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Achilles Tendon Ruptures/Tears - Diagnosis & Treatment

It’s extremely important to have an Achilles tendon tear diagnosed and treated as soon as possible. If treated quickly, you will likely get back to normal walking as well as stair climbing within 12 weeks. However, if treatment is delayed it can mean that your tendon heals in a lengthened position and you may not be able to regain full strength. In this article Maryke explains how to know that you’ve torn your Achilles tendon as well as what the correct treatment is.


I've also made a video where I explain some of this in more detail:



What it feels like when you tear your Achilles tendon


It usually happens during an activity where you load the calf and Achilles complex e.g. running, jumping, pushing a heavy object or in some cases just while walking or stepping down from something.


People often describe a sudden sharp pain or a sensation as if someone has kicked them on the heel or has hit them with a racket. You’ll often also hear a loud snap or pop, but not in all cases.


When you have a complete Achilles tendon tear, you may have surprisingly little pain. The research is showing that up to one third of patients will not report any pain in the Achilles tendon when they have a tear. This is because the tendon has fully snapped and there’s nothing pulling on the injured tendon anymore. People often describe just a mild ache in the calf or heel and a tiny bit of bruising or swelling.


You would expect someone with a torn Achilles tendon to struggle to walk, but this is also not the case for everyone. Most people will struggle to walk on their toes or do a single leg heel raise on the injured side, but if it is a partial tear or the other plantar flexor muscles are strong, you may still be able to go up on your toes without much problem.



Factors that can predispose you to tearing your Achilles tendon

  1. Longstanding Achilles tendinopathy: when you have an ongoing tendinopathy, it weakens your tendon. That is why it is so important to get a robust rehab programme and make sure that you strengthen your Achilles tendon properly when you have a tendinopathy.

  2. Fluoroquinolone antibiotics – this type of antibiotic has a really bad effect on the collagen in your body and can cause tendon injuries in as little as 1 dose and may also still affect it 6 months after taking the last dose. The most common one that is prescribed in the US is Ciprofloxacin or Cipro but they have several different brand names.

  3. Systemic corticosteroids: If you’re taking corticosteroid tablets or inhalers, it may increase the risk.

  4. Injections of corticosteroids: You also have an increased risk of rupturing your Achilles if you’ve had a corticosteroid injection into or around the Achilles tendon.

  5. Older people are more at risk. This is usually linked to their activity levels. The less active you are and the less you load your Achilles tendon on a daily basis through walking or other activities, the weaker it will be. So if you then suddenly jump off a step or push a heavy object it may not be able to withstand that force. Regular exercise that load the Achilles tendon is the best way to mitigate against this.

  6. Diabetes – uncontrolled sugar levels can affect your tendon health.

Consult a physio online for an assessment of your Achilles injury and a tailored treatment plan. Follow the link to learn more.

How are Achilles tendon ruptures or tears diagnosed?


The research is showing that 20% of cases are missed. So what is the best way to diagnose a complete or significant Achilles tendon rupture? You don’t necessarily need a scan as a clinician can make the diagnosis by listening to your history and also performing a few tests. The research has shown that it is actually better if they do ALL 3 of the following tests rather than just one or two. A score of 2 out of 3 means that it is extremely likely that you have a significant Achilles tendon tear.


Test 1: Angle of the ankle/foot


Achilles tendon tear test: Foot angle test
If the Achilles is torn, the foot hangs in dorsiflexion.

With the patient lying on their stomach on a bed so that their feet are dangling freely over the edge, observe the angles of the feet. Compare the one foot with the other. If the Achilles tendon is torn, the foot on the injured side will hang in more dorsiflexion. This test was modified by Matless in that he would get patients to bend their knees to 90 degrees and then observe the angle of the foot. Again, the injured foot would drop into more dorsiflexion while the uninjured one will be in slight plantar flexion. I discuss this i more detail in the video above.


Test 2: The Calf Squeeze Test (also known as the Thompson’s test)


Calf squeeze test or Thompson's test for complete Achilles tendon ruptures.
Normal motion of the foot for Calf Squeeze Test

With the patient lying on their stomach on a bed so that their feet are dangling freely over the edge, the clinician squeezes the calf muscles. If the Achilles tendon is torn, the foot will remain still while if the tendon is intact the foot will point down into plantar flexion (like in the picture) when you squeeze the calf.


Test 3: Feeling for a gap in the tendon


Palpating for a gap after you've torn the Achilles tendon.
Feeling for a gap is not a very sensitive test.

It’s not really that common to feel a gap in the tendon when it is torn. Also, the more time that passes between the moment you injure yourself and when someone performs this test, the less likely they are to feel a gap.


Important: These tests will likely not be positive if you’ve only got a partial tear in your tendon. The history of how it happened (sharp sudden pain) should still be enough to suspect a partial tear even if the above tests are negative.


Do you need a scan?


It is always good to get an ultrasound or MRI scan to confirm the diagnosis and gauge the extent of the injury, but it is extremely important not to delay treatment because you’re waiting for a scan. If there is anything in the patient’s history that suggests that they may have torn the Achilles (either partially or fully) place their foot in a plantar flexed position (either in a boot or at least in a shoe with a heel lift if nothing else is available) and give them crutches to take all weight off it until they can have a scan. I’ll talk more about why this is necessary under the treatment section.


Do you need surgery when you’ve torn your Achilles tendon?


No, the research is showing that patients who are treated conservatively by placing their foot in a boot, which keeps their foot in plantar flexion and allows early mobilisation and rehab, achieve exactly the same long term results as the ones who undergo surgery. I discuss these different options in more detail in the video above.


The main factor that can cause poor healing is when a person does not have their foot immobilised in a plantar flexed position as soon as possible. If they are placed in a boot but the foot is in a neutral position or just left to walk on it, the two ends of the torn tendon pull away from one another. This can cause the tendon to heal in a lengthened position which means that you’ll likely not regain full strength. It can also mean that you will likely need to have surgery to get the two ends back together and that the surgery will be more complex as it will be more difficult for the surgeon to bring the ends together.


Am I more likely to re-tear my Achilles if I don’t have surgery?


No, the research is showing that the re-rupture risk is exactly the same between people who are treated conservatively vs. ones who have had surgery.


High Risk of DVT


It appears that having a complete Achilles tendon tear can often lead to developing deep vein thrombosis (blood clots in the calf) – a condition that needs to be identified and treated immediately when it occurs. If you experience any of the following symptoms, I would suggest that you contact your doctor immediately or go to A&E to have it checked:

  • Significant swelling in the calf

  • The calf or ankle may feel hot/warm to touch

  • It may look red in areas of the calf

  • You will likely experience quite a bit of pain in the calf or around the ankle and it is often described as a throbbing pain that is worse when your feet are down (e.g. sitting or standing) compared to when you’re lying down but it may feel different for you.


Rehab for Achilles tendon ruptures


Whilst clinicians may disagree about whether surgery or conservative treatment is the best solution for an Achilles tear, the one thing that they do agree on is that following an extensive, progressive rehab programme is key to making a good recovery. When and with what rehab you can start with, will depend on your specific case, whether you had surgery or opted for conservative treatment with a boot. There are also a few different protocols that can be followed depending on the type of boot you’ve been wearing and what your doctor has felt is best.


How we can help


We can help guide you through your rehab to ensure that you make the best recovery possible. If you suspect that you’ve torn your Achilles tendon, the first step should always be to see a doctor or physio in person who can diagnose it for you and can immobilise your foot in plantar flexion in a boot and/or refer you to surgery if appropriate.


Our role starts once you’ve been cleared to start with rehab. It can take 9 months or longer to properly regain the strength and control in your calf/Achilles complex. Yes, it is likely that you may end up with a slight reduction in strength on the injured side compared to the uninjured side, but I often find that patients are prematurely discharged from rehab or not actually prescribed the correct level of rehab to allow them to regain full strength.


Let me know if you have any questions. Need more help with your Achilles injury? You’re welcome to consult one of us online via video call for an assessment of your injury and a tailored treatment plan.

Best wishes

Maryke


About the Author

Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn, ResearchGate, Facebook, Twitter or Instagram.



References:

  1. Barfod, K. W., et al. (2020). "Risk of Deep Vein Thrombosis After Acute Achilles Tendon Rupture: A Secondary Analysis of a Randomized Controlled Trial Comparing Early Controlled Motion of the Ankle Versus Immobilization." Orthopaedic journal of sports medicine 8(4): 2325967120915909.

  2. Brukner & Khan et al. (2016) CLINICAL SPORTS MEDICINE: INJURIES, VOL. 1

  3. Guss, D., et al. (2015). "Acute Achilles tendon rupture: A critical analysis review." JBJS reviews 3(4).

  4. Manent, A., et al. (2019). "Acute Achilles Tendon Ruptures: Efficacy of Conservative and Surgical (Percutaneous, Open) Treatment—A Randomized, Controlled, Clinical Trial." The Journal of foot and ankle surgery 58(6): 1229-1234.

  5. Singh, D. (2017). "Acute Achilles tendon rupture." British Journal of Sports Medicine 51(15): 1158-1160.

  6. Wu, Yaohong, et al. "Is surgical intervention more effective than non-surgical treatment for acute Achilles tendon rupture? A systematic review of overlapping meta-analyses." International Journal of Surgery (2016).