Achilles Tendon Rupture

Achilles was a Greek warrior who fought in the Trojan war. According to legend, as an infant his mother could make him invulnerable to injury by dipping him in the waters of the River Styx. Unfortunately, she held him upside down in the water by his heel, leaving that area unprotected. As fate (or the Gods) would have it, he was struck in that same heel with an arrow during the battle, and was killed. The term “Achilles heel” has become a synonym for weakness.

Anatomy
The Achilles' tendon is the largest tendon in the body. It connects the muscles in the back of the calf to the back of the heel. It is the major plantar flexor of the ankle. However, it is not the only one. There are other muscles in the leg that can also plantar flex the ankle.

The tendon itself is a thick structure made of long fibers of collagen, a complex compound that makes up the “connective tissues” in our bodies. This tendon originates proximally off the posterior calf muscles, the gastrocnemius and the soleus. It then runs down to the back of the heel bone, the calcaneus, where it inserts, or attaches into the bone. All tendons have a surrounding structure, the tendon sheath, that provides nourishment for the tendon, and lubrication so that the tendon can glide back and forth.

Achilles Tendon Injury
While the Achilles' tendon is very large, it is susceptible to rupture during some athletic activities. It generally seems to rupture in active men between the ages of 25 and 50. It often will occur playing basketball or volleyball, when jumping or pushing off to start running. Patients who rupture their Achilles' tendon often are doing an activity that they will only participate in intermittently. The classic case is the "Weekend Warrior" male.

Rupture occurs with an acute pain in the posterior calf, often associated with a sound or sense of a “pop”. The rupture is usually about 2 – 3 inches above the heel bone, in an area where the blood supply of the tendon may be diminished. A rupture may be confused with an ankle sprain. There will be weakness walking, possibly and inability to bear weight. Sometimes there will be bruising, and usually there is visible swelling about the ankle. It may be possible to see or feel a defect in the posterior ankle.

If the Achilles tendon is ruptured it will still be possible to plantarflex the ankle. That is the motion to “point the toes”. There are several other muscles in the posterior calf that will perform this function if the Achilles tendon is ruptured, so if you can still do this it does not mean that the Achilles tendon is intact.

When the Achilles tendon ruptures, the proximal and distal ends will come apart, and it may be possible to feel a defect through the skin.  The ends of the tendon will also fray, with the fibers seperating so the ends have a consistency like horsehair.

Treatment
Achilles tendon rupture can be treated by casting or with surgery. The cast treatment involves placing a long leg cast, from the toes to the thigh, with the knee bent and the toes pointed down. The cast will hold the ends of the tendon together so that they will heal together at the right length.  That cast must be worn for 6 weeks, and no weight can be put on the leg so crutches, a walker or a wheelchair must be used. After 6 weeks that cast is removed, and a short leg walking cast is applied, from the toes to just below the knee. That is worn for an additional 6 weeks. After that, a CAM walker is used as a removable brace for another month.

For a discussion of Surgical Treatment of Achilles Tendon Rupture Go Here.