Management of Achilles Tendon Rupture

The optimum management of Achilles tendon rupture has still to be fully agreed despite extensive investigation.

Achilles tendon ruptures can be missed after being miss-diagnosed as ankle sprains.  They are uncommon, approximately 18 occur in every 100,000 patients per year. They are most common in men ages between 30 and 40.  Risk factors include the “week-end warrior”, following steroid injection and the use of fluoroquinolone antibiotics (such as Ciprofloxacin).  The rupture usually occurs four to six centimetres above the heel insertion.

It is the biggest tendon in the body formed from the tendons of the two muscles in the back of the calf.

On rupture, a pop is often heard or felt with weakness on push-off and pain after.  On examination there is usually bruising and a palpable gap where the tendon has ruptured.  When the calf muscle is squeezed the foot fails to push-down (Thompson’s Test).

Ultrasound examination is especially useful as it shows whether the rupture is partial or complete and the size of the gap between the tendon ends.

The outcome of conservative (non-operative) treatment has improved with the use of special boots that allow a small amount of controlled movement (Vacoped boot).  This method of treatment has fewer complications than operative management.

Compared with the conservative treatment, operative fixation has a lower risk of re-rupture (approximately 2%) and better functional outcome in terms of power.  It is however associated with a higher complication risk.

I think it is vital that following a suspected Achilles tendon rupture an ultrasound scan is undertaken. This shows if there is a rupture, and the size of the gap when the foot is plantar flexed (foot pushed down).  If there is little or no gap and informed discussion can be had regarding whether conservative or surgical fixation should be undertaken.  If there is a large gap, I personally feel that surgery should be undertaken, to prevent the formation large amounts of elastic scar tissue which will elongate the muscle/tendon/bone unit causing reduced power of push off.