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Treatment and Physiotherapy Management of Torn Achilles Tendon

The largest and strongest tendon in the body is the Achilles tendon in the distal posterior calf. Typical patients with Achilles tendon rupture are men in good health of 30-50 years and who have not suffered serious injuries or any kind of difficulty with the leg before. Rovo typically occurs in people who have not been recently active and who may indulge in infrequent physical activity such as playing a weekend sport, players known as “weekend warriors”.

The two large calf muscles, the gastrocnemius and the soleus, each have a tendon and these converge to form the Achilles tendon approximately 15 centimeters above the calcaneus. Tendons transmit forces from muscles to bones and to do this they have high durability and sufficient stiffness, good tensile strength and allow 4 percent stretching before damage. Damage and breakage to the fibers can occur when the stretch reaches 8 percent. Most of the tendon rupture and degeneration occurs where the blood supply is worst, about 2-6 centimeters above the heel.

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 a sudden foot push off, an unexpected upward forcing 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 who exert themselves when they are unfit, relatively older people, steroid users and those who exert themselves in extreme ways.

Achilles tendon forces in running can be very high and have been measured at six to eight times body weight. The patient typically reports a sudden snap or thump to the back of the lower calf, sudden severe pain, ability to walk but not run or climb stairs. On examination there may be a swollen or bruised calf, a palpable tear in the tendon and an inability to stand on tiptoes. A history of steroid treatment, a previous tendon rupture, or an unusually high activity level (eg weekend warrior) may also be important findings.

Conservative or surgical management is used, with a greater number of re-ruptures without surgery. The elderly, sedentary people, those with poor skin healing and certain medical conditions are more suitable for conservative treatment. Infections, injury or repair breakdown, and other complications are more common in diabetes, peripheral vascular disease, and other conditions that impede healing. A short or long leg cast can be applied in plantar flexion, gradually moving the ankle up over a period of six to ten weeks. Once the foot is flat enough, weight bearing can be allowed and the patient placed in an adjustable orthosis.

Surgery can be open or percutaneous and after surgery the ankle is kept plantarflexed in a plaster of Paris or rigid orthosis, where the patient returns so that the ankle is repositioned upwards as the tendon heals, until the ankle is freed from the splint. four to six weeks after the repair. Shorter periods of immobilization seem to be more successful than longer ones. In general, surgical repair can have lower re-rupture rates, faster return to normality, and better strength and endurance compared to conservative treatment.

Now the physiotherapist can start the rehabilitation program with a range of movement exercises without body weight, teaching a normal gait pattern and giving a heel lift to limit forced dorsiflexion in walking. Swimming and static cycling are good initial exercises, progressing gradually 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.

The outcome of an Achilles tendon rupture is usually good to excellent, with most athletes able to return to normal activities. However, the re-rupture rate is 0-5% in surgically repaired tendons and almost 40% for those having conservative management. Patient education is important to continue with proper training, stretching to reduce the possibility of re-rupture and the selection of appropriate footwear.

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