Acute achilles tendon rupture

 

Achilles tendon rupture is often missed, but is a common problem. It is most frequent in men aged between 30-45 and usually occurs during sports, often whilst pushing off sharply. The risk is higher if you have not 'warmed up' sufficiently. The tendon usually ruptures with an audible 'pop'. Bruising, pain and swelling may be considerable. Despite complete rupture of the tendon, the patient can still push the foot to the floor, by virtue of the presence of other flexor tendons which pass behind the ankle. Simmonds test (known as Thompson's test in the US) should be performed to make the diagnosis:

 

Broadly speaking, there are two ways of treating an achilles tendon rupture: surgical or non-operative management. There are pros and cons of each. Surgery carries risks of wound healing problems, infection, nerve injury, painful scar formation and boot clots. Non-operative management avoids many of these risks, although there is still a danger of blood clot formation. 

Classic research literature suggested that achilles tendon ruptures managed conservatively (without surgery) had a re-rupture rate of 13% compared to 5% in surgically managed ruptures. This research was in  patients who had been treated for prolonged periods in plaster cast, without bearing weight or moving the ankle. Current scientific thinking suggests that managing a tendon injury in this way leads to formation of weak, poorly organised, scar tissue. It is therefore unsurprising that managing a tendon rupture in this manner leads to a high re-rupture rate. 

More modern research has shown that, provided certain criteria are met, many achilles tendon ruptures can be managed without surgery, whilst still producing an acceptable re-rupture rate. It appears that the key to reducing re-rupture rates is to use a 'functional rehabilitation regimen'. This means that the tendon should be carefully loaded whilst still ensuring that the rupture is protected. Early movements of the ankle ensure that the tendon heals in a stronger fashion. By adhering to a carefully structured functional rehabilitation regimen, re-rupture rates of 1.1% have been reported, whilst avoiding all the potential complications associated with surgery (Hutchison et al. Journal of Bone and Joint Surgery 2015). 

I advocate non-surgical management of achilles tendon rupture in appropriate cases using a functional rehabilitation regimen. The VacoPed boot allows early weight bearing, precise control of foot position and may help to reduce swelling by virtue of the pneumatic vacuum cushioned lining.  

In some cases, surgery is still indicated: if the tendon ends do not come together when the foot is pushed into equinus (flexed downwards), then an operation is required to bring them together at the correct tension. After surgery I recommend management in the same functional rehabilitation regimen once the wound has healed.

 

Indications for surgery:

  • Acute rupture with gapping >15mm on ultrasound in equinus
    • AND age <65 and active lifestyle
    • AND complete achilles rupture
  • Chronic or neglected rupture

 

Indications for non-surgical management:

  • Partial rupture

OR

  • Complete rupture with apposition of tendon ends <15mm with ankle in maximum equinus

 

My recommended rehabilitation regimen for physiotherapists treating patients with an achilles tendon rupture - whether it has been managed with surgery or conservatively is available as a PDF download by clicking here.