An achilles injury can be painful and recovery can take a long time. Today, we’re going to discuss the treatment option of achilles surgery. Here’s what you need to know.
What is an achilles rupture and how is it diagnosed?
The achilles sits at the back of the lower leg and connects the calf muscles to the heel bone.
It is a powerful tendon that stores energy and its role is to assist the calves to move the ankle and foot into plantar flexion.
Due to its ability to store a large amount of energy, it is the strongest tendon in the body, but also the most commonly ruptured (1, 3). Achilles tendon ruptures are most common in those aged between 30-40 who are physically active or are colloquially known as weekend warriors.
A rupture of the achilles tendon involves either a complete or near complete/partial tear and most commonly occurs 3-6cm above the heel bone (2, 3).
A rupture can occur during a forceful motion such as pivoting, jumping, an acceleration of running or during a fall. The tendon becomes overstretched and cannot withstand the load and due to the tendon storing a large amount of energy, the tendon snaps.
Symptoms of an achilles tendon rupture include a sudden popping or snapping sensation at the back of the calf, pain, swelling and difficulty walking. Those who have experienced an achilles rupture will often say that they feel as though they have been kicked in the back of the leg when the tendon ruptures.
Diagnosing an achilles tendon rupture is relatively straightforward, particularly in the case of a complete rupture. The achilles tendon will no longer be able to be felt or palpated (4) and there will be an obvious defect in the lower leg.
A test that is used to diagnose a rupture is called the Thompson test, which involves squeezing the calf muscle. In an intact tendon, the ankle will plantarflex. However, if the achilles is ruptured, the ankle will not plantarflex and result in a ‘positive’ Thompson test.
There will also be a weakness in the leg and pain when palpating the calf muscles closer to the knee joint.
Is surgery the be all and end all of achilles rupture treatment?
The research available on the treatment of an achilles tendon rupture raises the debate of whether a conservative treatment plan is enough to heal a ruptured achilles tendon.
In some cases, surgery is by far the best treatment option, however conservative treatment (non operative treatment) may also be suggested depending on a number of factors.
One study suggests that opinion is divided and more research was needed to better understand the differences in outcomes of either surgery or conservative options such as immobilisation and orthotics (3).
The decision of whether conservative or surgical intervention is the best option is based on a number of factors including how far apart the ends of the tendons are, which can be viewed on ultrasound or MRI (1).
Surgery is not always necessary in partial ruptures and some complete ruptures, with treatments such as the use of casting, moon boots, shockwave therapy and strengthening programs typically having good outcomes.
Some of the research also suggests that if conservative treatment is the best option, the use of orthotics to provide support and stability can help to reduce the risk of re-rupture (1).
The research does show that the chance of re-rupture of the achilles tendon following conservative treatment is much higher than those who undergo surgical intervention.
Recently, studies have also shown that the chance of re-rupture in those who have surgery is less than 3%, however that can increase to up to 10-12% in those who opt for conservative management (4).
One study also came up with an algorithm that helps to decide what type of treatment is best for each individual case. This algorithm is known as the Copenhagen Achille Rupture Treatment Algorithm (CARTA) (2).
The same article suggested that whilst conservative treatments result in a higher rate of re-rupture, this may be an acceptable risk given some of the risks associated with surgery such as infections (2).
So, what does all of this research mean? It essentially means that treatment is decided on a case by case basis!
Why would I need achilles surgery?
Some of you are probably thinking something along the lines of “Well if there are other treatments available, do I really need surgery?”. Again, we go back to a case by case basis.
In the case of a complete rupture, surgery is often essential in order to restore the function of the achilles tendon and calf muscles.
If the tendon is not reunited properly, it can lead to a number of problems throughout the lower limb.
There are multiple things that need to be taken into consideration when deciding which path is best including your age, the strength of the tendon, your day to day or sporting demands, your ability to heal and whether you have other health conditions.
Some surgeons will immediately recommend surgery for elite athletes with high functional demands or young, healthy people, however they may be cautious of those who are in poor health or have a history of poor healing (2).
As mentioned previously, a main factor in whether surgery is required is to assess the gap between the ends of the tendon (3). If this gap is too large, the chance of conservative management being effective decreases significantly and surgery would automatically become the best treatment option. Surgeons will also opt for surgery if they believe that the risk of re-rupturing the tendon is high (4).
The research suggests that surgery is the first step in a very long rehabilitation process with its aim to restore the function and strength of the tendon as quickly as possible so that you can return to work and activity as soon as possible (5).
How will my achilles tendon be repaired with surgery?
In most cases, surgery to repair a ruptured achilles tendon will be performed within a week following the injury.
This is done to ensure that excessive scar tissue does not form as this may impact negatively on both surgery and healing.
Sometimes, surgeons will recommend delaying the surgery for a few days to allow the swelling to subside, making the surgery much easier to perform.
Therefore, it is important that if you have recently ruptured your achilles tendon and are awaiting surgery, you need to reduce swelling and pain as much as you can. By following the RICE principle of rest, ice, elevation and compression before surgery, you will help make the surgical process easier.
Recent studies have shown that some achilles rupture surgery can be performed using minimally invasive techniques depending on the extent of the rupture and the integrity of the surrounding muscles.
The surgical options may appear to be quite simple, however it is often a very delicate operation. Care needs to be taken to ensure that the tendon is not repaired too tight or too loose and that the surrounding structures remain intact.
There are 2 widely accepted surgical techniques used to fix an achilles rupture.
Percutaneous repair
Percutaneous repairs are done through smaller incisions and are considered to be minimally invasive. There is less damage to the surrounding tissues and results in less pain and faster healing times after surgery.
In some cases however, repair strength is most important and some surgeons will argue that if more incisions are necessary to achieve this then it should take priority.
Benefits of a percutaneous repair include lower rates of wound complications and a better cosmetic outcome (6).
Risks associated with a percutaneous repair include a high rate of re-injury and potential nerve damage (6).
Open repair
Multiple incisions are often made to the back of the lower leg. The ankle is placed into a neutral position at 90degrees and the ends of the tendon are sewed back together. This is then tested for strength to ensure that post-surgical outcomes are positive.
Benefits of an open repair includes lower rates of re-rupture and potential nerve damage (6).
Risks associated with an open repair include a high rate of wound complications (6).
Percutaneous repair is recommended for patients who are concerned with the appearance of their surgical scar or recreational athletes, however an open repair is usually recommended for elite athletes who cannot afford the change of a re-rupture.
What are the risks of surgery for achilles repair?
Every type of surgery carries a certain level of risks and these will be discussed with your surgeon.
The risks associated with achilles repair include infection, nerve damage, incorrect tendon length and incision site wounds and complications (1, 4). In some cases, the risk of re-injury is higher. Risks can be prevented with appropriate post-surgical management
I’ve had surgery to repair my achilles tendon, what happens now?
Following surgery, patients will spend a period of time in a cast where the foot will be placed in a plantarflexed motion to assist with healing. This casting usually runs from your knees down to your toes in order to stabilise the entire lower leg and prevent any movements.
Studies show that most patients are placed in a cast for up to 14 days after surgery to encourage the tendon ends to heal together (2, 5). The degree of plantarflexion is then steadily reduced until they are placed in a moon boot (CAM walker/walking boot).
Patients will usually transition from a cast to a moon boot as their healing progresses, along with light range of motion exercises to begin to restore function in the ankle joint and achilles tendon (5).
Previous treatment protocols focused on 6-8 weeks of immobilisation before weight bearing or beginning a strengthening program, however the research is now heavily leaning towards the benefits of beginning this much earlier in the rehabilitation process (4).
Multiple recent studies have shown that early weight bearing and the implementation of strengthening programs earlier in the rehabilitation process that includes light, passive range of motion exercises have produced better results in terms of healing and functionality (1, 4, 5).
The rehabilitation program must be structured, fully managed and staged in order to achieve the best outcomes (1).
In regards to the best rehabilitation protocol or program, current research does acknowledge that there seems to be a lack of consensus among health professionals as to the optimal or preferred protocol and more research is needed (3, 4, 5). It is very important to note that this is not uncommon in medicine, as there are so many factors that can contribute to healing.
One study came up with the Swansea Morrison Achilles Rupture Treatment (SMART) program which involved a comprehensive management plan including orthotics, early weight bearing, accelerated exercise regime and return to work/sport guidelines (1). The results of this study were that there were lower rates of re-rupture amongst its participants.
Most patients will return to walking in approximately 4-6 weeks and will return to full activity 4-6 months post achilles repair surgery. However, this will depend on a number of factors and you should consult your podiatrist before returning to activity.
Full strength and endurance of the achilles tendon is usually achieved approximately 4 months following surgery (3). Healing and rehabilitation following achilles rupture surgery is often long and calculated, with the aim to be to return the tendon to its pre-injury state and reduce the risk of reinjury.
Do you have a history of achilles issues?
If you have a history of achilles tendinopathy or tears, it is important that you consult a podiatrist for appropriate treatment in order to reduce your risk of re-injury.
This may include a stretching and strengthening program, trigger point dry needling or orthotic therapy.
Contact us today to book an appointment with one of our podiatrists.
REFERENCES
- Hutchison, A. M., Topliss, C., Beard, D., Evans, R. M., & Williams, P. (2015). The treatment of a rupture of the Achilles tendon using a dedicated management programme. The Bone & Joint Journal, 97(4), 510-515.
- Hansen, M. S., Vestermark, M. T., Hölmich, P., Kristensen, M. T., & Barfod, K. W. (2020). Individualized treatment for acute Achilles tendon rupture based on the Copenhagen Achilles Rupture Treatment Algorithm (CARTA): a study protocol for a multicenter randomized controlled trial. Trials, 21(1), 1-14.
- Gulati, V., Jaggard, M., Al-Nammari, S. S., Uzoigwe, C., Gulati, P., Ismail, N., … & Gupte, C. (2015). Management of achilles tendon injury: a current concepts systematic review. World journal of orthopedics, 6(4), 380.
- Soroceanu, A., Sidhwa, F., Aarabi, S., Kaufman, A., & Glazebrook, M. (2012). Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials. The Journal of bone and joint surgery. American volume, 94(23), 2136.
- Brumann, M., Baumbach, S. F., Mutschler, W., & Polzer, H. (2014). Accelerated rehabilitation following Achilles tendon repair after acute rupture–Development of an evidence-based treatment protocol. Injury, 45(11), 1782-1790.
- Henríquez, H., Muñoz, R., Carcuro, G., & Bastías, C. (2012). Is percutaneous repair better than open repair in acute Achilles tendon rupture?. Clinical Orthopaedics and Related Research®, 470(4), 998-1003.
