An Achilles tendon rupture is a debilitating injury to the ankle. These injuries can occur to the adult population outside of sports, but it is unfortunately not uncommon in athletes. Most commonly it involves athletes in their thirties. Usually the injury involves some sort of running event, such as a sudden stop or start or a change of direction. It is very common to hear an athlete say that he felt like he had been stabbed or shot in the back of the ankle. Athletes often describe feeling or hearing a loud pop. Often they think that someone hit or kick them in the back of the ankle only to turn around and see that no one is there. It is very painful, and the athlete usually has tremendous difficulty walking, let alone playing, immediately after the injury.
Diagnosis of the ankle injury
To a sports medicine physician, this injury is usually fairly easy to diagnose. The athlete will complain of tremendous amount of pain in the lower calf and back of the ankle. There will often be a lot of swelling and sometimes bruising. It is very common to be able to feel a gap between the tendon edges where it is torn. The athlete will usually have difficulty plantarflexing the ankle, which is the motion the ankle makes when pressing the gas pedal. With a torn Achilles tendon, the surgeon can squeeze the calf and the foot does not flex downward, which it usually does if the tendon is intact. X-rays are usually negative. Often we do not order an MRI for this injury, but sometimes it can be helpful to give more information about the quality of the tendon and any underlying chronic tendon degeneration.
Surgery or cast treatment for an Achilles tendon rupture
Ideal treatment options are controversial. Most athletes undergo surgery to repair the tendon. Nonoperative treatment is an option, especially in non-athletic people. The tendon almost always heals, although there is a concern for re-rupture of the tendon. Surgery to repair the tendon has a lower reinjury rate, although there are risks of the wound opening, infection, and nerve injury. Having said that, I think that surgery is appropriate for most high-level athletes. There are many ways the surgery can be performed. Most commonly, the surgery involves making a two- to three-inch incision over the tendon and repairing it side to side with sutures. There are some techniques that use very small incisions, although these techniques are controversial as well.
Recovery from an Achilles tendon rupture
Recovery from an Achilles tendon rupture is a long process whether or not surgical repair is performed. If the patient elects to try to get the tendon to heal without surgery, he or she will usually be placed in a cast. The cast will be changed frequently to bend the ankle back more towards the head over progressive weeks. Usually the patient is in a cast approximately six weeks. At that point, ankle range of motion and strengthening are instituted. If surgery is performed, I think that the rehabilitation can be much more aggressive. Range of motion can be started sooner, and gentle exercises to encourage strengthening without compromising the repair can be performed. The overall process is still lengthy, however. Return to sport-specific activities and finally sports can take 3 to 4 months, if not longer.
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