Why does the Achilles tendon tear?
A healthy tendon can withstand enormous loads, but with age its blood supply deteriorates and the fibers are rebuilt. The area a few centimeters above the heel is especially vulnerable. A rupture usually occurs against the background of already existing degenerative changes, which the person did not suspect, during a sudden movement: starting, jumping, rising on the toe, an unexpected step back. Additional risks are posed by certain medications and repeated injections of hormones into the tendon area, as well as a sudden return to exercise after a long break.
- Degenerative tendon changes with age
- Sharp push-off, jump, start
- Returning to sports without preparation
- Taking fluoroquinolone antibiotics
- Glucocorticoid injections into the tendon area
- History of chronic tendinopathy and Achilles pain
Symptoms
The classic picture is a sudden sharp pain and a sensation of impact from behind above the heel, sometimes a click is heard. The man turns around, thinking he has been hit. Then the pain subsides, and it is possible to lean on the leg, but the gait changes: there is no push-off, walking on the entire foot. It is impossible to stand on your toes on one leg. A depression is felt above the heel, after a few hours swelling and extensive bruising appear. With a partial rupture, the symptoms are less pronounced and the diagnosis is more difficult to make.
- Clicking and hitting sensation on the back of the shin
- Inability to rise to the toe
- Prolapse along the tendon when palpated
- Swelling and bruising above the heel
- Lameness with lack of push-off
- Positive calf squeeze test
Diagnostics
The diagnosis in most cases is made during examination. The main technique is the calf compression test: the doctor squeezes the calf muscle of the patient lying on his stomach, and normally the foot bends down; with a complete rupture there is no movement. Ultrasound confirms the rupture, shows the distance between the ends of the tendon and allows you to assess their position with the foot bent, which is important for choosing tactics. MRI is prescribed for partial ruptures, old injuries and repeated ruptures. An X-ray is needed to rule out avulsion of a fragment of the heel bone.
- Calf Muscle Squeeze Test
- Checking the ability to stand on your toes
- Ultrasound of the Achilles tendon, including dynamic
- MRI for partial or old rupture
- X-ray of ankle and heel
- Comparison with the opposite leg
Treatment: surgery or conservative treatment
There are two possible approaches, and both give good results with proper rehabilitation. Conservative treatment is fixation of the foot in a toe-down position in a cast or a special orthosis, followed by gradual removal of the foot to a neutral position. It is suitable if the ends of the tendon are juxtaposed when the foot is flexed, and is more often chosen in older patients and with low athletic demands. Surgical suture of the tendon is preferred for large divergence of the ends, chronic or repeated rupture and in active athletes: it slightly reduces the risk of re-rupture. The decision is made together with the doctor, taking into account the duration of the injury, ultrasound data, age and lifestyle.
- Fixation with an orthosis or plaster in an equinus position
- Gradual change in foot angle over weeks
- Surgical suture of tendon
- Early functional load in an orthosis according to the protocol
- Prevention of thrombosis during prolonged immobilization
- Reconstruction for an old rupture
Rehabilitation and return to sport
Recovery occurs in stages and takes at least 4–6 months, regardless of the method chosen. First, the fused tendon is protected with an orthosis with heel pads, allowing measured support. Then gradually reduce the height of the heel pad, add stretching and strength exercises for the calf muscles, and work on balance. Calf raising on one leg usually becomes possible by the third or fourth month. Running is allowed after restoration of strength and full range of motion, and jumping and playing loads are allowed last. Rushing at any stage increases the risk of another rupture.
- Orthosis with heel pad and dosed support
- Gradually moving the foot to a neutral position
- Exercises for calf muscle strength, including eccentric exercises
- Balance and gait training
- One-leg calf raise as a control test
- Running and jumping - in later stages, with doctor's permission