Understanding Achilles Tendon Ruptures
By Christina Breda Antoniades
If you've ever been sidelined with an injury you probably already know that getting hurt can be as frustrating as it is painful. Tears, sprains and strains can keep you out of the game for weeks, months or even permanently.
For the athletically inclined, tearing, or rupturing, an Achilles tendon — that long cord that runs up the back of your lower leg — is a risk, but one that can be reduced with a few simple steps. To find out how ruptures happen, what doctors do to fix them and how you can steer clear of such injuries, we talked to Dr. Steven Haddad, an orthopaedic surgeon and assistant professor at Northwestern University.
Q: What's the most common way people rupture their Achilles tendon?
A: These injuries usually occur due to a sudden acceleration against a fixed, or contracted, Achilles tendon. For example, if someone is playing a sport like basketball or tennis — two common offenders — and they contract their tendon as they're getting ready for a jump shot (or to lunge for a shot in tennis), and then they push off, this sudden acceleration can rupture the Achilles tendon.
A number of studies suggest the tendon may have pre-existing degeneration, although I don't think that is necessarily true. I think any tendon can rupture under sudden force of this nature. When a rupture does occur, the ends of the tendon separate at least 3 cm. The gap fills in with blood, which becomes scar tissue.
Q: What do people feel when it happens?
A: If they're playing basketball, patients feel as if someone kicked them in the back of the leg. If they're playing tennis, they often say they feel like a ball struck them in the back of the leg. In both instances, I've had patients tell me that they turned around to confront the person who hit them, and found no one was there! The pain dissipates fairly rapidly, but they usually start to notice a limp and weakness.
Q: What should you do if you injure your Achilles tendon or think you've injured it?
A: Get off the court and go to an emergency department or your orthopaedic surgeon for a definitive diagnosis.
Q: How important is quick treatment?
A: Actually, you can wait up to three weeks to repair an Achilles tendon without compromising the result. Still, a diagnosis within a few days is encouraged. If a doctor is going to treat this conservatively, early treatment involves plantar flexing the ankle to bring the tendon ends together, or as close together as possible. That's not possible if scar tissue is already present. More important, about 25 percent of Achilles tendon ruptures are missed, and as such, go on to a poor outcome — weakness, pain and risk of re-rupture.
This isn't a diagnosis that can be made over the telephone. Even with an Achilles tendon rupture, a patient can sit in a chair and move his or her ankle up and down in a non-weight-bearing position. That's because there are five other tendons that cross behind the ankle joint. To make the diagnosis, a physician must place the patient on his or her belly, flex the knee so the foot is sitting up in the air, and squeeze the calf. If the foot doesn't move up and down as the calf is squeezed and released, the patient likely has an Achilles tendon rupture. This is called the Thompson test. It's simple, but effective.
Q: What are the treatment options?
A: Surgery is often done, unless medically contraindicated. Surgery involves bringing the ends of the tendon together by weaving a suture through the ruptured tissue. These ends are then tied, pulling the tendon together. Patients are often placed in physical therapy within three weeks of the procedure, to begin early range of motion and to limit the development of scar tissue around the tendon repair. They generally begin bearing weight in a boot about five weeks after surgery, and are in tennis shoes by three months postoperatively. Occasionally, the patient can wear a full-length cowboy boot eight weeks after the procedure. All told, however, it takes six months to a year to feel that normal strength has returned.
Q: What are some possible complications from surgery?
A: Complications of surgery include infection, nerve damage that can result in permanent numbness, incisional wound necrosis, deep venous thrombosis (blood clot), and re-rupture of the tendon.
Q: How do you avoid Achilles tendon injuries to begin with?
A: Avoid activities that require sudden acceleration, or at least be cognizant of such sudden forces on your Achilles tendon. Also, stretch out the Achilles tendon prior to participating in sport. Spend at least 15 minutes warming up before any athletic activity. A warm tendon is a more forgiving tendon, and has less risk of rupture. Also, if foot deformity is present, orthotics can help dissipate strain on the Achilles tendon. Consult your orthopaedic surgeon for more ideas.
Dr. Steven L. Haddad is an assistant professor of clinical orthopaedic surgery at Northwestern University in Chicago. He practices foot and ankle surgery with the Illinois Bone and Joint Institute Ltd. in Glenview, Ill.
