Achilles Tendon Rupture

Injuries of the Achilles tendon and associated musculature of the calf are not uncommon.  These injuries occur more commonly in males than females.  The most typical age range is 35-50, although injuries do occur in younger and older persons.

There are different sites that can be injured:

• In the calf muscle (called the gastrocnemius), typically more towards in the inner side of the calf muscle than the outer side.
• In the Achilles tendon, near the muscle attachment (a high Achilles injury)
• In the Achilles tendon, in its midsection (typically 5-7cm above the heel attachment)
• At the Achilles attachment area (also called an avulsion injury)

Typically, these injuries occur during sudden forceful movements, such as with sports like basketball, soccer, tennis, and racquetball.  There is usually sudden pain and a pop.  Many patients will describe a sensation like they were hit on the Achilles with a stick.  Afterwards there may be difficulty propelling of the foot, or rising up on the toes, or negotiating stairs.  The immediate pain can subside, but there is typically some swelling and perhaps bruising that can occur.

Immediate treatment while waiting to see the doctor should include:

• Rest – stop your activity and get off the leg
• Ice – apply ice packs for 10-15 minutes, every 3-6 hours
• Compression – apply an ace wrap if you have one handy
• Elevate – elevate your leg to heart level or higher

When you see your doctor, the diagnosis is typically made by physical exam alone.  A MRI examination is usually not needed, but may be used in some circumstances.

The treatment for the injury will typically be guided, based on the location of the injury (as described earlier), among other factors that the doctor will take into consideration:

Injury at the level of the calf muscle

Also called a gastrocnemius muscle tear (or strain), this injury is usually located at the inner (medial) side of the calf muscle (medial gastrocnemius tear).  Treatment of this type of injury is non-surgical:

• A removable walking cast is usually advised until the tenderness resolves and shoes can be resumed.  This may take 4-6 weeks.
  The removable walking cast can be removed for therapy, sleeping and bathing.
• Crutches may be used, but can be discarded as soon as full weight bearing can be achieved in the removable walking cast.
• Apply ice for 10-15 minutes every 3-6 hours for the first 48 hours, then ice for 5 minutes followed by heat for 15 minutes three times per day thereafter.
• You may take an anti-inflammatory medication such as ibuprofen (if tolerated) for the first two weeks.
• A physical therapy referral for ultrasound and other treatments may be advised.
• Typically, weight bearing exercise activities are kept restricted for at least two months.
  Swimming or stationary cycling activities may be allowed sooner.
• Complete healing may take 4-6 months.

Injury of the Achilles tendon, near the muscle attachment (a high Achilles injury)

This injury is typically treated with a non-removable cast.  The injury is too high for surgery to be an option.

• A below-knee cast (from just below the knee to the tips of the toes) is applied.
  The initial cast may be applied with your foot positioned in a downward direction to allow the ends of the tendon to lie closer together for initial healing.
  You may be brought back in 2-3 week intervals until the foot can be positioned at 90 degrees to the leg in the cast.
  The first 6 weeks in the cast are typically non-weight bearing with crutches or other suitable device to assist with the non-weight bearing requirement.
• After 6 weeks in the non-removable cast, a removable walking cast is started.
  The removable walking cast can be removed for therapy, sleeping and bathing
  The period in the removable walking cast may need to last for an additional 2-6 weeks.
  Your doctor will review a home physical therapy program with you (more on this program later) that will typically start not long after your non-removable cast is removed.
• Your doctor may also refer you for formal physical therapy appointments.
• Typically, weight bearing exercise activities are kept restricted for at least 4 months or more.
  Swimming or stationary cycling activities may be allowed sooner.
• Complete healing may take 12 months or more.

Injury of the Achilles tendon, in its midsection (typically 5-7cm above the heel)

This injury is the classic Achilles tendon rupture.  The scientific literature is divided on whether surgical or non-surgical treatment is best.  At the Foot and Ankle Surgery Department in the Santa Rosa Kaiser Permanente facility, we have moved away from advising surgery on every Achilles tendon rupture to a greater frequency of non-surgical care for these injuries with very satisfying results.  Pros and cons – surgical versus non-surgical care.

Surgical repair has been described in some literature as having a lower re-rupture rate.
The length of casting and recovery time is typically not significantly different between surgical and non-surgical care.

Surgical care adds the risks of surgery, there are for you to view.  Whether surgical or non-surgical care is advised, the cast and aftercare is the same:

• A below-knee cast (from just below the knee to the tips of the toes) is applied.
  The initial cast may be applied with your foot positioned in a downward direction to allow the ends of the tendon to lie closer together for initial healing.
  You may be brought back in 2-3 week intervals until the foot can be positioned at 90 degrees to the leg in the cast
  The first 6 weeks in the cast are typically non-weight bearing with crutches or other suitable device to assist with the non-weight bearing requirement.
• After 6 weeks in the non-removable cast, a removable walking cast is started.
  The removable walking cast can be removed for therapy, sleeping and bathing.
  The period in the removable walking cast may need to last for an additional 2-6 weeks.
• Your doctor will review a home physical therapy program with you (more on this program later) that will typically start not long after your non-removable cast is removed.
• Your doctor may also refer you for formal physical therapy appointments.
• Typically, weight bearing exercise activities are kept restricted for at least 4 months or more.
  Swimming or stationary cycling activities may be allowed sooner.
• Complete healing may take 12 months or more.

Injury at the Achilles attachment area (also called an avulsion injury)

This injury is often treated surgically.  Surgical care adds the risks of surgery, there are for you to view.  After the surgery, the cast and aftercare is typically as follows:

• A below-knee cast (from just below the knee to the tips of the toes) is applied.
  The initial cast may be applied with your foot positioned in a downward direction to allow the ends of the tendon to lie closer together for initial healing.
  You may be brought back in 2-3 week intervals until the foot can be positioned at 90 degrees to the leg in the cast.
  The first 6 weeks in the cast are typically non-weight bearing with crutches or other suitable device to assist with the non-weight bearing requirement.
• After 6 weeks in the non-removable cast, a removable walking cast is started.
  The removable walking cast can be removed for therapy, sleeping and bathing.
  The period in the removable walking cast may need to last for an additional 2-6 weeks.
• Your doctor will review a home physical therapy program with you (more on this program later) that will typically start not long after your non-removable cast is removed.
• Your doctor may also refer you for formal physical therapy appointments.
• Typically, weight bearing exercise activities are kept restricted for at least 4 months or more.
  Swimming or stationary cycling activities may be allowed sooner.
• Complete healing may take 12 months or more.

Home physical therapy program

1.  Alphabet Range of Motion exercises

• Typically, the first exercise to be started (once out of a non-removable cast).
• While holding your knee and leg still (or cross your leg), you simply write the letters of the alphabet in an imaginary fashion while moving your foot and ankle (pretend that the tip of your toe is the tip of a pencil).
• Motion the capital letter A, then B, then C….all the way through Z.
• Do this exercise three times per day (or as your doctor advises).

2.  Ice massage

• Freeze a paper cup with water, and then use the ice to massage the tendon area as deeply as tolerated.
• The massage helps to reduce the residual inflammation and helps to reduce the scarring and bulkiness of the tendon at the injury site.
• Do the ice massage for 15-20 minutes, three times per day (or as your doctor advises).

3.  “Eccentric” Calf Strength exercises

• This exercise is typically delayed and not used in the initial stages of rehabilitation – begin only when your doctor advises.
• This exercise is typically done while standing on just the foot of the injured side.  Sometimes, the doctor will advise you to start with standing on both feet.
• Stand on a step with your forefoot on the step and your heel off the step.  The heel and forefoot should be level (neither on your tip toes nor with your heel down)
• Lower your heel very slowly as low as it will go, then rise back up to the level starting position, again very slowly.  This is not a fast exercise.
• Repeat the exercise as tolerated.  The number of repetitions may be very limited at first.  Progress the number of repetitions as tolerated.
• Do this exercise one to two times per day (or as your doctor advises).