Achilles Ruptures
Common injuries in elite athletes and weekend warriors
Achilles ruptures are common injuries among both elite athletes and weekend warriors. They most commonly occur during tennis, basketball, volleyball, pickleball, and soccer. Classically, the athlete feels a pop and sudden pain in the back of the heel or leg. The athlete commonly feels as if his or her 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 strongest tendon in the body, and serves an incredibly important role in both sports and activities of daily living. 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 not only in running, jumping, and competitive sports, but also in standing on one’s tip toes and normal walking gait.
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 3 weeks, and then a walking boot without a heel lift for another 5 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 potentially diminished plantarflexion strength and a 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.
Minimally invasive Achilles tendon repair
Surgical treatment of Achilles tendon ruptures brings the ends of the tendon together, restoring 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.
Dr. Bohl performs Achilles tendon repairs through a minimally invasive technique using the Arthrex mid-substance Speedbridge system in the vast majority of cases. Minimally invasive Achilles tendon repair likely has meaningful advantages over traditional open techniques, including in recovery time, complication rates, and early postoperative pain.
The procedure takes about 30 minutes. Patients go home the same day. Following surgery, the ankle is splinted and the Willits accelerated rehabilitation protocol is initiated — 2 weeks in a splint, 3 weeks in a boot with a heel lift, and 5 weeks in a boot without a heel lift. Physical therapy is started 2 weeks after surgery.
Dr. Bohl typically allows unlimited walking on flat ground at 3 months postoperatively, light jogging in a controlled environment at 4 months, and return to full sport at 5 months. While the patient should ultimately be able to return to all prior athletic activities, the patient should also note that not all patients perform at the same level they did before the rupture, and that full athletic potential may not be realized until 12 months postoperatively.
Missed achilles ruptures, re-ruptures, and delays 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.