Achilles Tendon Injuries

The Achilles tendon is located in the lower back of the leg. It is the largest and the thickest tendon of the body. Injuries to the Achilles tendon are common among athletes and nonathletes alike.

A tendon injury may result in complete rupture or tears of the tendon. Chronic overuse while running and jumping may result in inflammation of the tendon.

X-ray showing the normal soft tissue shadow of Achilles tendon.

The Achilles tendon connects the calf muscles with the heel bone (calcaneum). The tendon helps the calf muscles to flex the foot. The foot is pressed against the ground to produce counter force. This action is utilized in walking, running, and a variety of other activities such as jumping and walking tiptoed.

Causes of Tendon Rupture

The Achilles tendon is susceptible to rupture in the age groups of 30 – 40 years old. The cause may be violent or even minor trauma. The tendon bears constant wear and tear from day to day activities.

• Diabetics and Obesity are risk factors for tendon tear or rupture with minor trauma.
• Steroid injection given in the ankle makes the tendon more prone to rupture.
• Antibiotics such as fluoroquinolones may also result in Achilles tendon rupture due to side effects.
• Fall from height landing and landing with a straight knee commonly injures the tendon.
• The accidental forceful upper movement of the foot can lead to rupture.
• High impact activities such as jumping and sports such as softball, basketball, track, and field may result in tendon injuries.
• A sudden increase in training or tight calf muscles may also result in Achilles tendon injuries.
• Sharp injuries to the back of the lower leg may result in tendon injuries.

The Achilles tendon usually ruptures an inch or two above the insertion in the heel. This because the area relatively receives less blood supply.

Symptoms

The symptoms of Achilles tendon injuries are sudden pain with swelling. The patient may report a loss of function of the involved leg.

The patient is unable to walk tiptoed and has decreased strength. There may be associated swelling just above the heel. The patients report to hear a pop or snapping sound at the time of the rupture.

Achilles tendonitis is the inflammation of the tendon fibers. The symptoms are usually pain and swelling above and around the heel. The pain is usually less in intensity compared to tendon rupture.

Diagnosis

The diagnosis of Achilles tendon injuries is best made by an orthopedist. The physician will take a detailed history of the events leading to injury. The physical examination included an examination of the swelling and tender points. Special tests are done to check the integrity of the tendon such as squeezing the calf muscles to look for foot movements.

The radiological examination includes an X-ray to look for any associated fractures and the clear space behind the shin bone. An ultrasound will usually detect tendon tear and the gap between the two ends. MRI can provide a detailed view of the torn or ruptured tendon.

Management

The management of inflamed tendon is usually conservative with rest, icing, compression and elevation, and sometimes splints. Nonsteroidal anti-inflammatory drugs NSAIDs may be used to reduce pain and swelling.

Minor tears of the tendon heal on their own and do not require any surgical intervention. The affected leg may be placed in a cast/splint to allow adequate rest to the tendon while it heals.

Torn Achilles tendon with a significant gap between the tendon requires surgical repair. Both open and minimally invasive techniques may be used to repair the torn tendons. Old ruptured tendons with significant gaps often require an additional graft to repair the tendon.

Rehabilitation

After the surgery, the lower leg along with the foot is placed in a cast. The cast is changed after a few weeks to a more neutral position. After the cast is cut in 6-8 weeks, the walking boot is used and physical therapy is started. The physical therapy is aimed to strengthen the muscles and increase range of motion.