RICE & MICE: Achilles tendon rupture

In Greek mythology, the legend of Achilles says he was dipped into the river Styx by his mother, Thetis, in order to make him invulnerable. However, she had to hold onto his heel in order to dip him in the water, thus missing a spot. The only way Achilles could be killed was by injury to his heel.

The Achilles tendon is the strongest and thickest tendon in the body and can withstand large forces, yet it’s one of the most frequently ruptured tendons. Rupturing an Achilles tendon is a very serious injury that takes months to rehabilitate. Athletes who have ruptured their Achilles include those from the NFL, NBA, NHL, professional soccer, and college athletes. When you point your toes or lift up on your toes when walking, you engage your calf muscle and Achilles tendon. In contrast, if you pull your toes and foot up toward your shin, you stretch your Achilles tendon. The tendon is likewise stretched when standing on a step or upward incline.

Each year a handful of NHL-ers find that their Achilles heel is quite literally their Achilles heel.

Vancouver’s Sami Salo is currently on an AHL conditioning assignment after missing the start of the 2010-11 season due to a ruptured Achilles tendon suffered in the off-season. In 2008, when former Flyer, Justin Williams was with the Carolina Hurricanes, he ruptured his Achilles tendon in a preseason workout. He had surgery in September and surprised everyone when he returned less than 4 months after the surgery to play with the Hurricanes.

The Achilles tendon is commonly injured during explosive acceleration in which there is a forceful stretch of the tendon while the calf muscles contract. The majority of these injuries happen to males. It is also a common injury for middle-aged weekend warriors to suffer from.

Oddly enough, the left Achilles tendon is most often injured of the two. Ruptures occur between 2 and 6 cm above its attachment to the heel bone.  One of the reasons that the left Achilles tendon is torn more frequently may be related to handedness; right-handed individuals "push off" more frequently with the left foot.

Achilles tendon ruptures almost always create a loud and very audible, “POP” followed by what I understand to be excruciating pain. Most people say it feels like someone took a baseball bat to the back of their heel. The tears can range from partial thickness to full, complete ruptures. In the case of complete ruptures, there is an immediate inability to walk normally, stand on tiptoes and there will certainly be a great deal of pain and swelling.

Most complete ruptures will be evident by a gap felt in the tendon at the point of tearing, but diagnosis can be made with a good amount of certainty through a simple test, called the Thompson test (aka Simmonds’ test or the Simmonds-Thompson test).

The athlete lays face down on an exam table with their lower leg (from about mid shin down) hanging off the table. The trainer or medical personnel will most likely start with the uninjured side by squeezing the calf muscle. If the Achilles is intact, the foot will point down slightly. If there is a tear of the tendon, the foot will not move. X-rays are usually not useful for identifying or confirming tears. Musculoskeletal ultrasound or MRI can provide a definitive diagnosis as well as allow grading of a partial tear.

Most athletes are immobilized in a walking boot and given crutches from day one. Immediate treatment of the pain and swelling starts with, yep that’s right – RICE! (Rest, ice, compression and elevation) Nonsurgical treatment generally limits non-weight-bearing to two weeks, and use modern removable boots, fixed or hinged, rather than casts. Physiotherapy is often begun as early as two weeks following either surgical or nonsurgical treatment. Nonsurgical treatment may be a choice for minor ruptures, less active patients, and those with medical conditions that prevent them from having surgery.

Surgical treatment is useful for complete ruptures and there is a period of time spent immobilized in a cast or boot, called a cam walker or cam boot. Since the tendon shortens as it heals, a heel lift is typically used for six or more months starting when the cast comes off. Physical therapy is also initiated at that point to help restore flexibility and strength.

Achilles tendon surgery may be done in an open procedure, with one big incision, or in a less invasive procedure, called percutaneous, in which several small incisions are made in order to fix the tendon. Sometimes a nearby tendon may be used to reinforce the Achilles repair if the structures are sound enough. A dissolvable reinforcement mesh may also be used to strengthen the repaired tendon.

Rehabilitating a ruptured Achilles tendon begins with range of motion type stretching. This will allow the ankle to get used to moving again and get ready for weight bearing activities. Then there is functional strength, this is where weight bearing should begin in order to start strengthening the tendon and getting it ready to perform daily activities and eventually in athletic situations.

Specific rehabilitation protocols will vary depending on procedure of repair and surgeon as well as speed of progression.  For approximately the first 2-4 weeks after surgery the athlete may be in an adjustable boot that can be set for a certain about of foot flexion, they are almost always non-weight bearing during this time, control of pain and swelling is very important and the athlete is encouraged to wiggle the toes and participate in leg raises and other exercises of the leg.

In weeks 4-8, weight bearing is increased to toe touchdown as well as partial weight bearing as tolerated. The walking boot is adjusted each week to allow more stretching of the new repair. Passive range of motion and Achilles stretching usually increases at 6 weeks. Strengthening exercises are started. The athlete is usually able to ride a bicycle at this point putting pressure on the heel only so as to not engage the muscles of the calf. Between 2-3 months, full weight bearing is encouraged as tolerated and the athlete is usually weaned out of the boot and into a regular shoe with heel lift wedges. Range of motion and strengthening exercises are increased.  The athlete will progress to cycling in a regular shoe and/or swimming.

In the 3-6 months after surgery, the athlete is totally weaned off of heel lifts and strengthening exercises continue. At 6 months rehab will progress to jogging, running, jumping and noncompetitive sporting activities. By 8-9 months the athlete can usually return to play. 

Disclaimer: Information on found in RICE & MICE on flyersfaithful.com is not intended to be medical advice. Any information or materials posted on the web site are intended for general informational purposes only, and should not be construed as medical advice, medical opinion, diagnosis or treatment. Any information posted on the web site is NOT a substitute for medical attention. See your health-care professional for medical advice and treatment.