The Achilles tendon is a strong fibrous cord that connects the primary calf muscles (the gastrocnemius and soleus) to the heel bone (calcaneus). It is the longest and strongest tendon in the human body and can experience loads of up to 4 times your bodyweight when walking and up to 8 times your bodyweight when running.
The Achilles tendon is one of the most important structures in the lower body, playing a vital role in walking, running, and jumping and any other activity that involves pushing off the foot. Unfortunately, due to its heavy use and vulnerability to injury, the Achilles tendon is the most ruptured (torn) tendon in the body, particularly in athletes or individuals engaging in high-impact sports.
How does it happen?
An Achilles tendon rupture most commonly occurs when there is a sudden and forceful contraction of the calf muscles when the ankle is dorsiflexed (when the top of the foot is flexed up) but other causes include:
· Sudden, forceful movement of the foot against resistance such as a push-off in activities like jumping, pivoting, or sudden acceleration while running.
· Trips or falls when foot is used forcefully to break fall.
· Poorly managed Achilles tendinopathy.
Who is at risk?
Those who play sports, especially those involving intense physical exertion, as this can increase the stress on your Achilles tendon. It can also happen as an overuse injury or repetitive strain, such as in long-distance running or certain types of dances, which can cause micro-tears in the tendon eventually leading to a rupture. Other risk factors include:
· Age (with those over 30 being more prone)
· Sex (5 times more likely to occur in men than women)
· Prior Achilles tendon injuries
· Tight calf muscles
· Improper footwear
· Certain medications like corticosteroids or fluoroquinolone antibiotics can weaken the tendon
· Obesity placing more stress through the tendon
Signs and symptoms of an Achilles rupture
These can be easily diagnosed by your doctor or physiotherapist by a clinical examination meaning scans are usually not required. Unfortunately, there are not any warning signs and symptoms leading up to the injury and it is possible to have no signs and symptoms with an Achilles rupture, but most people have one or a combination of the following:
· Sudden, sharp pain at the back of the leg and heel
· A feeling of having been kicked or stabbed in the calf or heel
· A “pop” or “snap” sound at the time of the injury.
· Swelling and/or bruising at the back of the leg and heel
· Difficulty walking or standing on your tiptoes
· You may have a palpable “gap” in the tendon a few centimeter above your heel bone.
Do I need surgery?
Historically, most Achilles tendon ruptures were repaired surgically, however these days more and more patients are being treated conservatively. This is because research has shown that there is no statistically significant difference in functional outcomes between those who have had surgery and those without surgery for up to 2 years after their injury. There are however some slight differences between the potential benefits and risks of either option such as re-rupture rate, cost, and complications so it is important to consult with your orthopedic surgeon to direct your management and discuss if surgical or non-surgical intervention is warranted.
With both approaches there may be a period where a plaster cast will be used followed by a boot with wedges, which are then to be gradually removed over time until you can walk without a raised heel and wean into a normal shoe again. This may also include NSAIDs and a guided physiotherapy program.
What is the role of physiotherapy?
Whether an Achilles tendon rupture is treated surgically or conservatively, physiotherapy plays a central role in rehabilitation, as it aids in restoring function, reducing pain, and helping individuals return to their normal activities. The rehab for both also looks very similar. Here's how physiotherapy supports recovery:
· Pain management and swelling control: ice therapy, gentle massage, and compression can help alleviate discomfort. In some cases, physiotherapists may use modalities like ultrasound or electrical stimulation to promote healing and reduce inflammation.
· Restore range of motion: range of motion exercises will commence once the tendon begins to heal. These are designed to restore flexibility and mobility to the ankle, which can become very stiff after a rupture. This will also help reduce scar tissue buildup and improve the tendon’s elasticity, so that it can handle stress without re-injuring.
· Strengthening the muscles around the ankle and calf: The calf muscles need to regain strength to help the Achilles tendon bear weight and function properly so exercises like heel raises, calf stretches, and eccentric strengthening exercises are important to rehabilitation.
· Restore function: In the final stages of recovery, physiotherapy works to ensure the injured person can return to their normal activities safely. This involves sport-specific exercises ensuring the Achilles tendon can withstand stress. This may involve running, jumping, and pivoting to prepare for a full return to their sport.
· Preventing future injuries: educating patients on how to prevent future injuries is crucial and may involve strengthening not only the Achilles tendon but also the muscles of the lower leg, improving overall flexibility, and advising on appropriate footwear and activity modifications.
Conclusion
Achilles tendon ruptures can be debilitating and the management of these has evolved over the years. How these are now treated is made on a case-by-case basis depending on the patient’s activity level, overall health and their personal preferences, however, whether these are treated surgically or conservatively, physiotherapy is an important part of the rehabilitation process ensuring the tendon heals correctly and that the individual regains full functionality. Through an indiviualised-based approach involving pain management, mobility restoration, strengthening, and functional rehabilitation, physiotherapists help patients recover effectively and return to an active lifestyle with a reduced risk of reinjury.
Return to sport testing
Here at our clinic, we have access to state-of-the-art technology that is used worldwide to measure an individual’s precise ankle strength, power, movement, balance, asymmetry and more. These can help empower the client as well as help our physios make more accurate data-informed decisions regarding return to play.
Written by
Cathal O’Kane
Senior Physiotherapist
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