I had an interesting case hobble into the clinic yesterday. An 87 year old man tells me he awoke one morning with some pain in his left foot. He swears up and down that he didn't injure it in any way, but he now can't walk on it normally. Sure enough, as I watch him come down the hall, he's moving, but only with the assistance of heavily leaning on his cane. I know this guy and he usually can move better than this.
After some gentle examination, his left calf is certainly a bit swollen, and there appears to be a gap in his Achilles tendon. I ask him to get up onto his tiptoes, and he has no strength to do so. A few other physical tests confirm my thoughts, and a diagnostic ultrasound confirms a complete rupture of the tendon!
How Does The Achilles Tendon Get Torn?
This example is certainly the exception to the rule. The Achilles tendon is the connection between the calf muscles (gastrocnemius and soleus), and the heel bone (calcaneus). It helps the foot push off the ground when running or jumping. When it is torn, therefore, people can't get up on their tip-toes with any strength.
The classic history is a middle aged person playing a sport where quick movements or explosive jumping is involved like sprinting, basketball, tennis or squash. The person will often feel like they've been hit or shot in the back of the leg, and often either blame their playing partner for hitting them or look for the object that "hit" them. The event is usually sudden and therefore very memorable. The examination is also usually fairly straightforward with an obvious gap in the tendon, and no passive motion of the foot when testing the calf. The diagnosis is usually then confirmed by diagnostic ultrasound.
One other uncommon, but not unheard of cause is from taking quinolone antibiotics, of which Cipro is best known.
How Do You Fix It?
Generally speaking, there are TWO options - surgical or non-surgical.
Surgical management essentially sews back the two ends repairing the connection. The risks include bleeding, infection and a small risk of re-rupture in the range of 4-5%.
Non-surgical management involves wearing a boot cast with the foot slightly plantarflexed (toes pointing down) for 6-8 weeks. This allows the torn ends to come into contact with each other and heal while immobilized. Benefits are that one avoids surgery, but the risk of re-rupturing the tendon is significantly higher, in the range of 10-15%.
One should never generalize, but "generally speaking", I recommend surgery for younger athletes, and those who are going to go back to explosive type sports. For older athletes (ie over 40), I try to guide them towards non-surgical management, as the outcome is still quite good (ie 85-90%), and only go to surgery if this route fails.
Have you every torn your Achilles?
How was it managed?
Let me know!