Achilles tendon injury is an injury involving a fibrous cord that connects the calf muscles to the heel.
It is a particular tendon because:
- It is the one that has to bear the greatest load,
- It is the longest.
The tendon can rupture completely or only partially.
Who does it hit?
Studies show it occurs in approximately 1.8-2.5 in 100,000 people each year.
Generally the affected subjects are:
- Young people or middle-aged adults, with an average age of 37 to 43.5 years
- Active (Uquillas et al. – 2015).
It often affects sportsmen, especially those who play basketball (Raikin et al. – 2013) and make a lot of jumps.
Why does the Achilles tendon rupture more often than other tendons?
Apart from the tendon supraspinatus of the shoulder (which runs between two bones), the Achilles tendon is the most commonly injured.
There are characteristics of the tendon that make it vulnerable.
- The sheath that lines the tendon is thinner than that of the other tendons e does not carry a sufficient amount of nutrients ,
- Tendon nourishment comes from the calf and heel.
Because the tendon is very long, the core receives less oxygen and nutrient supplies.
Hence, the central area of the tendon is more prone to injury.
How does tendon injury develop?
There are two theories on the development of Achilles tendon rupture:
- According to the first theory, chronic degeneration of the tendon leads to a rupture without the need to apply excessive loads ( Longo et al. – 2009 ). This theory was first created after Arner et al. ( ARNER et al. – 1959 ) found degenerative changes in all 74 of their patients with acute Achilles tears.
In practice, the reduced blood flow to the tendon causes hypoxia (drop in the amount of oxygen).
The consequence is tendon degeneration.
In my experience, this can be caused by the formation of contractures and adhesions between the calf tissues .
- The other theory is based on the fact that the tendon breaks more easily when subjected to an oblique force when the tendon has a shortened length, that is, not when it is stretched.
In this situation, maximum calf muscle contraction can cause rupture. This risk is exacerbated when muscle coordination is poor.
For this reason it is more frequent in Sunday sports.
What are the risk factors?
Among the risk factors are:
- Age, in the sense that older athletes,
- Body mass index, overweight people ( Lemme et al. – 2016 ),
- Male athleteswho play sports in an amateur and non-continuous way ( Lantto et al. – 2015 ).
What are the causes of Achilles tendon injuries?
Acute Achilles Tendon tears can be caused by:
- From a sudden and excessive load,
- The plyometric activities(for example, the jump), when a large eccentric force (or negative) is followed by a large concentric contraction (contraction with muscle shortening) ( O’Brien 1992 ),
- From degeneration,
- Rarely, from a systemic disease( Järvinen et al. – 2005 ),
- Taking anabolic steroids,
- Taking fluoroquinolone antibiotics,
- Cortisone injections( Inhofe et al. – 1995 ).
The drugs mentioned weaken the tendon.
Histological (tissue) studies have shown that most patients have degenerative changes in the tendon .
Recently, the incidence of Achilles tendon ruptures has increased.
This is due to the increase in physical activity in adults and elderly people ( Lantto et al. – 2015 ).
Achilles tendon rupture signs and symptoms
Early symptoms are:
- As soon as the tendon ruptures, the patient has:
- A Crack sensation or a whiplash in the tendon,
- A sagging of the calf and heel.
- The pain is immediate but gradually disappears ( Eggeret al. – 2017).
- The foot remains in plantar flexion.
- The patient limps.
Most patients who have an Achilles tendon rupture have no symptoms prior to the injury ( Hoffmann et al. 2011 ).
Symptoms of Achilles tendon rupture not immediate
At first the patient has:
- Pain behind the ankle.
Later a hematoma forms .
Also, if the injury is complete, the calf becomes:
- Completely ineffective.
The pain can subside quickly, and the smaller tendons can retain the ability to bend the toes.
Without the Achilles tendon, it is almost impossible to bend the toe forward (plantar flexion).
Walking on tiptoe becomes impossible.
Test for Achilles Tendon Injury
A positive Thompson test result can help confirm the diagnosis.
- Patient prone with foot over the edge of the table.
- The examiner compresses the calf with the fingers, outside and inside the muscle.
- If the foot does not move, a complete break should be suspected.
This test isolates the connection between the calf muscle and the tendon.
That is, it excludes the other tendons that may still allow weak movement.
Other tests are:
- Strength control in plantar flexion , in case of injury, is reduced,
- The passive dorsiflexion of the foot in the event of a tendon rupture is greater (Matles test).
Conservative therapy for Achilles tendon injury
The first few days, it is recommended to:
- Keep the leg at rest.
- Avoid loading weight on the injured ankle as much as possible.
- Use crutches as long as advised,
- Apply ice packs for the first few days. To reduce pain and swelling you can keep your ankle in cool water for 20 minutes, every three to four hours for the first two days.
- Keep the leg up. Rest your leg on a pillow when sitting or lying down.
The two main options for non-intervention management are:
- Immobilization in the brace,
- Early functional rehabilitation.
Usually we proceeded with:
- The immobilization in the brace for 4 weeks,
- Switching to a mobile model for another 4 weeks.
Studies show that 86% of the results are good or excellent.
In the functional rehabilitation protocol , patients must keep the foot in a wedge boot with gradual reduction of plantar flexion for 6 weeks.
After that, physiotherapy begins.
Functional reinforcement has been found to:
- It is preferred by patients,
- It allows a faster return to activities.
The functional rehabilitation program had a lower recurrence rate , i.e. it is more difficult to rupture the tendon again.
In practice it is the same that occurs in operated patients.
According to Lantto et al. (2016), calf muscle strength was recovered earlier in operated than in non-operated patients.
Porter et al. (2015) found that an accelerated functional rehabilitation program, in which patients started moving their ankle as soon as possible (instead of after 10 days) allowed for a faster return to running. .
I believe it is important to always look for the cause of the injury.
In this case, muscle contractures in the calf or adhesions between the tissues can result
Use a heel
Your doctor may recommend inserting a heel or orthotic into the shoe as you recover.
This remedy serves to protect the Achilles tendon from stretching which can make the situation worse.
Prognosis of Achilles tendon rupture
Most people return to normal activity levels with surgical or conservative treatment.
Physiotherapy can speed up recovery time.
The reduction of the calf muscle is a fairly frequent complication.
Weight bearing begins approximately six weeks after breaking with a support under the heel.
You can generally go back to running after about four to six months .
However, even if the majority of athletes return to running and playing, it takes at least 2 years for 100% recovery (to return as before) .
0 – 3 Weeks:
- Adjustable brace locked at 30 ° of plantar flexion, cannot hold the hammer foot.
- The load is not allowed for 3 weeks, you cannot walk on tiptoe.
- Reduction of pain and edema (with ice, drugs, massage therapy and laser therapy ).
- Toe movements, gentle foot movement in the brace, straight leg elevation, knee flexion and extension.
- To maintain physical fitness we recommend the exercise bike by pushing with the heel, weight training and hydrokinesi therapy (physiotherapy in the pool).
3 – 8 Weeks
- Gradually increase the load on the injured leg and retrain in step according to tolerance.
- After 6 weeks you can go to full load.
- Walk with a brace increasing the dorsiflexion by 5 ° every week to 10 ° of plantar flexion.
- After 8 weeks, high-heeled shoes (i.e. cowboy boots) can be worn.
- You can perform isometric exercises of the muscles of the lower limb with the exception of the calf, light movements of active dorsiflexion of the ankle until the Achilles tendon is gently stretched.
- Gradually increase the intensity and amplitude of the isometric movements of the Achilles tendon.
- Slowly increase passive range of motion and Achilles tendon extension after 6 weeks.
- Carry out proprioceptive exercises (for balance) and strengthening of the deep muscles of the foot.
- At 6 weeks, you can add the exercise bike with the heel rest on the pedal. Deep water workouts.
- Daily manipulation and massage of the calf and other leg muscles.
8 – 12 Weeks
- Full load with heel if tolerated, step re-education.
- Wear a normal shoe. Gradually begin to increase active and counter-resistance exercises of the Achilles tendon (ie submaximal isometric, isotonic, and with rubber bands).
- The complete range of passive movement of the tendon must be achieved without forcing.
- Progress with cycling and swimming.
- You can drive with the brace.
3 – 6 Months
- Remove the shims under the heel.
- Perform closed kinetic chain exercises, for example: squats, lunges, bilateral toes, toe lifts, slow and controlled eccentric contractions with body weight.
- The following activities can be performed: cycling and rowing, NordicTrack unless there is excessive fibrosis, a program can be done right at home.
- Progress in jogging / running training, jumping and eccentric exercises(negative muscle contraction).
- You can switch to non-competitive sports activities, simulation exercises of the sport practiced.
8 – 9 Months
Return to competitive sport and hard work .