Achilles Tendon Tear- Orthopedics

The Achilles tendon is the piece of connective tissue that joins the calf muscle to the bone of your heel. The tendon sometimes tears when the foot bends in a particular way, namely dorsiflexion (when the foot bends upwards).

An Achilles tendon tear is a common injury that can happen when you run or jump and occurs most often in athletes and middle-aged men. There are some instances where the use of corticosteroids and antibiotics, specifically ciprofloxacin, increases the risk of an Achilles tendon tear. The injury is disabling because the area swells up and makes it painful to walk.

Who treats Achilles tendon tears?

Doctors who specialize in sports medicine and physical medicine are usually involved in treating an Achilles tendon tear. For surgical intervention, you will be referred to an orthopedic surgeon.

Diagnosis

A physical exam can establish a tendon rupture. Physical exams include the Matles test and the Thompson test. 

• In the Matles test, the patient lies flat on their back with their knees bent. If the tendon is ruptured, the foot will be in dorsiflexion.
• In the Thompson test, the calf muscle is squeezed. If the foot does not show plantar flexion, the tendon is ruptured.

Although a physical examination and tests can lead to a diagnosis, the extent of the tear is often best determined by using imaging tests such as an MRI or ultrasound. Both techniques can be used, but an MRI may be better for detecting and evaluating the extent of a partial tear. These imaging tests can also help establish the treatment best suited for a particular patient.

Treatment options for an Achilles tendon tear

Surgical and non-surgical methods are available for treating an Achilles tendon tear. Age is a factor that may be taken into consideration when deciding on the best treatment. Surgery might be a better alternative for young people, but it might not be the best option for elderly patients.

Current treatment methods for an Achilles tendon tear are given below.

Splints

As a first step, the injured area will initially be splinted, and then a specialist will decide if you should wear a brace or cast or if surgery is required.

Immobilization with a cast or brace

This is a conservative approach by keeping the leg immobile. The patient’s discomfort is alleviated through medication and ice. Here are the other facets involved:

• Pain-relievers and nonsteroidal anti-inflammatory medications (NSAIDs) can be administered to help with the pain of the torn tendon
• Swelling can be reduced by placing an ice pack on the affected area
• The patient should use crutches to avoid using the leg with the injured tendon
• A cast or a walking boot is often used to keep the region immobile and to stop the patient from using the leg. The idea is to keep the leg still until it has healed completely
• Patients should wear a cast for 6 to 8 weeks

Some doctors suggest the use of a dynamic ankle brace for an Achilles tendon rupture. Studies have shown good outcomes for patients with such a brace, but it likely depends on your particular situation as to which brace or cast will work best for you.

Surgery

Surgery is often recommended when a tendon is completely ruptured or if a partially torn tendon does not repair within three months.

There are two different techniques utilized, either an open procedure or minimally invasive surgery (MIS). In an open procedure, one long incision is made at the back of the leg, over the calf muscle.

MIS is preferred because it decreases infection risk and increases the rate of wound healing. During MIS, several small incisions are made rather than one large incision. Many surgeons today use the percutaneous Achilles repair system (PARS), which is one of the minimally invasive methods of repairing a damaged tendon.

Post-operative care

• Fatigue is common after the surgery, and it will take a while to gain energy
• You will most likely have a bruise around the area after surgery
• You have to wear a walking boot for 6 to 12 weeks while you recover and your tendon starts to heal
• You may undergo an ultrasound or MRI after the surgery to assess the repair
• Rehabilitation is also needed after surgery
• It may take a couple of months before you can return to playing sports if you are an athlete

Complications

The two main complications of Achilles tendon repair surgery are as follows:

• Infection: This can be both a deep infection in the tissue or a superficial one on the outer edges of the wound.
• Nerve damage: there is a slight risk of injury to the sural nerve, which runs down the back of the leg.

People who smoke and use corticosteroids are at an increased risk of complications.

References:

• Hsu, A. R., Jones, C. P., Cohen, B. E., Davis, W. H., Ellington, J. K., & Anderson, R. B. (2015). Clinical outcomes and complications of percutaneous Achilles repair system versus open technique for acute Achilles tendon ruptures. Foot & ankle international, 36(11), 1279-1286.
• McComis, G. P., Nawoczenski, D. A., & DeHaven, K. E. (1997). Functional bracing for rupture of the Achilles tendon. Clinical results and analysis of ground-reaction forces and temporal data. JBJS, 79(12), 1799-1808.
• McMahon, S. E., Smith, T. O., & Hing, C. B. (2011). A meta-analysis of randomised controlled trials comparing conventional to minimally invasive approaches for repair of an Achilles tendon rupture. Foot and ankle surgery, 17(4), 211-217.
• Neumayer, F., Mouhsine, E., Arlettaz, Y., Gremion, G., Wettstein, M., & Crevoisier, X. (2010). A new conservative-dynamic treatment for the acute ruptured Achilles tendon. Archives of orthopaedic and trauma surgery, 130, 363-368.
• Shamrock, A. G., & Varacallo, M. (2022). Achilles tendon rupture. In StatPearls [Internet]. StatPearls Publishing.
• Szaro, P., Nilsson-Helander, K., & Carmont, M. (2021). MRI of the Achilles tendon—A comprehensive pictorial review. Part one. European Journal of Radiology Open, 8, 100342.

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