Torn Achilles Tendon - Signs and Treatment

A rupture of the Achilles tendon often affects people who are active in sports. Surgery is often necessary. Most of the time, the tear is preceded by irritation or inflammation of the Achilles tendon. More about symptoms, diagnosis and therapies

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The upper end of the Achilles tendon merges into the three-part calf muscle. The lower end is attached to the heel bone

© Getty Images / Matej Kastelic, W & B / Dr. Ulrike Möhle

Achilles Tendon Injury - In Brief

A painful Achilles tendon is often due to irritation or inflammation of the tendon or the surrounding sliding tissue. Diseases such as gout, diabetes or osteoarthritis can promote this. Special antibiotics or cortisone can also damage the tendon.

The acute tendon irritation can be treated with rest, immobilization and anti-inflammatory medication. However, a previously damaged (stressed) tendon can tear. Depending on the position of the tendon ends in relation to each other, either surgery must be performed or immobilization with the help of an orthosis or plaster of Paris. The leg is then fitted with special orthotics for several weeks.

Overview: What Are Achilles Tendon Injuries?

The Achilles tendon (Tendo calcaneus) is the strongest tendon in the human body, it can withstand about 25 times the body weight. The tendon connects the heel bone - the so-called heel bone - with the calf muscles. It enables us, for example, to stand on tiptoe and push off while running and jumping.

The most common Achilles tendon injuries are irritation and inflammation of the surrounding sliding tissue, small wear defects in the tendon or complete tears in the tendon (medical: Achilles tendon rupture).

A crack is seldom caused by external force. Much more often, the cause is chronic, severe overload, for example during sport or hard physical work. A distinction is made between the partial and the more serious complete rupture of the Achilles tendon. Complete tear means that the tendon is completely severed.

After an Achilles tendon rupture, the affected upper ankle is only functional to a very limited extent. If at all, it is only possible to put the foot down and put weight on it with severe pain. It is no longer possible to stand on tiptoe.

A healthy tendon almost never breaks. Most of the time, the tendon tissue is already damaged: by persistent irritation or inflammation from microtraumas (small tears), which have reduced the resistance of the tendon tissue. This can become noticeable in the run-up to the tear in the form of recurring pain (achillodynia).

It extends from the calf muscle to the heel bone: the Achilles tendon

© W & B / Szczesny_istock / sensationaldesign

causes

The most common cause of an Achilles tendon rupture is not the force of external force, but a sudden, heavy load on a previously damaged tendon - for example, through movements that place particular stress on the ankle.

Such movements are most common in sports that require quick sprints, sudden stops, and changes of direction, such as

  • tennis
  • Soccer
  • Handball
  • Baketball
  • squash

However, cracks also occur in completely untrained people who suddenly overwhelm their tendons - for example, who want to run quickly across the street when they see "yellow".

Tendon damage increases the risk of a tear

Tears in completely healthy Achilles tendons are extremely rare. If the tendon is without any previous damage, a part of the heel bone at the tendon insertion is more likely to break out than the tendon itself to tear. But hardly any Achilles tendon is without previous damage. Often these are overloaded by persistent irritation and inflammation and poor circulation.

Some diseases can promote such irritation in the Achilles tendon, for example

  • arthrosis
  • gout
  • Diabetes mellitus

A special group of antibiotics, the fluoroquinolones, has been shown to damage the tendons and thus promote a tear.

Other risk factors

There are also other factors that increase the risk of an Achilles tendon rupture:

  • Malpositions of the feet
  • unsuitable shoes (especially with raised, pressing heel caps)
  • shortened calf muscles
  • insufficient warm-up before exercise
  • repeated overload in sports
  • generally older age

A previous partial tear increases the likelihood of a further rupture. Even completely untrained people run a high risk if they suddenly engage in a sport in which they have to repel themselves abruptly (for example high or long jump).

A tear in the Achilles tendon can feel like a blow to the heel.

© W & B / Bernhard Huber

Symptoms

Symptoms of tendon irritation

Chronic irritation or inflammation of the Achilles tendon causes repeated pain when the calf muscles are tensed or stretched, or when the ankle is stressed for a long time.

Typically, getting out of bed in the morning and taking the first steps barefoot is also very uncomfortable. The reason is that at night the feet are mostly held in an equinus foot position - that is, toes are stretched "downwards", heels are pulled up. When it first occurs in the morning, the Achilles tendon becomes particularly tense due to the shortened calf muscles. This morning pain after getting up when "warming up" is characteristic of an Achilles tendon irritation.

The irritated Achilles tendon can often be palpated in a fusiform thickened form about five centimeters above the heel bone. When pressure is applied to the corresponding thickened area of ​​the surrounding sliding tissue, the symptoms increase. In the case of a highly acute inflammation, a harsh friction noise may be heard when moving the foot.

If pain in the Achilles tendon recurs, a doctor, usually an orthopedic surgeon or trauma surgeon, should be consulted. If a crack is suspected, medical advice is required immediately.

Symptoms of the Achilles tendon tear

The Achilles tendon tear is often accompanied by a clearly audible, whip-like sound. It almost always occurs during a so-called rapid strength load (sprint or jump). The injured person often feels a painful stab or blow in the calf or heel when the tendon ruptures. When playing football, the injured often believes that an opponent has kicked him in the heel.

As a result of the tear, the tip of the foot can no longer be lowered (bent "down"). Standing up or walking are occasionally still possible, but cause severe pain. Standing on the ball of the toes is no longer successful, the foot can no longer be rolled off.

diagnosis

Anamnese:

The doctor inquires about current and previous complaints in the Achilles tendon area. For example, he would like to know which actions triggered the current pain, he asks about accompanying illnesses, about sports, work and exercise habits.

Physical examination:

Then the doctor checks how the patient walks, whether he can walk on tiptoe and stand on one leg. The affected ankle is assessed for function and sensitivity to pain. The doctor will also palpate the area around the tendon. If there is a crack, a dent can be seen a few centimeters above the heel.

The "calf pinch test" according to Thompson: If the doctor presses the calf muscles together, the foot normally moves reflexively into an equinus foot position - that is, the tip of the foot "down". If this no longer clearly works, the "calf pinch test" is positive, i.e. noticeable. Then in all likelihood there is a ruptured Achilles tendon.

Further investigations:

An ultrasound examination (sonography) is carried out to confirm the diagnosis. The structures of the Achilles tendon can be seen. In the case of a tear, the ends of the tendon and the gap between them are easy to visualize.

A rarely necessary additional examination is magnetic resonance imaging (MRI) to confirm the diagnosis. However, this can be used to clarify, for example, whether small parts of the tissue inside the tendon have died that were the cause of the tear. In the case of direct injury, for example from a shock, an X-ray examination of the adjacent bones may also be necessary.

Physiotherapy is an important part of therapy for Achilles marriage injuries

© iStock / People Images

What helps with irritation of the Achilles tendon?

If the Achilles tendon is irritated, the doctor usually recommends protecting the ankle joint in a slight equinus foot position - that is, the toe is stretched "down" and the heel is raised. Relieving and supportive bandages and raised shoe heels help, for example - here it is important that the heels are worn on both sides, even if only one side is affected. This advice should also be heeded. Because irritation tends to become chronic and increases the risk of cracking. The equinus foot position relieves tension from the strained tendons and calf muscles. Until the pain subsides, sufferers should refrain from sports that put a lot of strain on the Achilles tendon and calf muscles.

In support of this, the painful area can be cooled for the first few days or rubbed with ointments that promote blood circulation. Pain relievers like diclofenac or ibuprofen can provide significant relief. However, attention must be paid to possible side effects in the gastrointestinal and cardiovascular area.

The doctor can inject a mixture of anti-inflammatory cortisone and a topical anesthetic into the area around the inflamed area and usually help quickly and effectively. Other substances such as hyaluronic acid are also used here. However, this infiltration must be carried out professionally. If the mixture is injected directly into the tendon and not into the surrounding tissue, the risk of a tear increases enormously. Too frequent doses or injections into the tendon can also increase the risk of a tear.

Torn tendon: what to do?

First aid if an Achilles tendon is suspected

If an Achilles tendon rupture is suspected, medical help should be sought as soon as possible, ideally in orthopedics or trauma surgery. As a first aid measure, the leg is relieved and elevated. The painful area can be gently cooled. Caution: Do not put ice directly on the skin, otherwise there is a risk of frostbite!

In principle, there are two treatment methods, conservative and surgical care.

Conservative therapy

In the so-called conservative therapy of the Achilles tendon tear, an operation is dispensed with. If the tendon ends lie against each other during the ultrasound control with the foot extended, conservative therapy can definitely be used. Pre-existing conditions that would make surgical intervention very risky as well as old age can influence the decision for conservative care.

First, an orthosis or a lower leg cast in equinus foot position is worn for two weeks, followed by boot or shoe orthoses for six weeks. During this time, the equinus foot position is gradually reduced according to the doctor's instructions. Thrombosis prophylaxis should be used when the leg can only be partially loaded. Physiotherapy and physical applications are then also used.

Conservative therapy is usually a little longer than surgical treatment, because the tendon needs time and rest to be able to heal. It is not uncommon for the tendon to lengthen. The smallest movements, which cannot be avoided even in a calm form, and the scar itself lead to this. Then there is no tension.

In such a case, there is not much that can be done conservatively. Those affected remain limited in the long run. Once the tendon is too long, the force from the calf muscles can no longer be transmitted. Fast running or even jumping are a thing of the past. Normal walking can also cause problems, leading to limping or limping. A shortening of the tendon can then only be achieved through an operation.

Operation of a ruptured Achilles tendon

If, in the case of a tear, the two ends of the sight are far apart, surgery is the procedure of choice (Achilles tendon reconstruction). The tendon and the function of the ankle can only be fully restored with the fastest possible restoration. Without timely therapy, the calf muscles may regress (atrophy). In the Achilles tendon reconstruction, the tendon ends are sewn back together. If the tendon quality is poor, special suturing techniques are used. The body's own tendon material can also be incorporated. The most common method is now the minimally invasive surgical method (picture gallery below): Using several small incisions, the tendon is sutured under the skin with special instruments. The advantage here: there are fewer wound healing disorders.

Achilles tendon surgery with small incisions

© W & B / Dr. Ulrike Möhle

TO THE PICTURE GALLERY

© W & B / Dr. Ulrike Möhle

In minimally invasive procedures, surgeons repair the Achilles tendon by making small incisions in the skin with surgical instruments.

The surgeon makes an incision above the tear and pushes two spoon-like instruments under the skin.

Then the suture is threaded through the skin, the lower stump of the tendon, and the surgical instruments.

© W & B / Dr. Ulrike Möhle

Now the surgeon pulls the sutures up through the skin incision using the spoon instruments.

© W & B / Dr. Ulrike Möhle

The surgeon sutures the tendon under the skin in a kind of frame. The stumps are brought together again and can grow together.

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After the operation

After the operation, an orthosis or a lower leg walking cast in an equinus foot position is provided for four to six weeks. According to one scheme, this equinus foot position is gradually reduced until the foot is back in its normal position. While the foot can only be partially loaded, thrombosis prophylaxis should be used.

Physiotherapy then helps to get the shortened calf muscle and the stiffened joints of the leg going again. It is important to follow the surgeon's instructions. You can best estimate how much strain the freshly sutured tendon can take. Lymph drainage against swelling and physiotherapy are also on the program until the foot can be fully loaded. This is followed by training to learn how to walk properly again. All of this takes time. Whether patients can play soccer or squash again after a torn Achilles tendon depends very much on how the rehabilitation phase takes place and how conscientiously and intensively they train muscles and stability. Because the training does not end when the injured foot is more or less resilient in everyday life.

Those affected should expect at least around ten weeks of physiotherapy. If the tendon heals well, you can exercise moderately after three to four months. Finally, after a year, patients should be able to stand on tiptoe again with the operated leg and bob up and down. This is the final test. If he succeeds, they can go back to the field. And that without hesitation. After a healed Achilles tendon rupture, all loads can be exerted as before.Further rest for fear of a renewed crack does not make sense.

Important in physiotherapy

Limited time window: You have about a year after the operation to regain your previous level of training. What you haven't achieved by then can hardly be achieved later.

So go to physical therapy consistently after the operation. You can also get advice there on what sensible regular training looks like, even if you can already walk normally again.

Risks of the operation

Problems can also arise, however: the tendon is located directly under the skin, only covered by a small amount of soft tissue, and has poor blood circulation. It is easy then that the wound does not heal well. This can result in major interventions in which you have to transplant skin from other parts of the body.

With the minimally invasive method, also known as the percutaneous technique, there is another risk that is not so rare. The sural nerve, which runs right next to the tendon, is injured in around 5 out of 100 cases. The consequences: nerve pain in the affected area or a feeling of numbness if the nerve has been destroyed.

If the tendon tear is already a few weeks old or the ends of the stump have slipped apart, open surgery can hardly be avoided. This is the best way to see the tendon. After all, a tendon is quite a fibrous matter.

Which therapy method is more suitable in each individual case and which complications and disadvantages the respective treatment method can bring with it should be discussed individually in a specialist practice or specialized center. Factors such as old age, concomitant diseases and the individual sporting requirements of those affected are also taken into account when choosing therapy.

Tips for the optimal surgical treatment

If your Achilles tendon has torn, seek treatment at a foot and ankle surgery center, where such surgeries are done frequently.

The clinic or center where you are cared for should offer a follow-up treatment plan. This is important. Successful surgery is only the first step. Whether the tendon is as resilient afterwards as before, on the other hand, depends very much on how the rehabilitation phase is designed.

If you need a walking aid after the operation, you can use a foot relief rollator. The electrically operated trolley is particularly helpful for patients who also have problems with wrists or shoulders, because they put less strain on the affected areas than with crutches.

Achilles tendon rupture: how can you reduce the risk?

The normal wear and tear of the Achilles tendon cannot be prevented. Nevertheless, there are ways to reduce the general risk of injury:

  • do not overload, ensure recovery phases after sport or exertion
  • Regular, moderate exercise is cheaper than rare peak performance
  • Always warm up the muscles well before training
  • only gradually increase the load when exercising
  • Pay attention to good, individually fitting shoes

Dr. med. Martin Talke

© W & B / private

Consulting expert

Dr. med. Martin Talke is a specialist in orthopedics and trauma surgery, rheumatology with additional qualifications in sports medicine and physical therapy. From 1980 to 2012 he worked in his own orthopedic practice in Berlin. Since 2013 he has been working in a medical care center in Berlin.

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German Society for Trauma Surgery: Achilles tendon rupture (= Achilles tendon tear). Online: http://www.dgu-online.de/index.php?id=280 (accessed on February 19, 2018)

Important NOTE:
This article contains general information only and should not be used for self-diagnosis or self-treatment. He can not substitute a visit at the doctor. Unfortunately, our experts cannot answer individual questions.

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