Achilles tears: rupture, recovery and rehabilitation

I am watching the NBA Western Conference playoffs as I write this blog post. Many people saw these playoffs irrevocably altered when Kobe Bryant went down with an acute Achilles tendon rupture last month.

The list of NBA players who have ruptured their Achilles tendon includes Isiah Thomas (arguably never the same afterwards), Dominique Wilkins (as good as ever by some assessments) and Elton Brand. Probably more people in Philadelphia watched Ryan Howard become injured on the way to first base during the NL division series against St Louis in 2011.

You may, in fact, know someone who has had the misfortune of having their Achilles tendon completely tear. It is a serious injury with potentially a significant impact for an active person at any age and at any level of sports. You may also know that many healthy active people will have a problem with their Achilles tendon at some point in their athletic lives. So what is this injury?

What Is It?

The Achilles tendon is the largest and strongest tendon in the human body. It is formed by the tendons of the gastrocnemius and soleus muscles. It is approximately 15 cm long in the adult and can handle the stress of up to 10 times body weight; typically it handles the stress of 5-7 times body weight. The area of the tendon most commonly injured is the watershed area, approximately 2-6 centimeters proximal to the distal insertion of the tendon on the heel bone – so called because it has a decreased blood supply compared to other parts of the Achilles tendon. Most Achilles tendon problems will occur in this mid-portion of the tendon.

Achilles tendon disorders include Achilles tendonosis, tendonitis, partial tear, and complete tendon rupture. 6-18 percent of runners will have an Achilles tendon problem at some point. 7-9 percent of elite runners will have some Achilles tendon symptoms annually, so this is not a problem solely for the recreational runner or weekend warrior. Up to a quarter of all competitive athletes will report having an Achilles tendon problem at least once; likely this percentage is higher in athletes engaged in running and jumping sports. A discussion of all Achilles tendon injuries is beyond this single blog post; this post will focus on the understanding the Achilles tendon and specifically what happens with a complete rupture.

75 percent of Achilles tendon ruptures occur in the 30-40 year old age range, typically in those engaged in sports or exercise. The injury occurs in males more than females, and may occur on the left side more often than the right. Biomechanically, the athlete may be pushing off with the affected leg, as with Kobe, or there may be a sudden forced eccentric contraction of the tendon that causes the rupture. In an eccentric contraction, the tendon is being lengthened at the same time it is being instructed to contract (shortened); interestingly, this is both a mechanism for tendon injury and, in a controlled setting, an accepted mode for tendon rehabilitation. Certain sports have more strenuous, repetitive, eccentric impact loading and jumping activities—e.g. basketball, squash—although rupture can occur in any sport.

The athlete may feel a sudden pop or snap, and will immediately have difficulty bearing weight on the injured leg. Patients have reported feeling as if someone kicked them in the heel, or even wondering if someone has shot them in the leg. Interestingly, the athlete may or may not realize the extent or seriousness of the injury. They may mistakenly think that they have strained or "pulled" a muscle, and that after a short period of taking it easy that they can resume sports normally.

Risk factors for having a complete rupture of the Achilles tendon include:

Diagnosis
                                                                                                                                                                                        A suspected Achilles tendon rupture should be evaluated soon. A thorough history and a good physical exam will be helpful; exam findings may include a tender palpable defect in the tendon, a "hatchet strike", and a Thompson test is a fairly sensitive exam maneuver  in diagnosing a complete rupture. There may be increased ability to passively dorsiflex the ankle (pushing the toes towards the ceiling or superiorly),  and decreased strength when actively plantar flexing the ankle (pointing the toes towards the floor or inferiorly).

Imaging may be used to confirm or exclude other diagnoses. Choices can include an x-ray, MRI or ultrasound. Despite a good history and exam, and imaging studies, it can be challenging to differentiate between a partial or chronic tear and an acute complete tear; in addition, up to 20 percent of Achilles tendon acute ruptures can be missed at the time of initial clinical presentation.

Rehab

Optimal treatment of an acute complete tear is still open for debate and discussion, and is likely best determined on a case by case basis with "shared decision making" between the provider and athlete.Operative treatment may have a higher likelihood of returning a young, healthy athlete to his/ her pre-injury level of performance. It also may have a lower risk for re-rupture of the tendon. Surgical treatment, however, does have a higher incidence of complications,, such as infection or nerve damage. Non-operative treatment is an appropriate and acceptable choice for management as well, and in the right population it has acceptable outcomes. It may have a higher risk for rerupture but a lower risk for any complications related to invasive treatment.

Return to play after an acute Achilles tendon rupture may take 6-9 months in an active, healthy young athlete. Of course, as with other serious sports related injuries, recovery may take longer, and there is no guarantee that performance will recover to the pre-injury level despite aggressive and conscientious management and rehabilitation.  There is no single best way to prevent Achilles tendon ruptures that has been demonstrated in the medical literature, and this area is in much need of further research by sports medicine professionals.  That being said, it is likely prudent to preserve the integrity of the Achilles tendon, and to prevent, if possible, the development of any Achilles tendon issue. Athletes of all ages and abilities should strive for good flexibility, appropriate footwear, avoiding significant training errors in their chosen sports, and in seeking external advice if they have symptoms that do not improve with the rest, ice, or activity modification.

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