Treatment for Achilles Tendon Rupture

by PTonline

Those who have experienced an Achilles tendon rupture say they hear a snap or a pop when it happens, followed by a feeling that makes them think they’ve been kicked in the back of the heel or even shot.

“I’ve also had patients describe it like a window shade rolling up,” says David McIntosh, DPT, a physical therapist at Redbud Physical Therapy in Tulsa, Okla. Walking properly becomes impossible and toe raises become a long-forgotten dream, although with a partial rupture patients may be able to move the affected foot.

The Achilles tendon is a large, strong, fibrous cord connecting the gastrocnemius and soleus muscles to the calcaneus. Its essential function allows people to rise up on their toes, point the foot downward, and push off every time they take a step.

Tearing away pain

Strains to the Achilles tendon are divided into three grades, McIntosh says. Grade I is a pulling away of the fibers within the tendon; Grade II is a partial tear; and Grade III is a complete rupture. Other conditions that can affect the Achilles tendon are bursitis and tendonitis.

“Typically, the older male, as the tendons start to break down over age, is more susceptible to injury,” says McIntosh, who reports that men in their late 30s or 40s are often affected.

James Shields, PT, DPT, OCS, physical medicine flight commander at Wright-Patterson Medical Center at Wright-Patterson Air Force Base in Ohio, adds that other patients at risk are former high school or college athletes who are injured while running, or when playing basketball or racket sports.

“It does seem that Achilles tendon patients have a history of competitive athletics,” says Shields, who also is a major in the U.S. Air Force. “They are also the population who are more likely to be your weekend warrior.”

Symptoms of an Achilles tendon strain include pain or swelling near the heel and an inability to plantar flex the foot or walk normally. Potential causes include overuse, running on hills and hard surfaces, poor stretching habits, tight or weak calf muscles, using worn-out shoes, and overpronation.

Activities involving stop-and-start footwork also lead to Achilles tendon injuries, McIntosh says, with basketball ranking as the top culprit. Additionally, people who are flat-footed are more susceptible to Achilles tendon injuries because the condition places more stress on the tendon when walking, McIntosh adds. Other conditions that predispose someone to Achilles injury include microtrauma and acute tendonitis.

Interestingly, injury to the left Achilles tendon is more prevalent than injury to the right, Shields says. The theory behind this is that most people are right-handed and push off with their left foot. Those who have suffered a rupture to one Achilles tendon are more likely to suffer one to the other tendon, he says, possibly from underlying biomechanical deficits or exposure to fluoroquinolone antibiotics such as ciprofloxacin. Although the quadriceps, rotator cuff, long head of the biceps, and extensor pollicus longus tendons are also vulnerable, the most common site of fluoroquinolone-associated tendon disruption is the Achilles tendon.


Some believe steroid injections can contribute to Achilles ruptures, Shields says, but people tend not to receive these injections until they’ve already had significant Achilles problems, and studies showing that corticosteroid injections may increase the rupture rate have been limited to case studies only.

Eccentric recovery

“When you talk about whether to do conservative rehab or surgery, the difference there is going to be if you have a rupture of the tendon, which is a tear that goes all the way through,” McIntosh says.

Surgical repair and nonsurgical treatment both have their advantages and disadvantages, Shields observes. Patients who have their Achilles tendon repaired surgically are more likely to return to their sport, and are more likely to regain full power, he says. Atrophy is less of a problem and the re-rupture rate is lower than with nonsurgical treatment. But the advantages of the nonsurgical route are lower cost, quicker rehab time, and a lower risk of infection.

Partially torn Achilles injuries are treated with ice, stretching, electrical stimulation, and anti-inflammatory medications. Postoperative therapy for ruptures involves immobilizing the foot by placing it in a cast or walking boot for up to two months, McIntosh says, in addition to stretching exercises to prevent the ankle from “locking down.”

“If you were not to do anything, you would definitely get a stiff ankle, which would make it more difficult to walk,” he says. That, in turn, could lead to knee and hip injuries caused by walking incorrectly.

With a rupture, rehab usually begins around 10 days after surgery and includes submaximal isometrics, active dorsiflexion, and passive plantar flexion. Advances in treatment, Shields says, include the emphasis on eccentric training for chronic Achilles tendinosis as opposed to concentric training. An eccentric exercise for the Achilles tendon, for example, would entail standing on a step and lowering the heel down.

“You can control a greater load on an eccentric contraction than you can lift on a concentric contraction,” he says.

Stretching usually is recommended to prevent an Achilles injury. A good way to stretch the Achilles tendon, McIntosh says, is to lie on your back on a flat surface and pull the ball of the foot back with a belt. Doing it with a straight leg stretches the gastrocnemius muscle, while doing it with the knee bent stretches the soleus muscle that lies beneath.

Despite the fact that stretching is almost always recommended as a way to prevent Achilles tendon injuries, Shields notes that while decreased flexibility is associated with these injuries, increased flexibility has not been scientifically proven to decrease risk.

“The evidence that it helps in prevention has not been substantiated to the extent you would think, given the advertising it gets,” he says. “It’s very difficult to prove prevention.”