Achilles tendon tear: Causes, Symptoms, and Treatment

The Achilles tendon is the supposedly strongest tendon in the human body. It is located at the calcaneus tuber and combines the end tendons of the three calf muscles as the end tendon of the musculus triceps surae (calf muscle).

In the case of an Achilles tendon rupture, which is caused by degenerative damage, it is a complete severing of the tendon, usually as a result of direct or indirect force.

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Development of an achilles tendon tear

In addition to the wear and tear factors, which are due to the weaker blood supply to the tendon tissue with increasing age and the purely mechanical explanations for the occurrence of an Achilles tendon tear, there are also biological aspects which will be briefly explained at this point.

Concerning these biological aspects, patients are particularly at risk who take certain drugs, such as cortisone or cytostatics.

Antibiotics from the group of gyrase inhibitors (fluoroquinolones) such as ciprofloxacin (Ciprobay) or ofloxacin (Tarivid) are also thought to increase the risk. They are used to treat cystitis (inflammation of the bladder), but also diseases of the nasopharynx.

  • suffer from diabetes (= sugar disease).
  • suffer from chronic diseases of the connective tissue (rheumatism, gout, autoimmune diseases).
  • suffer from general circulatory disorders or chronic connective tissue diseases.
  • suffer from specific infectious diseases.

Mainly when Achilles tendon tears occur on both sides, biological aspects can be assumed to be the cause.

Even with good physical condition, a rupture of the Achilles tendon can occur. This is particularly the case if the tendon fibers were not warmed up sufficiently during the warm-up phase, or if so-called lactic acid fatigue occurs due to a low PH value. In both cases, the Achilles tendon is mechanically overstressed, and tearing is encouraged.

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Causes

A rupture of the Achilles tendon usually occurs spontaneously, without the person affected having pain or other symptoms. In almost 90% of the cases, it is a rupture that occurs when the tendon is subjected to heavy sporting strain. Therefore, most of those affected are also young men who are active in sports. Nevertheless, in most cases, there were minor injuries (micro-fractures) to the tendon beforehand, which reduced its resilience during the following sporting activity. Also, the tendon can be damaged by injuries, for example, by a cut in the heel area. If this injury is intense, the tendon can be completely severed.

Some drugs also affect the strength of the tendons in the body. Taking such drugs can, therefore, lead to an increased susceptibility to tendon ruptures of all kinds. Drugs that can promote tendon rupture include certain antibiotics (gyrase inhibitors), corticosteroids, and immunosuppressants. Although the Achilles tendon can withstand extreme mechanical stress, it can be subject to wear and tear due to age or illness.It is less resilient in people who are not active in sports because it is not subject to stress.

Besides, the Achilles tendon of athletically inactive people is less resilient, as they are not used to strain and therefore tend to yield more quickly when strain suddenly sets in. The signs of wear and tear also lead to reduced extensibility of the tendon. The connective tissue fibers of which the tendon is made are partially damaged in this case so that the structure of the tendon, which provides support, is no longer intact. All these factors can additionally promote a rupture of the Achilles tendon.

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Other causes of an Achilles tendon rupture

Problems of the Achilles tendon

The Achilles tendon, as such, is mechanically very resilient. A maximum load capacity of up to 400 KP is assumed. The cause of an Achilles tendon rupture is usually favored by wear and tear processes, which can be intensified by a possibly poor training condition. With such causes, the entire muscle and tendon apparatus is significantly less elastic, making the rupture more likely. As a result of maximum load (unexpectedly high force), for example, when starting to sprint, when jumping off or coming up after a jump, when skiing or playing football, an Achilles tendon rupture can occur. As a rule, the rupture is accompanied by a loud bang, the acoustic appearance of which can be compared to a whip cracking. Usually, the Achilles tendon is then wholly torn. The Achilles tendon usually tears at the narrowest point. You can feel this point yourself: starting from the uppermost part of the heel bone (rear edge), you go up about 5cm.

After a tear, plantar flexion (active bending of the ankle joint, e.g., tiptoe flexion) of the foot is no longer possible due to the missing connection between the calf and the rear edge of the heel bone; the patient can no longer walk normally.

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Symptoms of the Achilles tendon tear

As already explained above, the rupture of the Achilles tendon is accompanied by a loud bang (whiplash). Besides, the patient suffers from stabbing pain and is no longer capable of active plantar flexion due to calf compression. Typically, the patient is no longer able to stand on one leg or toe on the diseased leg.

A tear of the Achilles tendon becomes visible from the outside due to a swelling at the back of the ankle joint, and possibly also a bruise becomes visible. The doctor can also feel a distinct dent in the musculature.

Pain due to a torn Achilles tendon

The affected person usually notices a rupture of the Achilles tendon due to the immediate onset of pain, which usually makes further strain on the affected extremity immediately impossible.

The intensity of the pain depends on the extent of the damage caused to the tendon by a complete or incomplete rupture and can be very intense even under resting conditions. The injured person feels as if he or she has received a violent kick against the heel. The ability to walk is severely restricted.

In addition to the correct execution of the treatment measures by the attending physician, the patient should also strictly observe the prohibition of sports and the medical instructions, as pain can become chronic even after successful treatment and lead to permanent limitations of the patient’s ability to walk (achillodynia).

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Diagnosis of the Achilles tendon rupture

A rupture of the Achilles tendon can be diagnosed in different ways. If the tendon is completely severed, a gap above the heel can often be palpated. A fresh rupture of the Achilles tendon reveals a severe and painful swelling of the tissue, as well as redness or blue discoloration of the heel region. The patient can no longer walk on tiptoe because the rupture of the Achilles tendon cuts the connection between the calf muscles and the heel bone. If the patient lies on his stomach on a couch and his calf muscles are squeezed together, the foot would generally have to bend towards the sole (plantar flexion). With a torn Achilles tendon, this no longer happens for the reasons mentioned above. This phenomenon is also called a positive Thompson test.

The instrumental diagnosis of Achilles tendon rupture is based primarily on sonography (ultrasound examination). The treating physician can use the ultrasound machine to directly display the affected region on the screen and assess the extent of the rupture. The choice of the treatment method is then also determined by this. If the ends of the Achilles tendon are only slightly apart, the patient can usually be helped by conservative therapy. However, if the distance between the ends is extensive, often only surgery can help. In addition to ultrasound, an MRI of the Achilles tendon can also help to diagnose a torn Achilles tendon. The MRI is used if the ultrasound is not conclusive enough or if atypical complaints are indicated without a clear cause. The MRI makes it easier to identify already healed ruptures, in complete tears, and other changes in the tendon.

Diagnosis of an Achilles tendon rupture

As soon as the first symptoms of the Achilles tendon rupture have subsided, the patient will notice that he or she is no longer able to walk normally. This is known as a functional failure, which is also noticeable in that the patient is usually not able to stand on one leg or toe.

Clinical examination

In the first few hours after the Achilles tendon rupture, the treating physician can palpate a dent an inch above the insertion. However, this is only possible in the first few hours after the accident. Later, a hematoma forms there due to bleeding, which would make the diagnosis of the Achilles tendon tear much more difficult.

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Thompson test

Plantar flexion is usually eliminated after the Achilles tendon rupture. In patients with deep flexor muscles, residual flexion may be retained, although this is usually significantly different from the reasonable condition. To better assess plantarflexion (bending of the foot), the so-called Thompson test can be performed to diagnose the Achilles tendon rupture. For this, the treating physician presses on the calf area. This compression (see figure) makes plantar flexion impossible in the case of an Achilles tendon tear.

In about 70% of all cases, a rupture of the Achilles tendon can also be detected and precisely localized using sonography.

An X-ray can also be taken to exclude a bony tear of the Achilles tendon. This exclusion can have decisive effects on the treatment.

Treatment

The course of the Achilles tendon tear is mainly influenced by the chosen treatment method. Surgical treatment methods can more often be accompanied by wound healing disorders and infections in the surgical area. With intensive therapy combined with physiotherapeutic training, the original mobility and performance capacity of the tendon can be regained in most cases. Furthermore, it is decisive whether the tendon is completely torn or only torn. If it is completely torn, a distinction can be made as to whether it has torn off together with a piece of bone or not. Since the type of Achilles tendon damage also determines the therapy, this factor is decisive for the course and prognosis of the disease. Especially for top athletes, full performance can often no longer be achieved, as the tendon cannot return to its original state 100%. At least some residual scar tissue remains, which can already reduce the performance level in high-performance sports. It is essential that the Achilles tendon tear is detected early and treated accordingly. Otherwise, it can lead to permanent functional impairment with a decline in calf muscles. The same applies to failed operations or other unsuitable therapeutic measures.

Conservative therapy

Conservative therapy means that the Achilles tendon rupture is not treated surgically, but other methods are used to heal it. Conservative therapy measures are used mainly with only torn tendons, as well as with older patients, who will subsequently put less strain on the tendon.

These measures mainly include temporary immobilization of the affected ankle in a unique plaster cast or shoe. These particular shoes are equipped with a heel elevation that promotes the torn tendon to heal. Besides, the patient can put weight on foot again at an early stage, thanks to the particular unyielding shoe. After about 3 weeks, additional physiotherapeutic measures are usually initiated to promote and restore the mobility of the Achilles tendon, including the lower leg and foot. This therapy should be continued until the original functionality is regained.

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Operative therapy

Surgical therapy must often be considered, especially for young people who want to do sports, as well as when there is a long distance between the ends of the torn Achilles tendon. The operation can be performed either under local or general anesthesia. The torn tendon is exposed during the operation, and the free ends are reattached to each other with sutures. If the tendon has torn off together with a piece of the calcaneus, the torn-off piece of bone is screwed back onto the calcaneus. Thus the tendon is simultaneously reattached.

If the tendon is severely worn and porous, it may be necessary to have a plastic tendon surgery. For this purpose, a piece of tendon is removed from the patient at another location, which then serves to bridge the damage to the Achilles tendon. The tendon of the musculus plantaris longus is often used for this purpose. It does not perform any vital function and is created in most patients.

The advantage of the surgical therapy compared to conservative measures is that the Achilles tendon is more stable afterward, and a renewed rupture occurs significantly less frequently. Following surgical therapy, the foot must be immobilized for several weeks. Afterward, physiotherapeutic measures can be initiated to regain the functionality of the foot.

Abstention from therapy

If the tear is not treated, the strength of the tendon will decrease considerably.

If the Achilles tendon rupture is not treated, this can lead to severe functional losses. The ends of the tendon grow scarred together again within a few months, but this leads to a significant lengthening of the tendon through the scar tissue. This causes a functional restriction of the calf muscle, as it cannot develop the optimal strength due to the lengthened tendon. Affected patients suffer from a lack of strength in the ankle joint. In this case, even intensive training measures cannot restore full functionality. A comparable symptom pattern can develop if therapy measures fail. Therefore, an experienced doctor should be consulted for therapy of the Achilles tendon rupture.

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Healing time

The healing time of an Achilles tendon rupture depends on the severity of the rupture. If the tendon is completely torn, the duration of therapy is usually at least 6-8 weeks. The strain on the tendon should be slowly increased again and only return to the initial level after about 3 months. Heavy loads, such as in high-performance sports, should only be reapplied after about 6 months.

Immediate measures

After the initial robust and stabbing pain, the patient is almost pain-free after a short time. The swelling that was mentioned in the symptoms is not always present. Nevertheless, a doctor must be consulted as soon as possible in every case. This is of fundamental importance for the correct diagnosis and subsequent therapy (cf.: Diagnosis).

After the rupture, only first aid measures can be carried out, which are limited to cooling the heel region and avoiding the occurrence on the injured leg, supporting the patient while walking (by supporting the patient, walking aids (crutches), if necessary also by a transport couch).

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Prophylaxis

Prophylactically it can only be stated here that regular sporting activities have a positive effect on the elasticity of the entire muscle and tendon apparatus.

At this point, the avoidance of abrupt and heavy loads could be mentioned. The avoidance of particular “risk sports” (squash games) could also be mentioned. Athletically active people should pay attention to a proper warm-up phase before the sport. Stretching exercises – especially after sporting activity – also serve as prophylaxis.

Prognosis

Prognostically, a rupture of the Achilles tendon can be considered reasonable. In the case of ideal therapy and appropriate rehabilitative measures, the performance level before the accident can be reached again under certain circumstances.

Often, however, an Achilles tendon rupture means the end of the career for top athletes, especially for those who have qualified in jumping or running sports.

About the form of therapy, it should be said that the prognosis is statistically better after surgical therapy than after conservative therapy. While about 4% of patients with surgical therapy develop new tears, the rate of conservative therapy is about 15%.

However, postoperative swelling often results in longer-lasting swelling. Patients also report numbness in the heel and ankle area.

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Summary

Only rarely does the Achilles tendon rupture occur with advance notice, for example, through pain or irritation. Consequently, people who are active in sports are more often affected by a rupture than average. An accumulation is found in sporty active men between the ages of 30 and 50 years.

The rupture of the Achilles tendon is usually not to be overheard. Patients speak of a loud bang or a whiplash, usually associated with stabbing pain. Since the Achilles tendon is indispensable for normal human gait, it must be ensured that the patient is treated professionally as soon as possible.

In principle, concerning therapeutic measures, a distinction is made between surgical therapy and conservative therapy, whereby both forms of therapy have their justification. Nevertheless, it can be said that younger patients are, in principle, more likely to benefit from surgical therapy, since the probability of stress (sport and work) is significantly increased in younger patients. In older patients, on the other hand, conservative therapy predominates for Achilles tendon rupture. Studies have also shown that some countries tend to use conservative therapy measures.

In the context of surgical therapy, a distinction is made between various forms of surgery, which will be discussed in more detail in the therapy (see above). Which measure is taken depends, among other things, on the age of the rupture or the type and nature of the tear.

In both forms of therapy, a duration of about 12 to 16 weeks must be estimated. The duration of immobilization is about 6 weeks. Immobilization is carried out in the first 4 weeks in the pointed foot position, whereby the degree of the pointed foot position varies. As a rule, the pointed foot position is 30 to 40° in the first two weeks and is then reduced to 10 to 20° in the third to fourth week. At the end of the immobilization, the lower leg walking cast is then made in a plantigrade (= 0°) foot position.

The load possibilities increase successively in this three-stage immobilization. This will be discussed in detail during the therapy (see below).

In particular, after intensive rehabilitation measures, one can assume that the patient will almost completely regain his or her accustomed performance capacity.

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