What is the Achilles?

The Achilles tendon is a strong tendon, formed from the gastrocnemius and soleus muscles, in the calf that attaches to the calcaneum. It is involved in flexing the ankle down, which is important for walking and running. Rupture can occur acutely from a sudden increase in activity intensity or as a result of progressive weakening of the tendon from inflammation related to over-use and excess strain.

 

Symptoms

At the time of rupture patients experience a sudden, explosive pain in the calf, often described as ‘like a gunshot’. This is followed by bruising, swelling and pain, as well as difficulty walking,

 

Management

There is no agreement on best treatment for these injuries. There is non-operative (immobilisation) and operative (repairing the rupture with sutures) options. The patient will be provided with recent evidence of outcomes, benefits and risks of each option before making a decision.

 

The non-operative approach will require you going into a plaster cast which brings the rupture ends in to close contact with each other for 2 weeks, and you will be non-weight-bearing during this period. At 2 weeks you be placed into a boot with the foot pointing downwards and allowed to place weight on the foot. At regular intervals the foot will be brought upwards in the boot and range of motion allowed within a protected range until the foot is flat in the boot. This will take approximately 8 weeks, and physiotherapy will be started early to work on the hamstring and quadricep muscles whilst in the boot.

 

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Operative management

The operative technique will be either done through a small transverse incision over the rupture site and small stab incisions on the heel or through a longitudinal incision next to the tendon. The first technique utilises a jig to pass sutures through the tendon above the rupture, and these sutures are then brought down under the skin and secured into the heel with suture anchors. This technique brings the rupture ends close together and avoids a big incision, with the associated wound complications. This is easier to perform in the acute stage when a palpable gap is present.

The later technique involves using a longitudinal incision centred at the rupture site and debridement of unhealthy tissue on each side of the rupture. The two tendon ends are sutured together utilising a scientifically proven stitching technique to give a strong repair.

 

If the rupture is chronic, or a failure of non-operative management, it may not be possible to get the tendon edges closer enough to each other to allow repair. In this case it may be necessary to detach the tendon to the big toe (flexor hallucis longus tendon) which is found behind the Achilles tendon and transferring this to the heel (calcaneum) near to the insertion site of the Achilles tendon. This transferred tendon will take on the role of the Achilles tendon.

 

Recovery

After surgery your leg will be in a backslab plaster cast which minimises tension at the repair site for 2 weeks, and you will be non-weight-bearing during this period. At 2 weeks you will be placed into a boot with the foot pointing downwards and allowed to place weight on the foot. At regular intervals the foot will be brought upwards in the boot and range of motion allowed within a protected range until the foot is flat in the boot. This will take approximately 6 weeks, and physiotherapy will be started early to work on the hamstring and quadricep muscles whilst in the boot.

 

Return to driving will not be before 8 weeks and you must be able to perform an emergency stop. It is important to inform your insurance company of the type of procedure that has been undertaken to ensure the cover is valid.

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Return to sports that are non-impact can be initiated at 6-8 weeks (training is allowed), however impact sporting activities are not permitted before 12 weeks

 

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Risks of Surgery

As with any surgery there are potential risks. This will be discussed in more detail during the consultation, however common complications are stiffness, swelling, nerve injury, infection, failure of repair, and clots.