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This is when the Achilles tendon at the back of your heel tears. The injury can be complete or partial.
An Achilles tendon tear can be acute or chronic depending on when the diagnosis is made. An injury presenting after 4 weeks would be considered chronic.
Please see foot & ankle anatomy for more information about the Achilles tendon.
It typically occurs when the Achilles tendon is suddenly and forcibly stretched while weight bearing.
It more commonly occurs in males aged 30 to 40 who are participating in sports. However it can affect anyone of any age and from seemingly innocuous events such as stepping off a kerb.
Risk factors for Achilles tendon rupture include:
Symptoms vary considerably. Some patients describe feeling as if they had been “kicked from behind” while others feel they had “sprained” their ankle. Often their is a loud audible “bang” or “pop” at the time of injury.
Most patients will describe considerable swelling and bruising shortly after their injury. Some people struggle to walk while others may have only a mild limp. Due to the varied presentation and symptoms, not surprisingly up to a quarter of Achilles tendon ruptures are missed.
Clinicians looking for a fracture (broken bone) on an x-ray will be falsely reassured when they see a normal x-ray. Tendons do not show up on an x-ray and Achilles tendon ruptures are not diagnosed in this way.
The diagnosis of acute Achilles tendon rupture is a clinical one based on history and examination findings.
On examination the following is noted:
Clinical picture of an acute achilles tendon rupture
Clinical picture of a patient with chronic right Achilles tendon rupture, note the thickened Achilles tendon and loss of normal resting tone and position of the foot (blue arrow)
Ultrasound is a quick, painless and non invasive method of visualising the Achilles tendon. It offers excellent real time high definition images of the Achilles tendon. The radiologist will be making note of the following during the examination:
MRI provides excellent high definition static images. It is useful in pre operative planning particularly with Chronic Achilles tendon ruptures, and to exclude any other pathology in the hindfoot. It is also useful in monitoring healing.
If one has sustained a partial tear of the Achilles tendon, left alone and untreated it can lead to a full rupture.
Patients with a complete Achilles tendon rupture left untreated will find that their gait pattern (the way you walk) will be affected, with difficulty in push-off (plantarflexion power) and subsequent limp. This will have a knock-on effect with some patients then complaining of knee, hip and back pain. There may also be reduced ankle stability.
Achilles tendon chronic rupture MRI
The aim of surgery or non operative treatment is allow the two ends of the tendon to come together. This can be achieved non operatively by placing the foot in an equinus position. This is where the toes are pointing down maximally. This brings the two ends of the tendon together and is a very effective way of treating this condition as long as it has been picked up acutely.
An ultrasound scan can help in confirming that the two ends of the tendon have indeed come together. Where there is a persistent gap or the injury has been missed and is chronic, surgery is advised to help bring the two ends of the tendon together and decrease the complications.
Patients treated non-operatively will typically have a plaster applied for two weeks in full equinus and be non weight bearing. At the two week stage they can then go into a boot with four wedges and start full weight bearing. At weekly intervals thereafter one wedge is removed at a time. This will gradually bring the foot into a plantigrade position at the six week post injury mark.
At two weeks, patients will be able to start active plantarflexion exercises with restricted dorsiflexion for a further 3 to 4 weeks. Physiotherapy typically recommences at weeks 3-4 post injury, and will continue for up to six months. It can take up to nine months for Achilles tendon ruptures to heal. It is important to follow the physiotherapy rehab regime and not to return to sports too soon as there is a re-rupture risk typically four months post-injury.
To summarise non operative management maybe suitable in the following cases:
Surgery involves bringing together the two ends of the torn Achilles tendon. The advantage of surgery is that potentially there is a:
Surgery may also be advised in the presence of a large gap, proven on ultrasound.
The actual operation would be undertaken under general anaesthetic and in almost all cases would be done as a day case procedure.
In the first instance the surgical repair would be undertaken using a minimally invasive surgical (MIS) technique.
MIS Achilles tendon repair A – A small incision is made at the site of the Achilles tendon rupture B – The tendon ends are brought together and repaired C – The wound is closed with minimal soft tissue damage images courtesy of Arthrex
Most surgeons would agree that patients with symptomatic chronic Achilles tendon ruptures require surgery.
The exact details of the operation depend on the individual case:
For small defects, and under 3 months presentation an end to end repair with FHL tendon transfer may be possible.
For large and chronic defects an FHL tendon transfer with or without interposition graft, V-Y tendon alignment and turn down flap may be necessary.
It should be borne in mind that complications can result from a condition with or without surgery.
Complications can occur as with any type of surgery. Please see Complications for more detailed explanation of post surgical complications.
Please read the information regarding what to expect post surgery on this website.
Remember that below is a guide to recovery and that everyone heals at different rates and some people do take longer. Use this information to help you understand your condition, possible treatment and recovery. The timeframes given below are a minimum, it is important that you appreciate this when considering surgery as your healing and recovery may take longer.
Almost all surgical procedures for Achilles tendon rupture will be undertaken as a day case.
You will have a backslab applied post operatively for two weeks.
A picture of a backslab plaster
Please do not remove your backslab until you are seen by your surgeon Mr Malik at the two week post operative clinic appointment.
You will be non weight bearing for 2 weeks post operatively. The physiotherapist will guide you with the use of crutches after your operation and before your discharge from hospital.
For the first two weeks following your surgery please keep your foot elevated to the level of your heart for 95% of the time.
A picture demonstrating high elevation
Naturally most people do not have a hospital bed at home. The same effect can be achieved by lying in a bed or lengthways on a sofa, with pillows behind your back and under your foot. You cannot have your leg elevated sitting in a chair. It is strongly advised that during the first two weeks you are house bound.
To minimise risk of infection keep the foot dry and cool. Avoid humid and hot environments. Keep the foot dry and when showering wear a Limbo bag.
To minimise the risk of blood clots please move your foot and ankle at regular intervals. Please ensure you are well hydrated. If you have a risk of blood clots please notify Mr Malik who may organise for you to have blood thinning injections as a precaution.
You will be reviewed at the clinic and your dressings removed. Your wound will be checked and if completely healed you will be given advice regarding soft tissue massage and scar desensitisation. Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area. You may shower and get the area wet only if the wound has completely healed and is dry.
At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position whenever possible to minimise swelling.
At this stage you can will go into a boot with four wedges and start full weight bearing. At weekly intervals thereafter one wedge is removed at a time. This will gradually bring the foot into a plantigrade position at the six week post injury mark. Short trips can be made outside, within limits of pain and swelling.
Driving will be permitted for short trips if the left foot has been operated on and you drive an automatic. If the right foot has been operated on it will be at least 6 to 8 weeks before any driving is advisable.
At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 3 to 4 months.
You will be able to start wearing normal footwear (swelling permitted), although stiff soled shoes are advisable. You will require physiotherapy for approximately 3-6 months. This will help optimise the outcome of your operation.
Final clinical examination. Discharge if satisfactory.
Please see guidance above and information here. Ultimately it is the responsibility of the patient to decide if they are safe to drive. A good way of knowing is if you can stamp your right foot heavily on the ground to mimic an emergency brake. If you have any hesitation or pain then it should suggest you are not safe to drive. Remember prolonged driving involves keeping your feet in a dependant position. This will worsen the post operative swelling.
This really depends on you and your job. If you have a job that involves a lot of standing, walking and is manual it may be 8 to 12 weeks. If you have a sedentary job, for example in an office and you have a reasonable commute you may be able to go back to work at 2 weeks, although this would be exceptional and not the norm.
Excellent pain relief and return to full function. Ability to participate in sports by 6 months. Sometimes up to a year before the foot feels “normal” and fully healed.
My right ankle had been mildly aching (especially when walking uphill) since Feb, but on 28th Aug while walking the dog I tripped on my left foot and put my right foot down heavily to save myself. It was immediately very painful, but I thought I had just sprained my ankle and that it would get better with rest, ice packs etc When it did not improve I went to my GP who thought it was an Achilles problem and referred my to Mr Malik. He saw me on 19th Sept and thought I had severed the tendon, which was confirmed by an ultrasound scan which showed the ends of the tendon were 2cm apart. He operated to repair the tendon on 23rd Sept.
Very few really. I obviously had to have the operation and Mr Malik’s confident approach gave me confidence as well.
The 2 weeks in the plaster when I had to keep all weight off my right foot. All daily tasks were a challenge, especially as my left ankle is not that strong.
I needed an Achilles tendon reconstructed (a tendon transfer) because I ruptured it during a fall at the beginning of August 2015. The tear measured 26mm but was not diagnosed when I first attended High Wycombe Minor Injuries Clinic.
I was concerned about undergoing a major operation at the age of 82 years and was frightened and worried whether the operation would be successful. I felt it might be better to leave things as they were because my damaged leg was not painful. The problem was that it was causing my other side, already damaged by a previous dislocation of the shoulder, to become extremely painful and made walking very difficult.
Surprisingly I found the experience much more straightforward than I anticipated. The treatment could not have been better. The cleanliness of High Wycombe Hospital was immaculate and the food was excellent. Mr. Malik and all the nursing staff could not have been more helpful or attentive. They changed my whole expectations of the NHS. I cannot speak too highly of my treatment. Since the operation I have been undergoing Physiotherapy with Mr. Zahoor at Amersham Hospital. He is extremely patient and clear in his explanation of my treatment and exercise programme.
The most challenging part of the procedure was not being able to bear weight on my foot. As I was in plaster for two weeks it was impossible for me to hop, even to the toilet.
I would advise any future patient to consider carefully the advice given by their consultant. I really did not want the operation but Mr. Malik was confident, despite my age, that I should go ahead because the Achilles injury would cause further problems to my other side. He was right because it worsened prior to the operation. If you are offered treatment by Mr. Malik, grab the opportunity with both hands. I send my thanks and gratitude to everyone.
I had been in some discomfort since June and a long hilly walk in unwise footwear. In August I had a fall which hurt a lot, but was not thought to be more than a sprain at first. After a couple of months when rest had not improved things I went to my local doctor and persuaded him to take a bit more interest because I was finding it difficult to do all the normal things I do, including cycling with a club, quite long walks and standing at work. A scan immediately showed what was needed.
Had I left it too late to expect a perfect repair? Would I be able to cope with a long period of inactivity? Could I persuade anyone to look after me for however long it took?
The operation was so easy from my point of view, quick , virtually painless, no after effects from the anaesthetic . The instructions in using crutches (including up and down steps) were adequate if rather brief, but adequate, the first plaster was less uncomfortable than I had expected, but having to hop for two weeks was not good for my back. The boot was not uncomfortable except in bed (but it did not keep me awake). We borrowed a wheelchair for a brief trip to the seaside and it was very useful.
It was an effort to fit in my normal busy life style, but fortunately I had a caring and competent partner and I was able to drive my automatic. Minor annoyances were mainly, being only temporarily incapacitated, I was unable to use locked public toilets or specific parking spaces. ( Fortunately I also have a friend with a blue card, so we went out together quite a lot). It was also virtually impossible to shower for the first two weeks, but no one complained!
You will need a really good friend for the first two weeks. Rest as instructed, but once mobile take sensible exercise, if it does not hurt keep moving just a bit. Try to do normal things, but take your time.
Orthopaedic Outpatient Department 30 Devonshire Street, London, W1G 6PU
tel: +44 (0) 203 7956053
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info@lfaclinic.co.uk
