Achilles tendon rupture

The Foot Clinic: your ally in Achilles tendon recovery

Achilles tendon ruptures are a common reason for consultation in traumatology. Unfortunately, the diagnosis of Achilles tendon rupture can initially go unnoticed, leading to difficulties in therapeutic management later on.

There is a diagnostic pitfall, especially when imaging tests, such as ultrasound, describe what is called a partial rupture.

What is an Achilles tendon rupture?

An Achilles tendon rupture is a loss of tendon continuity. The tendon ends may be more or less retracted. When the rupture is detected early, it is called an acute rupture. If the rupture occurred more than 6 months ago, it is considered a chronic rupture.

The therapeutic management differs depending on the time elapsed since the rupture; in chronic ruptures, the Achilles tendon can be of very poor quality.

How to recognize an Achilles tendon rupture?

An Achilles tendon rupture is a clinical diagnosis. There are physical examination signs that can be used to assess an Achilles tendon injury. The clinical exam is performed on a patient lying on their stomach with their feet hanging off the exam table.

The loss of physiological equinus is immediately visible and confirms the diagnosis of Achilles tendon rupture.

The Thompson test helps to support the diagnosis of Achilles tendon rupture; it involves manually compressing the calf muscles. When the Achilles tendon is intact, compression of the calf muscles causes the foot to move into equinus. In the case of Achilles rupture, no movement is transmitted to the foot.

Palpation of the Achilles tendon reveals a depression at the site of the rupture, allowing assessment of the height of the Achilles tendon rupture in relation to its insertion on the calcaneus.

Partial rupture of the Achilles tendon

There is no such thing as a partial rupture of the Achilles tendon. This diagnosis is usually made by ultrasound when "a few tendon fibers in continuity" persist. These tendon fibers correspond to the plantaris tendon, which accompanies the Achilles tendon.

In the event of a rupture of the Achilles tendon, the plantaris may be intact, leading to the erroneous diagnosis of a partial rupture of the Achilles tendon.

Complete rupture of the Achilles tendon

Total rupture or rupture of the Achilles tendon can occur on an apparently healthy tendon during physical activity, not necessarily a violent one. A sudden change in direction or a push-off can be enough. Usually, these Achilles tendon ruptures occur in former athletes who return to sport as if they had never stopped. Failing to warm up before playing sports and failing to stretch after exercise is a classic mistake, as is not staying hydrated. Overuse of the Achilles tendon, especially in the case of a sudden increase in training level, for example, is also a cause of rupture.

The rupture of the Achilles tendon can occur on an already damaged tendon. The medical interview looks for previous Achilles tendon pain before the rupture, as well as the use of medications that may promote tendon injuries, especially those of the Achilles tendon. The use of fluoroquinolone-type antibiotics is, for example, a factor in tendon injuries.

Treatments for a ruptured Achilles tendon

The debate remains open concerning the various treatments for the Achilles tendon. The goal of treatment is to achieve healing of the Achilles tendon at the most physiologically appropriate length possible.

Two treatments can be offered: orthopedic treatment and surgical treatment, each having their respective advantages and disadvantages.

Orthopedic treatment is indicated in acute ruptures of the Achilles tendon; it involves immobilizing the ankle in a cast in an equinus position initially, then gradually correcting the position of the foot over several weeks to progressively increase tension on the Achilles tendon during its healing.

The main advantage of orthopedic treatment is the absence of surgical complications by definition. The disadvantages are a longer period of immobilization in a cast with a risk of Achilles tendon elongation during its healing. This elongation will make contraction of the triceps surae muscle less effective, with a risk of muscle wasting in the calf muscles.

Orthopedic treatment is always offered, but it is mainly suited for patients with low functional demand who do not want to undergo surgery, as there is a non-surgical alternative. In cases of trophic disorders or poor skin condition, orthopedic treatment is also proposed to avoid the risk of skin healing problems and infection at the surgical site.

The rate of Achilles tendon re-rupture is higher after orthopedic treatment.

Surgical treatment is indicated for both acute and chronic ruptures of the Achilles tendon; it involves repairing the Achilles tendon to restore proper tendon tension while limiting postoperative tendon elongation.

Several repair techniques exist: open surgery, endoscopy, or percutaneous methods. Cast immobilization lasts around 3 weeks, after which weight-bearing is allowed using heel lifts of various heights.

The advantages of surgical repair are better control of the tension of the Achilles tendon, limiting the risk of atrophy of the triceps surae, and a lower rate of Achilles tendon re-rupture compared to orthopedic treatment.

There are 2 scenarios in chronic ruptures of the Achilles tendon:

The Achilles tendon is of sufficiently good quality to be repaired; in this case, shortening plasties of the Achilles can be done with reinforcement using the plantaris muscle or a Bosworth-type procedure.
The Achilles tendon is degenerative and of poor quality; in this case, a palliative tendon transfer of the flexor hallucis longus can be performed so that healing does not have to rely solely on the Achilles tendon.

How long does it take to heal from a torn Achilles tendon?

The healing time for tendons is about 6 months.

At 3 months after an Achilles repair, the tendon is strong and allows daily activities without limitation. At 6 months, it is possible to start running and jumping again, as the tendon is remodeled.

Rehabilitation after Achilles tendon rupture

One and a half months after treatment for a ruptured Achilles tendon, rehabilitation can begin. Rehabilitation involves massaging the scar as well as the Achilles tendon to reduce the risk of adhesions. Gentle muscle strengthening is recommended at this stage.

At 3 months, muscle strengthening is more important, and it is possible to cycle and swim.

At 6 months, resuming all sports activities is possible, and re-athletization can begin.

The operation for a ruptured Achilles tendon

In the event of an acute rupture, surgical treatment consists of repairing the Achilles tendon. This repair can be done by making an incision over the rupture, resecting the damaged tendon ends, and then suturing the tendon ends under tension.

The repair can be done percutaneously, or even under endoscopy. These techniques are used mainly when the skin presents risks of healing disorders (venous insufficiency, poorly controlled diabetes, arterial pathologies).

When the tendon is of poor quality, it is possible to reinforce it using the plantaris tendon or to perform a Bosworth-type plasty.

A plaster cast immobilization for 3 weeks after open repair helps to limit the risk of healing complications. Then a walking boot can be used for another 3 weeks.

In the case of chronic rupture, if the tendon is of poor quality, which is often the case, a palliative treatment by transferring the flexor hallucis longus tendon is proposed. This involves taking the flexor hallucis longus tendon behind the ankle under arthroscopy, then transferring it into a bone tunnel in front of the Achilles tendon. A plaster cast immobilization for 45 days is done before resuming walking and rehabilitation.