The Achilles Tendon

The amazing Achilles tendon deserves some overdue respect. It pushes your bodyweight around thousands of times every day and never makes a peep. It is thick, strong and resiliant yet when it starts to complain you better listen. Resolving the ailments of the Achilles tendon can be challenging. It can, often without warning, give up the ghost and suddenly rupture, presenting you with an almighty problem.

Our dear friend joins the calf muscles at the back of the lower leg to the foot. It transmits the propulsive power of these muscles to lift you up in the air against the constant force of gravity every time you take a step. The forces involved become intensified beyond belief as it enables performance of awesome athletic feats like jumping, landing, springing and sprinting. The Achilles tendon truly is another feat of incredible engineering.

Should it 'go' it will often do so with an almighty 'bang'. People often complain of thinking they have been shot. This I think is because of the suddenness of the incident, the audible crack or snap as the tendon ruptures together with the fact that the injury often causes people to fall to the floor as if they have been shot by a sniper. All in all it can be a pretty traumatic incident.

Complete Rupture of The Achilles Tendon

In the case of complete rupture the tendon will be totally divided. There will be a palpable and often visible gap between the two ends of the damaged tendon. In addition to the pain and inability to walk there may be marked swelling. The swelling is not always present or is certainly less than you may expect in many cases. This is because the tendon can have a relatively poor blood supply and will therefore not bleed excessively. The poor blood supply is one of the predisposing factors to a possible injury.

Partial Rupture of The Achilles Tendon

The tendon may well tear incompletely, leaving some strands intact. The signs and symptoms can be very similar to a total rupture. Walking is likely to be very difficult if not impossible.

It is not always easy to tell the difference between a total and a partial rupture of the Achilles Tendon. Normally a fairly reliable diagnostic test is 'the squeeze test'. This is performed with the patient lying on their front. If the belly of the calf muscle on the affected side is squeezed, the foot will move in a downward direction if the tendon is still intact. Absence of any foot movement is an indicator of total rupture of the tendon.

Treatment

Current trends seem to be in favour of repairing a damaged Achilles tendon surgically as soon as possible. The techniques of suturing ruptured tendons have improved dramatically over recent years and although an injury of considerable severity the results of surgery are much better than in the past. Surgeons will often recommend suturing partially torn tendons.

Following surgical repair the foot is rested and protected in a cast or splint. This is often for a period of a few weeks during which time the position of the foot, in the splint or cast, is periodically altered to allow gradual stretching of the repaired tendon. This is so that the repair does not heal in a shortened position so making rehabilitation of full ankle and foot movement difficult.

Following removal of the protective splinting, rehabilitation in earnest can begin. The process can be long and arduous and only the persistent will win through and achieve an excellent result. There is no doubt that it is hard work to regain the stretch and the strength in the tendon and the associated calf muscle. Many people will give up too soon and not achieve the maximum function they are capable of unless they are encouraged and shown the correct road.

As with many injuries there is a point at which fear of re-injury can take over and flood the mind. This point is just a sticky plateau, as most points like this are, and victory will go eventually to the brave and persistent. Fear of re-injury though is not unfounded, as it can occur. It is, however, not frequent as the repairs are very strong.

A trip or fall, often on a step, is likely to be the culprit. Although if the worst should happen the non too happy surgeon will normally be able to re-suture the offending tissue. The extra trauma and immobilisation time will however have an impact and rehabilitation will tend to be physically and psychologically more taxing in such cases.

The time frame from repair to full functional recovery can be anywhere between six and twelve months.

Alternative ways of treating a ruptured (total or partial) tendon have been in a plaster with the foot in 'equinus' or plantarflexion (with the toes and foot pointing down). In this position the ends of the tendon can be opposed and healing can occur.

The same protocol of slowly stretching the tendon by altering the foot position in the cast is often applied. After a period of between six and twelve weeks the patient is taken out of the cast and some seriously gut wrenching rehabilitation begins. I will never forget the looks of anguish on the faces of those who try and put their foot down to walk when they are released from the grip of their plaster or cast for the first time. Thankfully now, although still immensely challenging, with the advancements in surgical skill, such battles are few and far between.

It used to be that the level of recovery from such injuries was such that return to full athletic activity could not be guaranteed. Again, with the advancements in surgical technique the prospects following these injuries are now much better.

Achilles Tendonitis and Paratendonitis

They remain a common problem that are still challenging to deal with successfully. If I could come up with an instant cure for a type of injury this one would be in my top two or three.

Tendonitis is not necessarily the precursor to a rupture. It is normally the result of overuse, new or excessive activity, direct pressure on the tendon from footwear or it may have no apparent cause.

In the majority of cases it appears in young and middle aged males who participate in sport. It normally affects one leg but can be in both. The Achilles tendons are sore to touch and stiff to 'get going' especially first thing in the morning, but feel much better when warmed up. So much so that often with the chronic, long lasting cases normal activities can be performed once the tendon has been stretched and warmed up.

Physiotherapy in the form of electrotherapy and soft tissue manipulation combined with the correct regime of rest and exercises can help. They are however in my experience far from guaranteed to solve the problem in the short term. It seems to be that if the problem is addressed quickly and prevented from becoming engrained or what is called chronic, it is much more easily resolvable.

The majority of cases though tend to be more longstanding by the time you see them. The inflammatory process has slowed down and seems to have got right into the structure of the tendon or its sheath or covering.

Surgical stripping of the tendon has been performed in the past to alleviate long standing troublesome tendonitis. My experience of this are limited. I would deduce that because of its relative scarcity as a technique that at best the results have been mixed.

All cases of achillles tendonitis or paratendonitis seem to settle eventually. In the meantime the usual physiotherapeutic techniques will help to alleviate some of the inflammation. The best approach for me is the CORRECT REHABILITATION PROGRAM.