The Achilles tendon (or heel cord) is the largest tendon in the human body. It connects the calf muscles to the heel. It is made up of many strands, making it strong and flexible. Its function is to help in bending the foot downwards (e.g. going up onto tiptoes and also helps to push us forwards when walking or running.
If the tendon is torn, this is called an Achilles tendon rupture. Sometimes the tear may be partial and usually occurs where the tendon joins the calf muscle. A partial tear is managed slightly differently from a rupture and usually involves resting the ankle in a boot for a few weeks.
Achilles tendon rupture affects about 1 in 15,000 people at any one time, increasing to 1 in 8,000 in competitive athletes. It can occur at any age but is most common between the ages of 30 and 50. The Achilles tendon usually ruptures without warning.
As with any muscle or tendon in the body, the Achilles tendon can be torn if there is a high force or stress on it. This can happen in activities which involve a forceful push off or lunging type movement e.g. football, tennis, badminton, squash. The push off movement uses a strong contraction of the calf muscles which can stress the Achilles tendon too much. The Achilles tendon can also be damaged by injuries such as falls and slips where the foot is suddenly forced into an upward pointing position. Sometimes the Achilles tendon is weak, making it more prone to rupture. This could be due to specific medical conditions e.g. rheumatological conditions or medication combinations such as steroids and certain antibiotics. It can also occur when there has been long term Achilles tendonitis. This is where the tendon becomes swollen and painful and leads to small tears within the tendon. These tears cause the tendon to become increasingly weak and therefore more at risk to rupture.
You may experience a sudden pain in your heel or calf. The pain may then settle to a dull ache or it may go completely. This can be associated with a snapping or popping sound. Patients often describe the feeling as if someone has hit them in the back of the leg, only to turn around and find no one is there. After rupture of your Achilles tendon, there may be some swelling and bruising in your calf and ankle. It is usually difficult to walk, with only a flat footed type of walking being possible. It is also usually difficult to push off the ground properly on the affected side. You may be unable to stand on tiptoes or climb stairs. A partial tear of the Achilles tendon is rare, so any acute injury to the Achilles tendon should be assumed to be a complete rupture.
It is usually possible to detect a complete rupture of the Achilles tendon on the symptoms, the history of the injury and a doctor’s examination.
A gap may be able to be felt in the tendon, usually 4-5 cm above the heel bone.
A special calf squeeze test will be performed. Normally if the Achilles tendon is intact this causes the foot to point downwards but if it is ruptured it causes no movement. To confirm the diagnosis and the exact site of the rupture it may be necessary to perform an ultrasound scan.
There are two treatment options available for Achilles tendon ruptures. These are non-operative (conservative) and operative (surgical). We employ conservative treatment (functional bracing) in the majority of patients, as the evidence suggests similar results to surgery without the associated complications. Occasionally, surgery may be considered, especially in cases of delayed presentation or atypical ruptures.
This is the use of a specialised boot that holds your leg in a set position to allow healing of the tendon while allowing you to function as normally as possible. With conservative treatment, you will follow a set regime that involves initially being in a boot with wedges placing the foot in a fully bent downwards (equinus) position. This puts the tendon ends as close as possible to each other to help them to heal. The boot is from the knee down to the toes, held in place with Velcro straps.
The boot should be worn at all times, including in bed, to ensure that your tendon is protected throughout the healing process. While wearing the specialist boot, you should fully weight bear on your whole foot.
As you will be less mobile than previously, you will have a risk assessment for bloods clots (venous thromboembolism (VTE)). If you are felt to be at risk, you will be prescribed blood thinning injections for six weeks from the date of your injury.
You will visit Fracture Clinic and physiotherapy for regular skincare appointments and to progress to rehabilitation when ready. During these visits you will be shown how to adjust the wedges from your boot one at a time to allow your foot to come up into a more neutral position.
The total treatment time will be approximately nine weeks. You will be referred for physiotherapy to start towards the end of your boot treatment. It may take several months for your symptoms to completely settle.
Risks of conservative treatment:
This is not usually the preferred treatment option as the risks of complications may outweigh the benefits. However, surgery may be considered for certain patient presentations, these being:
However, patients have to consider potential complications of surgical intervention (risk increase of around 16% compared to conservative treatment).
Risks of surgery:
Patients undergoing surgery will be booked in to have surgery within a week or two following clinic review. On the day of surgery, you will be admitted to the ward. Your surgeon will remind you of the surgical process and possible complications and will ask you to sign a consent form. The anaesthetist will also meet you and discuss any queries.
At some point during the morning or afternoon, you will be escorted to theatre. Once in theatre you will be given an anaesthetic. The procedure lasts about 45-60 minutes and involves making a cut in the skin over the Achilles tendon and repairing the tendon with sutures.
After the procedure you will have a cast applied. You will be shown how to use crutches as you should not weight bear on the cast. Most patients should be able to go home the same day. You should be accompanied home by a responsible adult.
You will be advised of your follow-up appointment date, either on the day or by letter in the post. Your stitches will be removed at two weeks following surgery in outpatients and you will then go through functional bracing (see above) like conservatively managed patients.
On presentation at A&E / Minor Injury Unit:
Fracture Clinic
| Week | Device | Position | Weight bearing status | Duration |
|---|---|---|---|---|
| Week 0-4 | Device Aircast boot | Position 3 wedges Patient to be referred for physiotherapy | Weight bearing status FWB (crutches may be needed) | Duration 4 weeks |
| Week 5 | Device Aircast boot | Position 2 wedges | Weight bearing status FWB | Duration 1 weeks |
| Week 6 | Device Aircast boot | Position 1 wedges | Weight bearing status FWB | Duration 1 weeks |
| Week 7 | Device Aircast boot | Position 0 wedges | Weight bearing status FWB | Duration 1 weeks |
| Week 8 | Device Supportive footwear | Position Provide single gel heel pad | Weight bearing status FWB | Duration 2 weeks |
NB: Skin should be inspected daily, the foot should always be kept in a toes down (equinus) position when not in the boot.TTWB – toe touch weight bearing FWB – full weight bearing.
Should you suffer from any of the following symptoms, please seek medical advice:
A referral will be made for physiotherapy to start from week 7.
This usually starts towards the end of your boot treatment. A physiotherapy referral request should have been made at the beginning of your treatment and you should have been contacted by the relevant physiotherapy team with an appointment date. Contact information for physiotherapy department:
Below is a basic protocol but this may differ according to the individual.
