to conservative management.

Now the physiotherapist can start the rehabilitation program with range of motion exercises without bodyweight, teaching a normal gait pattern and giving a heel raise to limit forced dorsiflexion in walking. Swimming and static bicycling are good initial exercises, progressing gradually on to weight bearing exercises, strengthening and eventually dynamic exercises such as balance, running and jumping. Return to normal activity varies in time but could be from four months after the surgery.

Achilles tendon rupture usually turns out with good or excellent results with most athletes getting back to their chosen sports. Surgical management has a re-rupture rate of 0-5 percent and conservative treatment up to 40 percent, so patient education by the physio in training and stretching performance and the best choice of footwear is important for the long term.

Jonathan Blood Smyth is a Superintendent Physiotherapist at an NHS hospital in the South-West of the UK. He specialises in orthopaedic conditions and looking after joint replacements as well as managing chronic pain. Visit the website he edits if you are looking for physiotherapists in London.

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