Ruptured Achilles

Findings

a)      The prone-lying attitude is vertical, whereas the normal foot has a degree of plantar flexion

b)      If an athlete lies prone, with the knee bent, the ruptured Achilles foot will lie horizontal, whereas the normal foot lies with 20-30 degrees of plantar flexion

c)      Simmonds’/Thompson’s squeeze test is positive

d)      The athlete cannot rise on toptoe, although passive dorsiflexion may be pain-free.

e)      The calcaneotibial compression test is negative

Cause

Extrinsic cause – the tendon being cut by a knife, glass, etc.

Intrinsic causes – acute overload of the Achilles, possibly during an uncoordinated movement between the quadriceps and calf muscles, particularly if the calf muscle is actively working whilst the knee is bent. The rupture may occur apparently de novo, or following existing degeneration or partial tear of the tendon, which may have been asymptomatic. It is more common in sedentary workers. Partial rupture of the Achilles can occur and is treated as a tendinopathy. Fluoroquinolones may increase the rate of rupture.

Treatment

a)      Surgery is advisable for sportspeople, the repair being stronger than the cast bracing.

b)      Cast or brace the foot into equines, and gradually move the foot towards neutral by readjusting the brace.

c)      Postoperative rehabilitation, via the Achilles ladders.

d)      Partial rupture may be treated initially as an Achilles tendinopathy.

Sports

      Athletics – a sudden increase in speed, or distance, may create too much load for the tendon. Camber running encourages lateral movement of the calcaneum and bowing of the tendon. Repetition sprints, with too little recovery time, can fatique the quadriceps, causing an upset in calf/quadriceps coordination. Uphill running may produce overload of the Achilles.                             

       Hill walking and climbing – when climbing using the forefoot, the heel may drop too low, increasing the forces on the Achilles. However, by using “high heels”, i.e. finding a rock to support the heel, or zig-zagging up the hill using the sides of the foot, this problem is prevented.

        Cricket – very often an Achilles tendon tears when a back foot shot is played to mid-wicket, and a quick single is run. The weight is on the ball of the back foot activating the calf and then the knee straightens for the run, upsetting the calf/quadriceps coordination.    

       All sports – sudden acceleration from a bent knee position and a plantarflexed foot.

Most results suggest that the damaged Achilles and calf never recover full strength. A surgical repair achieves the best return of power and athletes can return to sport. Stem cell transplants this time may have a future. Achilles rehabilitation should be maintained even after a full return to sport.

This diagnosis is still missed too frequently because too much emphasis is put on Simmonds/Thompson’s test, which can be made to produce plantar flexion by squeezing the posterior tibialis muscle. The prone-lying foot attitude is a very good indicator. Ultrasound is relatively cheap and should be used if there is any doubt as to the diagnosis. Late surgical repair may be undertaken, but the best results are obtained when performed within the first 2 weeks.

"Concise guide to sports injuries, 2^nd edition",Churchill Livingstone, Malcolm T.F. Read,  foreword by Bryan English