Achilles rupture

What is Achilles tendon rupture?

Your Achilles tendon is the strong band of tissue that joins your calf muscles to your heel bone, letting you point your foot down, rise onto your tiptoes and push off when you walk or run. An Achilles rupture is a complete tear in this tendon, usually caused by a sudden, forceful movement.

What are the symptoms of Achilles tendon rupture?

Most people notice an Achilles rupture straight away. You might feel:

• a sudden, sharp pain in the back of your ankle or calf, sometimes with a snapping or popping sound
• a sensation like someone has kicked you in the back of the leg, even though no one is there
• swelling and bruising around your calf and ankle
• difficulty walking normally, with a flat-footed style of walk
• an inability to push off the ground properly, stand on tiptoe or climb stairs on the affected side
• a gap you can feel in the tendon, a few centimetres above your heel, though swelling can sometimes hide this.

The sharp pain often settles into a dull ache, or eases completely, but the other symptoms usually remain until the tendon is treated.

What causes Achilles tendon rupture, and who's at risk?

An Achilles rupture usually happens when the tendon comes under more force than it can withstand. This is often during a forceful push-off or sudden change of direction in sports such as football, tennis, badminton, squash, running or basketball, when your calf muscles contract hard against a planted foot.

It can also happen after a fall or slip that suddenly forces your foot upward, or, rarely, from a deep cut to the back of the ankle.

Some things make the tendon weaker and more likely to tear:

• long-term Achilles tendonitis, where swelling and small tears build up over time
• steroid medication, particularly long-term use, or steroid injections near the tendon
• certain antibiotics called quinolones, such as ciprofloxacin, especially when combined with steroids
• conditions such as rheumatoid arthritis, gout, lupus or Cushing's syndrome.

Are there different types of Achilles tendon rupture?

Yes. Most Achilles injuries are complete ruptures, where the tendon tears all the way through and the link between your calf muscle and heel bone is completely lost.

A partial tear, where some fibres stay joined, is much less common. Because partial tears are rare, doctors usually assume any sudden Achilles injury is a complete rupture until a scan proves otherwise.

Doctors also sometimes group ruptures by how soon they're treated. One picked up and treated within 2–3 weeks of injury is usually more straightforward to manage than one discovered later, sometimes called a delayed or chronic rupture, which may need a different surgical approach.

How is Achilles tendon rupture diagnosed?

Your doctor can usually diagnose an Achilles rupture from your symptoms, how the injury happened, and a physical examination, without needing a scan.

One key test is the calf squeeze test, sometimes called the Thompson test. You'll lie face down with your knee bent while the doctor squeezes your calf muscle: if your Achilles tendon is intact, your foot points downward, and if it's ruptured, your foot doesn't move at all.

Your doctor may also feel for a gap in the tendon, usually 4–6cm above your heel bone, though bruising and swelling can sometimes hide this. If the diagnosis isn't clear, an ultrasound or MRI scan can confirm the rupture and show exactly where it is.

It's worth knowing that doctors sometimes miss an Achilles rupture at first assessment, so if your symptoms don't improve as expected, it's worth going back to be checked again. Your doctor will also consider other conditions with similar symptoms, such as Achilles tendonitis, a torn calf muscle or a blood clot in the leg.

How is Achilles tendon rupture treated?

There are two main approaches: treatment without surgery, sometimes called conservative treatment or functional bracing, and surgery. Non-surgical treatment is now used for most people, since evidence suggests it gives similar results to surgery with fewer complications, though your surgical team will recommend the best option for your specific injury.

Non-surgical treatment

This involves wearing a supportive boot that holds your foot pointing downward at first, allowing the torn ends of the tendon to heal together. Over several weeks, your team gradually adjusts the angle until your foot is back in a more neutral position.

• you'll usually wear the boot day and night for around 8 weeks, taking it off only to wash
• you'll be able to put some weight through your leg in the boot fairly early on, which helps the tendon heal
• because you're less mobile than usual, your team may also offer you blood-thinning medicine for several weeks to lower the risk of a blood clot in the leg (deep vein thrombosis, or DVT)
• physiotherapy usually starts before the boot comes off completely, to help rebuild strength and movement.

Full recovery, including regaining normal strength, usually takes several months, and it can take a year or more to return to your previous level of sport.

Surgical treatment

Surgery is usually only recommended in specific situations, such as a delayed diagnosis of more than 2–3 weeks after injury, a repeat rupture, or for some elite athletes.

During the operation, which usually takes 45–60 minutes under anaesthetic:

1. Your surgeon makes a cut in the skin over your Achilles tendon. This may be one larger cut, or several smaller cuts using a small camera, known as keyhole or percutaneous surgery.
2. Your surgeon stitches the torn ends of the tendon back together, sometimes reinforcing the repair with a piece of another tendon if the tear is more severe.
3. Your surgeon then closes the cut and fits a cast or boot to protect the repair.

Most people go home the same day, with a responsible adult to accompany them, and your team usually removes your stitches after 2 weeks. You'll then move into the same boot-based recovery as non-surgical treatment.

Both options carry some risk. These include:

• infection
• a blood clot in the leg or lungs
• numbness near the cut
• the tendon rupturing again, known as re-rupture.

When should you see a doctor?

See a doctor urgently, or go to A&E, if you feel a sudden snap or pop in the back of your ankle or calf, especially if you can't push off the ground properly or stand on tiptoe afterwards. Try not to put any weight on the affected foot until you've been seen, since prompt treatment tends to lead to better healing.

You should also seek urgent medical help during your recovery if you notice:

• sudden cramp-like pain in your calf, thigh or groin
• chest pain or shortness of breath (go straight to A&E)
• a sudden increase in swelling, numbness or pins and needles in your leg
• problems with a surgical wound, such as increasing redness, pain or discharge.

These can be signs of a blood clot or another complication that needs prompt attention.