Achilles Tendon Rupture FAQ’s

A ruptured Achilles tendon is when the tendon that connects your calf muscles to your heel bone tears. Typically, a rupture involves tearing of all fibers of the tendon. It’s a common injury, often happening during sports that involve sudden stops and starts, like basketball or tennis. The Achilles tendon is crucial for activities like walking, running, and jumping, so a rupture can be debilitating.

Ruptures involve disruption of all the fibers of the Achilles tendon. They occur in an area where the blood supply is poorest. This is usually 4-6cm from where it inserts.

Ruptured Achilles tendon look like.

4-6 cm from the insertion

Achilles tendon ruptures occur due to sudden force through the tendon that is greater than the tensile strength of the tendon fibers. This results in damage and tear of the fibers until the whole tendon is ruptured. There are also several risk factors. This includes episodic athletes (weekend warriors), use of fluoroquinolone antibiotics, steroid injections, smoking, and vascular disease. It is more common in males, aged 30-40.

Systemic diseases that may be associated with Achilles tendon injuries include the following:
· Chronic renal failure
· Collagen deficiency
· Diabetes mellitus
· Gout
· Infections
· Lupus
· Parathyroid disorders
· Rheumatoid arthritis
· Thyroid disorders
Foot problems that increase the risk of Achilles tendon injuries include the following:
· Cavus foot
· Insufficient gastroc-soleus flexibility and strength
· limited ability to perform ankle dorsiflexion
· Tibia vara
· Varus alignment with functional hyperpronation

Most patients feel sudden and sharp pain in the back of their ankle. They often describe the sensation of feeling like they have been kicked or shot behind the ankle. Soon thereafter, the area is bruised, swollen, painful, tender. There will be weakness in walking, running, and weightbearing.

It can happen to anyone at any time. However, it is most commonly seen in patients playing intense pivoting sports or running.

This can be variable. Some patients have severe pain. Others have minimal pain, but more severe associated symptoms. Pain is very subjective. It cannot be used as a sole indicator that the tendon is torn.

You will experience the symptoms described above. Once you are seen by a medical professional, an MRI will typically be ordered to confirm diagnosis and visualize tear characteristics.

We first use clinical history and examination findings to support a diagnosis of Achilles rupture. On exam we expect to find laxity of the Achilles complex, more dorsiflexion of the ankle on the affected side, positive Thompson test, gapping of the tendon at the tear side, tenderness, swelling, and weakness to plantarflexion.
Once we have clinical findings consistent with a rupture, the diagnosis is confirmed with an MRI. Treatment decisions can be made thereafter.

Signs of an Achilles tendon rupture.

On exam we expect to find laxity of the Achilles complex, more dorsiflexion of the ankle on the affected side, positive Thompson test, gapping of the tendon at the tear side, tenderness, swelling, and weakness to plantarflexion.

Signs of an Achilles tendon rupture.

The tendon heals vast majority of the time. However, the length of the tendon is important. If the tendon heals too long, we lose the biomechanical advantage of the tendon. This results in weakness, fatigability, and limitation in activity. The goal of any treatment (surgery vs no surgery) is to get the tendon to heal at the appropriate length.

These are very common injuries. Reported incidence rates among athletes are 7% to 18% in runners, 9% in dancers, 5% in gymnasts, 2% in tennis players, and less than 1% in American football players. Achilles disorders affect approximately 1 million athletes per year. The incidence of Achilles tendon ruptures varies in the literature, with recent studies reporting a rate of up to 40 patients per 100,000 patient population annually.

If you are suspicious that you have ruptured your Achilles, it is best to seek help immediately. If you need additional testing / surgery, delays can result in poor outcomes and more complicated procedures. Thus, it is better to see an orthopedist, urgent care, or emergency room immediately. It is not a life-threatening injury on its own.

On its own, an Achilles tendon rupture is not typically a life-threatening injury.

If you suspect that you have ruptured your Achilles tendon, we recommend not weight bearing on that side. Use crutches or a knee scooter to offload the ankle. See us in our office. Or go to a nearby urgent care / emergency room. The ankle should be casted in a flex position. This is important. Fractures and associated injuries should be ruled out. Once the ankle is casted, seek an orthopedist who can order relevant tests, and plan treatment.

Treatment of an Achilles tendon rupture may be surgical or non-surgical depending on several patient and injury factors.

Surgery tends to be indicated in those patients who are very athletic, who were not appropriately treated with “functional rehab” initially, who have a tendon gap of greater than 5mm, or have a delayed presentation.

Recent studies suggest that “functional rehab” is an effective non-surgical treatment strategy for Achilles ruptures. This involves a period of casting, then a period of slow / progressive weight bearing in a boot, a lot of physical therapy, and gradual return to normal walking / sports. However, it is important to note that functional rehab must be started within 24-48h of the injury. The ankle should be splinted in a flex position. Failure of this prevents our ability to treat with functional rehab.

Patients who had appropriate treatment with functional rehab had similar functional outcome, satisfaction, and similar rerupture rates as surgery. Bear in mind that this requires a specific protocol, and patient population to ensure successful treatment. If you fall outside of this protocol, surgery may be indicated.

Ruptured Achilles tendon repair – Image 1

Surgery for an Achilles tendon involves making an incision in the back of the ankle, preserving sensory nerves, and identifying the Achilles tear. We then use strong tensile suture and a suturing technique to oppose the ends of the tear. In this manner, the tendon can heal, and it heals at an appropriate tension / length. This is a critical factor in ensuring function of the Achilles tendon. Once the tendon is opposed and tensioned, the layers are repaired using sutures. A cast is then applied.

Ruptured Achilles tendon repair – Image 2

Ruptured Achilles tendon repair – Image 3

Ruptured Achilles tendon repair – Image 4

Newer repair techniques utilize special jigs that allow us to use a smaller incision. This involves the use of a jig to pass sutures percutaneously and repair the Achilles without a big open incision. One such system is the Arthrex PARS system. See images below.

Ruptured Achilles tendon repair – Image 5

Ruptured Achilles tendon repair – Image 6

Ask one of our experts if your rupture is amenable to repair with the PARS system.

There are many factors which influence a decision to operate on an Achilles tendon rupture. Most patients can be treated nonoperatively, as recent literature suggests that functional rehab has similar outcomes compared to surgery. Surgery has a slightly quicker return to work, but also a higher complications rate. In patients with several underlying medical conditions, surgery should be avoided due to high risk of complications. Note that functional rehab is not simply casting.
Surgery is indicated in those patients involved in high level athletics, patients who did not start casting / functional rehab with in 48h of injury, delayed presentation of a tear, MRI tendon gap size >5mm (high demand) or >10 mm (low demand), or patients where the Achilles is healing in an elongated position.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3509775/
https://pubmed.ncbi.nlm.nih.gov/33135439/

Yes. Assuming an average person of average activity, the Achilles can be treated with a protocol called “functional rehab”.
This involves splitting the ankle in plantarflexion for 2 weeks. Then you are placed into a rigid boot with 4 heel wedges for 2 weeks. At the 4-week mark, you start removing 1 wedge a week and increase weight bearing by 25% a week. Physical therapy typically starts around 4 weeks post injury. The boot is typically removed 8 weeks post injury. From there, you gradually build up strength, balance, endurance, and functionality.

Whether you have surgery or not, recovering from Achilles tendon rupture involves a period of immobilization, and then gradual return to weight bearing and walking. Typically, you are in a cast for 2-4 weeks, then in a rigid boot for up to 8 weeks post injury. Weight bearing can be started 4-5 weeks post injury and is increased in gradual fashion. Typical return to normal walking is approximately 2+months. Return to sport can range from 3-6 months depending on level of play.

There will be pain and swelling at the surgical site. This settles greatly after the first few days. The ankle is casted for approximately 2 weeks. During this time, you are not putting any weight on the affected foot/ankle. At 2 weeks post op sutures are removed and the ankle is placed into a rigid boot with heel lifts. At 4 weeks we start physical therapy. We also start gradually increasing weight bearing by 25% a week, and each week 1 heel life is removed. The boot is discontinued around approximately 8 weeks. That is when strengthening comes into play. We will provide an information booklet with more details regarding what to expect before, during, and after surgery.

There is a lot of research going into the use of platelet rich plasma (PRP) and bone marrow aspirate concentrate (BMAC). These adjunctive procedures are thought to help healing in sports related injuries.

Most of the literature around these injections is based around their use in patients undergoing surgery. The studies demonstrate mixed results. No large randomized controlled trials exist as of yet. However, some small studies suggest that there is earlier mobilization, quicker recovery of range of motion, and quicker calf circumference recovery with PRP / BMAC.

https://pubmed.ncbi.nlm.nih.gov/31370998/
https://pubmed.ncbi.nlm.nih.gov/25795246/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9501121/

To decrease risk of rupture, gradual and regular activity escalation is recommended. Sudden increases in specific pivoting activities places one at higher risk. Furthermore, steroid injection, certain antibiotics, and smoking are thought to play a role in risk of rupture. Warm up and stretching prior to use if recommended

Can you walk on a ruptured Achilles tendon?Can you walk with a completely ruptured Achilles tendon?
Most patients feel weakness and pain, which prevents them from walking. Although, some patients are able to walk with a ruptured Achilles tendon.

Animal studies suggest that it takes approximately 3 months for a tendon to fully heal and remodel to a pre-injury level. The rehab can take longer than this.

Ideally, a newly suspected Achilles tendon rupture should be splinted with the ankle in maximal plantar flexion. A sugar tong back slab splint is ideal. This will be transitioned to a rigid boot with heel wedges.

Splint Achilles tendon rupture – Image 1

Splint Achilles tendon rupture – Image 2

Splint Achilles tendon rupture – Image 3

This injury can be life changing. In athletes, it may end or postpone an athletic season. For the average person, it usually means that there will be a period where you will have less mobility. You may have a cast or a boot. You may have to use crutches for several weeks. You may require extensive physical therapy and exercises. Arrangements need to be made for transportation, work modifications, home accessibility modifications, and social support. Most patients recover to a pre-injury level with several months of appropriate treatment. Most athletes get back to playing high level sports.

After the initial phases of treatment, the Achilles has had a chance to heal. At this stage we will start physical therapy. This involves doing exercises which help build the Achilles tendon and associated muscles. There will have been atrophy of the muscle due immobilization. Doing these exercises daily is the best way to fight weakness and atrophy. Over time the goal is to get back to baseline strength and endurance.

The physical therapist should give you a home program. Try to do this program everyday. When you see the therapist, you should be trying to do those things you can’t do on your own. This includes stretches you can’t do on your own, use of equipment you don’t have, and local modalities (massage, ultrasounds, shockwave, TENS, etc.)

It is not recommended. Rupture of the Achilles causes mechanical disruption and pain to ankle plantarflexion. This will affect your ability to safely accelerate and brake. Furthermore, operation of a vehicle is not recommended with the use of a cast or brace.

Typically, patients return to driving once the brace is discontinued and they are walking normally. This is usually around the 8-week mark. It is important to have enough strength and reflexes to brake quickly in an emergency situation.

We recommended you start driving once cleared by your doctor. Start in an empty parking lot when you are confident in your stretch and reaction times. Work your way up to light traffic, heavy traffic, and finally the highway. It is important to do this in a safe and graduated fashion.

We do not recommend driving with a brace on. This compromises your ability to react in an emergency situation. It may make you prone to accidents

Most people will notice localized swelling for 3-6 months after a rupture, regardless of whether it is treated surgically or not. In some cases, patients may have swelling for over 12 months.

We recommend you continue physical therapy as long as it is helping you make progress. This is typically 3 months for most ruptures. Some patients find it useful to continue therapy for several months after they are walking.

Yes. It’s worth noting that environmental pressure is dropped in an airplane cabin. The pressure is less than what you experience at ground level. As a result, you may notice increased swelling and pain. You should exercise caution if you are flying with an unremovable splint or cast. You may have to remove a rigid boot to be comfortable.

Yes. Vast majority of athletes return to play after an Achilles rupture. Although there is huge variability in studies, this is estimated to be 80% of athletes. This may require 4-12 months of appropriate rehab to get to this point safely. Most return to play around 6 months post op.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5136353/

Yes. After appropriate treatment and rehabilitation.

Whether you have surgery or not, ideally you should try to keep pressure off the back of your heel (near the rupture site). Pressure in this area can affect vascularity, which can alter wound/tendon healing. It’s best to prop this area up on some pillows to maintain elevation and keep pressure off. Alternatively, you can sleep on your side with the affected side up.

Yes. Vast majority of patients return to baseline function, activity, and level of play. Treatment options are based around helping you return to your goals.

There is an association between plantar fasciitis and Achilles tendonitis. However, one does not cause the other. They can occur together or separately.

Yes, indirectly. Chronic Achilles tendon inflammation (tendonitis) can result in collection of scar tissue and inflammatory material in the tendon itself. This is called tendonosis. This tissue is not like your normal Achilles tendon. It causes pain and does not contribute to the tensile strength of the tendon. Over time, a significant portion of the tendon can be replaced with this unhelpful inflammatory tissue. This means that there is more force moving through the unaffected fibers. This placed the tendon at higher risk of rupture.

Typically, when we discuss Achilles ruptures, it refers to a complete tendon rupture. This means all the tendon fibers are disrupted. However, some patients have partial tears, where some fibers are preserved. Treatment depends on how much of the tendon is torn

The use of Fluoroquinolone antibiotics is associated with rupture of the Achilles tendon and tendonitis of all tendons. The risk of a rupture is 4 times more likely in those patients with recent fluoroquinolone use, and 46 times more likely in those patients with recent fluoroquinolone and corticosteroid exposure. Rupture can occur within days of use, but cases have been reported months later. The exact mechanism causing this is not well understood. Some examples of fluoroquinolone antibiotics include Ciprofloxacin, Levofloxacin, Norfloxacin, Pefloxacin, and ofloxacin.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2921747/

The following medications are associated with Achilles tendon ruptures: Fluoroquinolone antibiotics and corticosteroid medications (including injections)

Yes, indirectly. Chronic Achilles tendon inflammation (tendonitis) can result in collection of scar tissue and inflammatory material in the tendon itself. This is called tendonosis. Haglund’s deformity is associated with chronic Achilles tendon inflammation at the insertion. This tissue is not like your normal Achilles tendon. It causes pain and does not contribute to the tensile strength of the tendon. Over time, a significant portion of the tendon can be replaced with this unhelpful inflammatory tissue. This means that there is more force moving through the unaffected fibers. This placed the tendon at higher risk of rupture.

X-rays do not visualize soft tissues well. As a result, we typically cannot see an Achilles tendon rupture on an x-ray. However, it is important to rule out fractures and other ligament injuries. X-rays are useful in this respect. We may see some soft tissue fluid / swelling in the area of the Achilles. However, this is not a reliable sign of rupture.

Many cases of Achilles tendon ruptures are missed. This can result in poor healing and satisfactory results. Typically, these patients have chronic pain, weakness, fatigability, and more difficulty with day-to-day activities. They don’t tolerate running or sports.

The vast majority cases of Achilles rupture treated appropriately are not disabling. Most patients return to baseline (pre-injury) status with appropriate treatment and rehab.

Yes. It is very common to get spasms and cramping of the gastrocnemius and soleus muscle with Achilles ruptures. This will tend to settle down slowly as the Achilles heals. Muscle relaxants can be used to help with these symptoms.

During normal walking and exercise, force equivalent to 20 times your body weight goes through your Achilles tendon. Thus, more body weight means more force going through the tendon and increased risk of rupture.

While you are being treated you will require casting, rigid boot, crutches, mobility devices, etc. Due to this limited mobility and issues with accessibility, accommodations must be made to your environment to allow you to perform your daily tasks. As such, you should qualify for temporary ADA seating.

It is unlikely that you can run immediately after rupturing your Achilles tendon. With appropriate treatment, the goal is to get you back to running.

It is unlikely that you can wear high heels immediately after rupturing your Achilles tendon. With appropriate treatment, the goal is to get you back to wearing heels

Parkinson’s disease is not associated with Achilles rupture. However, there are reported cases of Parkinson’s medications that are associated with Achilles rupture. Due to poor muscle control, patients with Parkinson’s disease tend to have a slower recovery.

https://pubmed.ncbi.nlm.nih.gov/24614673/

Yes. These injuries are often misdiagnosed or missed completely. It helps to catch these injuries early on, for appropriate treatment. If you are suspicious regarding this injury, see the attention of one of our specialist

The Achilles is the primary plantar flexor of your ankle. However, other less powerful tendons are still likely intact. As such, if you rupture your Achilles, you may still be able to plantarflex your ankle.

Yes.

It is unlikely.

It is unlikely.

Yes. This is rare and usually associated with extreme exercise or trauma. However, it is more likely in patients on fluoroquinolones and corticosteroid medication.

This is often related to swelling around the foot and ankle. It causes limited ability to curl your toes. As swelling improves, so does toe range of motion.

Ankle braces can help with stability issues after a rupture, but there is little literature to support that they help prevent a rupture.

It is unlikely.

Yes

Yes

Yes

Yes.

It can be difficult while you are not weight bearing. However, you can start cycling, swimming, and walking, once cleared by your orthopedic surgeon. While not weight bearing, there are upper extremity cardiovascular exercise machines that can be used.

With appropriate treatment, healing rates are very high. Re-rupture rates are estimated to be 1.8%. The same mechanisms that result in the first rupture, can cause your Achilles to rupture again. You will feel similar pain, swelling, weakness, and loss of function, as compared to the first rupture.
You should urgently seek your orthopedist for examination and diagnostic imaging.

Approximately 4-6 months

You may hear a loud pop at the time of rupture. Sometimes it is audible to those in your vicinity. Sometimes there are no sounds at all.

These are very common injuries. Reported incidence rates among athletes are 7% to 18% in runners, 9% in dancers, 5% in gymnasts, 2% in tennis players, and less than 1% in American football players. Achilles disorders affect approximately 1 million athletes per year. The incidence of Achilles tendon ruptures varies in the literature, with recent studies reporting a rate of up to 40 patients per 100,000 patient population annually.

If you play basketball at a high level, an Achilles rupture will likely delay your season. However, with appropriate treatment, the vast majority of athletes return to the same level of play.

Achilles rupture is a mechanical deficiency that is the results of an acute event. Likely, there was a sudden sharp pain in the back of your ankle while playing sport. There was significant swelling, pain, weakness, and bruising thereafter.

Whereas, Achilles tendonitis tends to be a chronic inflammation of the tendon itself. It is worse in the mornings or after activity. There is no sudden weakness. Swelling tends to be moderate. Chronic tendonitis can increase the risk for a complete rupture.

Try to splint the ankle in a flexed position. The injured player should remain non weight bearing with crutches. We recommend transfer to an urgent care or emergency room for investigation and treatment.

Rigid tall ankle boot with 4 heel lifts

It is most common in jumping and pivoting sports. This includes basketball, tennis, track runners, gymnasts, and dancers.

Most Achilles ruptures are treated by orthopedist / orthopedic surgeons