Acute Achilles Tendon Rupture
Rupture, or tearing, of the Achilles
tendon is a common condition. This typically occurs in the unconditioned
individual who sustains the rupture while playing sports, or perhaps,
from tripping. There is a vigorous contraction of the muscle and
the tendon tears. The patient will often describe the sensation
that someone or something has hit the back of the calf muscle.
suddenly present, and although it is possible to walk, it is usually
painful. More importantly however, the leg is weak. This is particularly
noticeable when trying to push off while walking, and there is
not sufficient strength to do so.
||The diagnosis of a rupture of the Achilles tendon is easy to make, and no XR, MRI or other test is necessary. The defect in the tendon is easy to see and to palpate as seen in this picture.
|Diagnosis of rupture of the tendon is easily
made by your orthopedic surgeon, and in this patient one can
see the defect in the end of the leg when the tendon has ruptured.
While it is possible to treat this ruptured tendon without surgery,
this is not ideal since the maximum strength of the muscle and tendon
rarely returns. The reason for this is that the ends of the tendon
are ruptured in a very irregular manner, almost like the ends of
a paint brush. As soon as the tendon ruptures, the calf muscle (gastrocnemius
muscle) continues to pull on the tendon, and the end of the ruptured
tendon pulls back into the leg, which we call retraction. Once the
tendon retracts, it is never possible to get sufficient strength
back without surgery, because the muscle no longer functions at the
correct biomechanical length, and is now stretched out.
If for one reason or another your doctor does not recommend surgery,
it is essential to obtain special tests to check that the ends of
the tendon are lying next to each other so that healing can occur.
The best test to do this is called an ultrasound, and not an MRI.
There are patients for whom surgery cannot be performed, in particular,
due to existing medical conditions which may add to potential
for complications following surgery. For these patients, we use
designed boot which positions the foot correctly, and takes the
pressure and tension off the muscle and tendon. Most importantly
a cast is never used because it causes permanent shrinkage (atrophy)
of the calf muscle. We use a special boot, which permits pressure
on the foot with walking, and a hinge is incorporated into the
boot to permit movement of the ankle. We have demonstrated in many
of rupture of the Achilles tendon, that this movement of the
foot in the boot while walking is ideal for tendon healing.
||Many years ago, patients with a rupture of the Achilles were
placed in a cast in order to heal the tendon. This is no longer
used, since the case increases the likelihood of another rupture
of the tendon, and creates stiffness of the ankle, and weakness
of the leg muscles.
Surgical correction of the ruptured tendon is almost always necessary.
This is performed in order to regain the maximum strength of
the Achilles, as well as the normal pushing off strength of the
The strength of the muscle depends on the correct tension between
the muscle and the tendon. The only way that the correct tension
on the tendon can set is by accurately repairing the tendon ends.
Take a look at the picture below, and you can see why surgery
is necessary. When the tendon ruptures, the ends of the tendon
and multiple little strands of the tendon are present like pieces
||The rupture of the Achilles tendon is shown here. Note the
very long cut on the back of the leg. This is an old fashioned
operation. Now we are able to perform the surgery through a
tiny one-inch incision on the back of the leg.
There are old fashioned techniques for
repairing the tendon which require very long incisions (eight
inches) on the
back of the leg. These are complicated and associated with a
high incidence of infection in the skin after surgery. This is
consideration, since infection in the skin can lead to devastating
problems with the skin and tendon. This problem of skin infection
has, in the past, led surgeons away from surgical methods of
||Here you can see that the tendon ends have been approximated
with stitches. This is a large cut on the leg, and nowadays
is not necessary
Fortunately, now there is a new,
unique method available for operating on and repairing the tendon.
This new method requires only a
tiny incision of one to two centimeters in length. This is far
accurate surgery. Recovery after this procedure is easier and
complication rate is extremely low.
||Note the absence of scars in this patient. The stitches were
inserted through tiny punctures in the skin, The patient is
standing on tip toes three months following her surgery, and
has begun a training program to resume ball sports
Following the tendon repair no walking on the foot is permitted
for ten days. Then walking is begun in a removable boot. There
were some treatments used many years ago that relied upon a leg
cast. This led to tremendous weakness and atrophy of muscle that
was often permanent. Approximately fifteen years ago, with a
treatment pioneered by Dr. Myerson, the recovery after surgery
for repairing the Achilles tendon changed dramatically, leading
to maximum restoration of tendon healing and rapid return of
strength. Instead of a cast, a removable boot is worn and instead
of using crutches, walking is commenced very rapidly after surgery.
Therapy and exercises are begun soon after surgery. This therapy
process is critical in the recovery after tendon rupture, and
without a carefully monitored program, full recovery is never
possible. This treatment has made a huge difference in the recovery
process for both recreational and professional athletes.
||The rupture of the Achilles tendon here
was treated with a short incision and this patient is able to
stand on tip toes at 8 weeks after surgery. Rehabilitation with
exercise is very important early on after surgery to maximize