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Physiotherapy and Medical Treatment of Achilles Tendon Rupture
by Jonathan Blood-Smyth
The largest and the strongest tendon in the body is the Achilles tendon in the distal posterior calf. Typical patients with Achilles tendon rupture are men in good health from 30-50 years old and who have not suffered major injuries or any kind of difficulty with the leg before. Rupture occurs typically in people who have not been recently active and who may indulge in infrequent physical activity such as playing weekend sport, players known as "weekend warriors".
The two large calf muscles, the gastrocnemius and the soleus, each have a tendon and these converge and form the Achilles tendon about 15 centimetres above the calcaneum. Tendons transmit forces from muscles to bones and to do this they have high resilience and sufficient stiffness, good tensile strength and allow 4 percent stretch before damage. Damage and rupture to the fibres can occur when the stretch reaches 8 percent. Most of the tendon rupture and degeneration occurs where the blood supply is poorest, about 2-6 centimetres up from the heel bone.
The left Achilles tendon is ruptured more commonly than the right, in the region of the tendon with an impaired blood supply, as right-handed people push off strongly with their left leg to accelerate. Typical rupture scenarios are on sudden foot extension, forceful pushing up of the ankle and resisted downward movement of the foot. The tendon can suffer severe degeneration and this plus direct trauma can also cause rupture. Achilles tendon rupture occurs more often in patients on corticosteroids, somewhat older people, in sudden exertions by unfit individuals and in those who pursue extreme activities.
Running can impose high levels of force through the Achilles tendon, around six to eight times our body weight. The commonest report is a sudden blow or snap in the posterior ankle area, a severe immediate pain and difficulty pushing off or standing on tiptoe. Examination can show a bruised and swollen calf, a gap in the Achilles tendon, an ability to walk but not to climb stairs or run. Precipitating factors for rupture are having a rupture before, exerting oneself unusually strongly when unfit and taking medication such as steroids over some time.
Conservative or surgical management is used, with a greater number of re-ruptures without operation. Old people, sedentary persons, those with poor skin healing and some medical conditions are more appropriate for conservative treatment. Infections, wound or repair breakdown and other complications are more common in diabetes, peripheral vascular disease and other conditions which impair healing. A short or long leg cast may be applied in plantar flexion, gradually moving the ankle up over a period of six to ten weeks. Once the foot is fairly flat, weight bearing can be allowed and the patient put into an adjustable orthotic.
The surgical options are percutaneous or open operation with the leg put into a plaster or a brace with the ankle flexed downwards, the patient routinely returning for the ankle to be re-immobilized in a more neutral position. The ankle is in the brace or cast for four to six weeks and shorter periods of tendon immobilization seem to be more effective than longer ones. Surgical management shows reduced rates of re-rupture, faster return to normal activity, improved calf strength and endurance when compared to conservative management.
The physio will begin the rehabilitation with exercises to increase the ankle movements and gently stress the tendon, instruction in good gait and use of a heel raise to reduce stretching forces on the tendon. Static bicycling and swimming are useful non weight-bearing exercises, steadily progressing to exercises in weight bearing, muscle strength work and then to advanced work such as running, jumping and balance training. Four months after surgery a patient may be able to start back to normal activity.
The outcome of Achilles tendon rupture is usually good to excellent, with most sports people able to return to normal activities. However, the re-rupture rate is 0-5% in surgically repaired tendons and almost 40% for those having conservative management. Patient education is important to continue with appropriate training, stretching to reduce the chance of re-rupture and the choice of proper footwear.
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