Achilles Tendon Rupture Management and Physiotherapy

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 two large calf muscles, the gastrocnemius and the soleus, each have a tendon and these converge and form the Achilles tendon about 15 centimetres above the calcaneum. Tendons transmit forces from muscles to bones and to do this they have high resilience and sufficient stiffness, good tensile strength and allow 4 percent stretch before damage. Damage and rupture to the fibres can occur when the stretch reaches 8 percent. Most of the tendon rupture and degeneration occurs where the blood supply is poorest, about 2-6 centimetres up from the heel bone.
The left Achilles tendon is ruptured more commonly than the right, in the region of the tendon with an impaired blood supply, as right-handed people push off strongly with their left leg to accelerate. Typical rupture scenarios are on sudden foot extension, forceful pushing up of the ankle and resisted downward movement of the foot. The tendon can suffer severe degeneration and this plus direct trauma can also cause rupture. Achilles tendon rupture occurs more often in patients on corticosteroids, somewhat older people, in sudden exertions by unfit individuals and in those who pursue extreme activities.
The force through the Achilles tendon in running can be 6-8 times bodyweight so the forces are very high. Typical presentation is a sudden snap in the back of the lower calf with a sudden, severe pain, a loss of calf power, the calf may be swollen, the patient may have recently increased their activity, there may be a history of steroid use and a previous tendon rupture. There may be an obvious gap in the tendon on examination and the patient will be unable to stand on tiptoes and even though they can usually walk they are unable to run or climb stairs.
Doctors choose conservative or surgical management, operation having a higher risk of complications and conservative treatment a higher risk of re-rupture. Non-operative treatment is suitable for sedentary people, diabetics, older people and those with medical problems or poor skin integrity. Impaired blood supply, diabetes and other illnesses make wound breakdown, tendon separation and infections more likely. A calf or thigh length plaster may be used with the ankle flexed down, moving it up regularly over six to ten weeks. The patient is allowed to weight bear and given an orthotic as the tendon heals.
Open or percutaneous surgery can be used and after the operation the leg is plastered with the ankle in plantar flexion or put into a brace. The ankle angle is adjusted upwards regularly week by week as healing goes forward until after 4 to 6 weeks the brace can be removed. Surgical repair is more successful due to lower rates of repeated rupture, quicker return to activity, greater strength and better endurance when compared to non-operative treatment. Research indicates that immobilizing the tendon for shorter periods is more successful.
The physio will begin the rehabilitation with exercises to increase the ankle movements and gently stress the tendon, instruction in good gait and use of a heel raise to reduce stretching forces on the tendon. Static bicycling and swimming are useful non weight-bearing exercises, steadily progressing to exercises in weight bearing, muscle strength work and then to advanced work such as running, jumping and balance training. Four months after surgery a patient may be able to start back to normal activity.
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.

Article Source: www.harperandassociatesinsurance.com

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 Oxford.

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