An Achilles rupture refers to the complete or partial tear of the Achilles tendon, which is the largest and strongest tendon in the human body. It connects the calf muscles (gastrocnemius and soleus)
to the calcaneus (heel bone) and plays a crucial role in activities involving walking, running, and jumping. An Achilles rupture typically occurs due to an acute traumatic event or excessive mechanical load on the tendon, often during activities like sports or sudden acceleration/deceleration.
Risk Factors / Causes
- The incidence of Achilles tendon rupture increases with age (30-50 years), this is often attributed to the natural decline in tendon strength and elasticity with aging (Maffulli et al., 2019).
- Higher risk in males which may be related to higher participation in sports and physical activities (Fessy et al., 2021).
- Biomechanical factors:
- Explosive movements (running, basketball, tennis, soccer) place high mechanical load onto tendons
- Rapid changes in direction, sudden sprints or jumps increases the risk as the load and thus contraction by the tendon is greater (Maffulli et al., 2020).Diabetes/hyperlipidaemia/obesity.
- Inadequate conditioning/warm-up before sudden increases in activity levels can place excessive strain on the tendon (Soroceanu et al., 2019).
- Foot and Ankle structural abnormalities (flat feet or high arches) can alter biomechanics and lead to excessive stress on the Achilles tendon.
How does an Achillies Rupture occur?
An Achilles tendon rupture commonly occurs during activities involving explosive movements, such as running, jumping, or sudden accelerations, where the calf muscles contract forcefully, placing excessive strain on the tendon. This often results in a rupture, particularly if the tendon has been weakened due to degenerative changes (age related) or tendinopathy (load related). Achilles injuries may also be due to biomechanical compensations along the kinetic chain leading to overload thus injury.
When the tendon is stretched in deceleration or landing, this places high tensile forces on the tendon. Additionally, studies show that tendon degeneration in the “watershed” zone, located 2–6 cm above the insertion into the calcaneus, a region with poor blood supply, significantly contributes to rupture risk (Zhao et al., 2021).
Diagnosis and Examination
The typical presentation of an Achilles rupture is a sudden, sharp pain at the back of the ankle, often described as being “struck by a heavy object” or sometimes compared to being kicked or hit. Patients may report an audible “pop” at the time of injury. There is typically swelling and bruising in the posterior ankle region. You can also palpate a clear divet along the tendon where the Achilles tendon has been torn.
Physical examination will reveal an inability to adequately weight bear, an inability to perform a calf raise and a positive “Thompson test,” where squeezing the calf fails to produce plantar flexion of the foot (Hansson et al., 2020).
Imaging is helpful to confirm the clinical diagnosis and extend of damage to the tendon. An ultrasound is the preferred imaging modality due to its availability, lower cost, and ability to assess tendon structure. MRI will be used to assess the degree of rupture, tendon retraction, or associated soft tissue injuries (Maffulli et al., 2019).
Initial Management of an Achilles tendon Rupture
- Coordination with Healthcare Providers:
- Establish communication with the patient’s GP to ensure a cohesive treatment approach. This includes organising diagnostic referrals by way of MRI or ultrasound and discussing further referral to an Orthopeadic Surgeon which is required.
- Initial Treatment Protocol:
- Apply Tubigrip and a long CAM boot with appropriate wedges to maintain the foot in plantarflexion. Aim for a heel lift of 3-4 cm to match the desired angle of approximately 30 degrees, especially if opting for conservative management.
- Non-Weight Bearing (NWB) Instructions:
- Advise the patient to use crutches for mobility to avoid putting weight on the affected leg.
- Surgeon Consultation:
- Aim to arrange for the patient to see the surgeon within a few days of the injury to determine if conservative or surgical management is most appropriate
Conservative vs Surgical Management
Achillies rupture’s can be treated both surgically and non-surgically, depending on factors such as patient age, activity level, and the severity of the rupture. This is determined by the orthopeadic surgeon in consultation with the patient.
Conservative Management has become the standard form of treatment following an Achillies rupture and involves early functional rehab, with weight-bearing via crutches and in a CAM boot with heel wedges and controlled ankle motion. Initial management in this case will involve the promotion of tendon healing to ensure adequate healthy tissue is available to begin exercises safely.
Immobilisation with a CAM boot and the use of heel wedges to place the calf in a more relaxed position, has been shown to be effective in promoting healing. Heel wedges help reduce strain on the tendon by plantarflexing the foot, allowing for a more controlled healing position. Recent evidence supports early weight-bearing with the CAM boot, combined with gradual reduction of the heel wedges, as this approach accelerates recovery while minimising complications compared to prolonged immobilisation (Fessy et al., 2021). Maffulli et al. (2020) found this method provides outcomes comparable to surgery, with a lower risk of complications. Although surgeon protocols vary, physiotherapy rehabilitation is typically allowed to commence as early at 6 weeks post injury. Rehab begins with controlled weight-bearing and progresses to active exercises. Carlsson et al., 2021 noted that functional rehabilitation helps in reducing re-rupture rates and promoting quicker recovery.
Surgical Treatment involves repairing the torn tendon through surgery. According to Rossi et al., 2023 surgical repair generally leads to faster recovery and lower re-rupture rates compared to conservative treatment. This approach remains the gold standard for repair in active individuals or those with more complex ruptures as it follows an accelerated pathway towards rehabilitation. Uchiyama er al. (2024) found that 15/16 elite athletes returned to normal activities and training loads within 7 months following surgery. It is associated with a lower rate of re-rupture but carries the risk of typical complications. Early focus is on controlling swelling and protecting the repair before post-op rehabilitation can commence. Protocols include a structured program focusing on range of motion, strength, and functional activities.
Considerations and Return to sport
Regardless of which approach is taken, rehabilitation for an Achilles rupture involves a staged approach aiming to regain strength, flexibility, and function. Progressive loading and functional exercises, such as eccentric calf strengthening, are essential for promoting tendon remodelling and enhancing recovery (Maffulli et al., 2019). Return-to-sport is typically aimed for 6–12 months after the injury, depending on the rehabilitation progress and the individual’s activity level. It’s important to consider holistic rehabilitation by addressing the full kinetic chain aiming to improve deficits and prevent further or ongoing issues. Strength testing using the AxIT force plates and hand held dynamometer can be extremely helpful to monitor progress and facilitate a safe return to sport or previous level of activity.
Exercise
Calf Raises
Aim: Build strength and endurance in the gastrocnemius and soleus muscles, helping load the tendon. This is critical when training push off during normal walking gait.
How: Stand on one leg with your toes pointed forward. Raise up onto your tiptoes, then slowly lower your heel back to the ground. Stand up tall throughout. Repeat for reps.
Soleus Raise on a pilates reformer
Aim: Build muscle strength in the Soleus Muscles to support the calf in bent-knee positions such as running and jumping, further loading the Achilles.
How: Lay with your back flat on a reformer and the balls of both feet resting on the footbar. Keep your knees bent to 90 degrees and then raise up on your toes contracting your soleus muscle as you push away from the footbar. Slowly control the movement back to the starting position. Progress this exercise by adjusting springs and increase reps as required.
Broad jump
Aim: This dynamic exercise aims to improve strength, power, coordination, and cardiovascular fitness, but also loads the achilles tendon via the explosive aspect of the movement. Important during return to sport testing and rehabilitation.
How: Start tall with feet shoulder width apart. Start by squatting down and then jumping as far forward as possible performing a maximal leap on two feet and then landing in a squat position.
If you or someone you care for has an injury, a flare up, requires some rehabilitation or experiences an increase in pain, give the clinic a call on 9713 2455 or book online.