Achilles Ruptures
Common injuries in middle-aged athletes
Achilles ruptures are the injury of the weekend warrior — the 30-, 40-, or 50-something year-old who plays competitive sports a few times a week. The most common sports where we see Achilles ruptures are tennis, basketball, volleyball, and soccer. The classic story is the patient feeling a pop and sudden pain in the back of the leg. Patients commonly feel as if their heel was stepped on or hit with a ball, only to turn around and find that there is nothing there.
The Achilles tendon is the largest and longest tendon in the body, and serves an incredibly important role. By connecting the gastrocnemius and soleus to the tuberosity of the calcaneus, it is the critical plantarflexor of the ankle. As a result, it is key in running, jumping, and competitive sports.
Our understanding of how to treat Achilles tendon ruptures has progressed a lot in recent years, and we have new technology to aid us with treatment. Both nonsurgical and surgical methods of treatment are acceptable options for most patients.
Nonsurgical treatment
Nonsurgical treatment of Achilles ruptures should be considered by all patients. Dr. Bohl follows the Willits accelerated rehabilitation protocol for nonsurgical treatment, in which patients are initially splinted for 2 weeks, then transitioned to a walking boot with a heel lift for 4 weeks, and then a walking boot without a heel lift for another 4 weeks. Physical therapy is initiated at the same time patients start in the walking boot (at 2 weeks).
The main advantage of nonsurgical treatment is the avoidance of potential surgical complications. For this reason, for patients with certain health conditions that predispose to those complications may be advised to pursue nonsurgical treatment. Possible disadvantages of nonsurgical treatment include diminished plantarflexion strength and a potentially higher rate of re-rupture, although published studies have had mixed results.
Whether surgical or nonsurgical treatment is best is highly dependent upon the patient’s age, activity level, medical conditions, goals, priorities, and personal and professional demands. Dr. Bohl will take as much time as you need to educate you regarding these two options. The decision regarding which course to follow is completely yours.
Traditional surgical treatment
The theory behind surgical treatment of Achilles tendon ruptures is that by bringing the ends of the tendon together, you restore the natural length and tension of the gastrocnemius and soleus muscles. This optimizes the potential strength of those muscles and allows them to operate at full capacity for the rest of your life. Potential advantages of surgical treatment include greater plantarflexion strength and a lower re-rupture rate. However, the patient should note that this is a hotly debated area of foot and ankle surgery, and the decision on how to proceed should be informed by a full understanding of the risks of surgery as well.
Achilles tendons are traditionally repaired through a 3-inch surgical incision on the back of the heel. Strong non-absorbable suture is used to pull the top part of the tendon back down to the bottom part of the tendon. Tension of the muscle is compared to the other side for a perfect match. The repair is reinforced with additional absorbable suture. The ankle is splinted and Willits accelerated rehabilitation protocol is initiated — 2 weeks in a splint, 4 weeks in a boot with a heel lift, and 4 weeks in a boot without a heel lift. Physical therapy is started 2 weeks after surgery.
Minimally invasive surgical treatment
Dr. Bohl also performs a minimally invasive Achilles tendon reconstruction using the Arthrex Percutaneous Achilles Repair System (PARS). This procedure has all these same advantages of the traditional surgical treatment, but uses a less suture and is performed through a smaller (1/2 inch) incision. The surgery itself is a little faster, and the recovery and rehabilitation are similar.
Minimally invasive Achilles tendon repair is a relatively new technology, but evidence suggests it may have a lower rate of wound complications with a similarly low rate of failure. Dr. Bohl tailors his surgery to each individual patient and each patient’s preferences, so you can determine together which option makes the most sense for you.
Missed achilles ruptures, re-ruptures, and delay in treatment
Achilles tendon ruptures that do not receive treatment within the first few weeks of injury result in healing with a gap between tendon ends. Re-rupture has a similar effect. As a result, the gastrocnemius and soleus are shortened and unable to exert their normal plantarflexion force on the ankle. Patients may have plantarflexion weakness and difficulty with walking, running, jumping, and activities of daily living.
Dr. Bohl has extensive experience in treating missed Achilles tendon ruptures and re-ruptures. In most cases, the treatment of choice is a transfer of the flexor hallicus longus tendon from its normal attachment on the big toe to a new attachment on the calcaneal tuberosity. In this way, the flexor hallicus longus tendon can then take over as a plantarflexor of the ankle and restore plantarflexion force.
If you had a missed Achilles tendon rupture and are currently still weak or symptomatic, Dr. Bohl will be happy to evaluate you in the clinic. He will likely recommend an MRI of the ankle to determine how large the gap is between tendon ends. He will present you with treatment options and discuss the risks and benifits of proceeding with surgery versus giving the natural healing process more time.