Achilles tendon (also called calcaneal tendon) is a strong band of fibrous tissue that connects the calf muscles to the heel bone. The calf muscles (gastrocnemius and soleus) unite to form one rope-like structure called as Achilles tendon at the lower end of the calf that is attached to the calcaneum (heel bone). Together, the calf muscles acting through the Achilles tendon help you point the foot down, lift your heel off the ground and go up on your toes. The functioning of the Achilles tendon is needed for the activities like walking, running or jumping. When the tendon is stretched too much, it can tear or rupture.
Ruptures of Achilles tendon is commonly caused by the sudden increase of stress on the Achilles tendon. Some of these situations include:
• Uphill running
• Playing sports where there are quick start and stop
• Quickly changing speed from walking to running
• Falling from height
• Stepping into a hole
The area that is most susceptible to rupture is located within 6 cm (2.5 inches) of the point where the tendon is attached to the heel bone, as this area gets lesser blood flow.
Following are few noted factors that increase the risk of Achilles tendon rupture:
- Age and Gender. The peak incidence of Achilles tendon rupture has been noted in the age group of 30-40 years. Men are more likely to experience rupture (2-12 times higher rates than women).
- Type of sports. Sports that have running, jumping and sudden starting, stopping are more likely to cause Achilles injuries. These include games such as football (soccer), tennis, basketball, etc.
- Physical activity-related factors. Inadequate warm up, stretching and cool down; Wearing the wrong footwear; running on the hard or uneven surface; Sudden increase in the intensity, frequency and duration of activity.
- Medications. Steroid injections given to reduce joint pain and inflammation and certain antibiotics (levofloxacin, ciprofloxacin) are known to cause weakening of the tendons and increase the risk of Achilles tendon ruptures.
- A popping or snapping sound may be heard when the tendon tears
- Pain, which can be very severe and make it difficult or impossible to walk
- Inability to stand up on the toes of the affected leg
- Failure to bend the foot downward or push-off the leg when walking
- Swelling and change in the colour of the skin behind the heels
- A gap may be seen in the back of the ankle where the tendons are separated
Your doctor will inquire about the type of physical activity that caused the injury. Your foot, ankle and leg will be examined. You doctor will look for swelling and tenderness at the back of your ankle and the gap in the tendon where it might have been ruptured. You may be asked to move your feet, and the doctor may squeeze the calf to see if the foot bends downwards (Thompson test).
To determine the degree and the extent of the tear, an imaging study called MRI (magnetic resonance imaging) may be done.
There are surgical and non-surgical treatments for ruptured Achilles tendon. Your doctor will discuss the treatment that is best suited for you based on the degree of tear, your age, and the level of your activity.
If there is a severe degree or complete tear of the Achilles tendon, or if you are a young to middle-aged person, who is very active or engaged in sports, surgery may be done. The procedure involves making a small cut at the back of the leg and the two ends of the ruptured tendon are sewn together using sutures. Based on the degree of tear, the surgeon may use other tendons to reinforce the repaired tendon.
After the surgery, your leg will be immobilised using a cast, walking boot, brace or splint for 6-8 weeks. This immobilisation is followed by physiotherapy and rehabilitation to regain the full range of motion and strength over 4 to 6 months. Returning to sports may take a longer time.
Non-surgical treatment may be used for those with partial rupture, those who are relatively sedentary or not fit for surgery. The foot is kept immobilised in a cast or boot for a particular period (8-12 weeks or more) to allow the tendon to heal and join. This immobilisation is followed by physiotherapy and strengthening exercises.
After treatment for Achilles tendon repair, you are at increased risk for reinjury to Achilles tendon. Some of the precautions that you can take to prevent injury/re-injury to Achilles tendon include:
- Staying fit with regular exercises
- Wearing proper shoes appropriate for the activity
- Warming up and stretching before exercising or playing sports and cooling down after
- Strengthening the calf muscles slowly
- Using correct techniques to prevent unwanted stress or stretching of the Achilles tendon.
- Strapping or taping the ankle to make it more secure
- Warming up, stretching and cooling down
- Training properly to ensure readiness to play
- Gradually increasing intensity and duration of training
- Taking adequate rest between workouts or training sessions
The possible complications of Achilles tendon rupture include:
Non-healing or delayed healing– The Achilles tendon tear may take a long time to heal or not heal, and require further surgery.
Shortening of the tendon– During the healing process, scar formation may cause the tendon to become shorter than usual.
Deep vein thrombosis- There is a small risk of a clot forming in the blood vessels of the leg after an Achilles tendon rupture.
Complications of Surgery – Wound infection, delayed wound healing, scarring and shortening of the tendon, nerve injury that causes numbness or burning on the outer part of the foot are some of the other complications that can occur.
Re-rupture- There is a chance of the tendon tearing again. Some studies have indicated that the tendon re-rupture risk is about 4 in 100 with surgical treatment and about 12 in 100 with conservative treatment.
If you think you have injured or ruptured your Achilles tendon, you should see a doctor (orthopaedician) right away.
If there is worsening of pain or swelling in your ankle or foot, or there is purple discolouration in your foot or leg, consult your doctor immediately.
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