Achilles tendon tear (Achilles tendon rupture)

The Achilles tendon is a large tendon that connects the calf muscles to the bony structures of the heel. A rupture of this tendon can occur mainly in the context of sports injuries.

A disproportionately large number of men are affected by Achilles tendon rupture: The cause is likely due to a higher-risk behavior during sports activities. The peak age for this type of injury is between the third and fourth decades of life.

After a brief diagnostic procedure, surgical therapy is sought in most cases to optimize healing of the injury. Alternatively, conventional procedures are also considered, through which surgery can be bypassed. Thanks to high-quality surgical methods, the prognosis today is very good.

Direct trauma the most common cause

90% of Achilles tendon ruptures are due to indirect trauma. These are typical sports injuries in which the tendon is overstretched by a fast start or when jumping up and down. Especially sports with frequently changing step sequences are predestined for Achilles tendon rupture. These include, for example, ball sports such as football or tennis.

Indirect traumas and open injuries are rare

The remaining Achilles tendon ruptures occur as a result of direct trauma, i.e. a blow, impact or kick against the taut tendon. An open injury with severing of the tendon is extremely rare, but is possible, especially in the context of polytrauma in traffic or work accidents.

Degenerative changes are often overestimated

For a long time, degenerative changes, i.e. the ageing of the tendon in the course of life, were also discussed as a cause. The reason for this assessment was the fact that torn tendons examined under the microscope usually also showed signs of wear. Today, however, it is clear that wear alone is not a significant trigger for an Achilles tendon rupture. Even though this occurs in everyone over the years and can be aggravated by excessive sport and other stresses, it does not lead to a reduced tensile strength of the tendon.

Since it is a very large and strong tendon, its rupture is associated with a loud perceptible bang or blow. As a result, there is an immediate loss of strength in the foot. The ability to walk may be maintained, but toe stance is no longer possible. Pain may occur, but it does not necessarily have to be very severe, even if the injury is serious.

Anamnesis and physical examination

The diagnosis can usually be made by describing the typical symptoms. In the clinical-physical examination, a dent can often be felt above the heel, provided that the swelling of the foot has not yet occurred. In addition, certain reflexes in the area of the foot fail because the force of the calf muscles can no longer be transmitted to the foot.

Apparative examination only in exceptional cases

Even if an apparative examination can usually be dispensed with, sonography (ultrasound) or magnetic resonance imaging (MRI) are the most suitable. The ultrasound examination shows the course of the tendon, whereby a clear gap is visible in the case of a tear. The MRI is much more precise in the examination, so even small tears and structural changes can be imaged very well.

First aid for Achilles tendon rupture

First aid for Achilles tendon rupture provides for relief of the foot. In addition, the area above the heel should be cooled and stabilized with bandages. Elevated positioning serves to relieve the pain. After initial treatment, prompt specialist examination and treatment should be sought.

Therapy options: surgical or conservative

The treatment of choice is surgical therapy followed by immobilization. Especially in older patients or in cases of concomitant diseases that make surgery risky, conservative therapy can be used.

Conservative therapy

For conservative therapy to be successful, the ends of the torn tendon must not be more than one centimetre apart. For this reason, an ultrasound or magnetic resonance imaging examination must be performed before this therapy option is used.

If conservative therapy is an option, the foot is immobilized in a plaster splint. After a few days, the splint is removed and a special shoe with a raised heel is put on. With this shoe, the foot can be fully loaded again, which allows early mobilization. The height of the heel is gradually reduced until it can be removed completely.

In order to promote healing and achieve early mobilisation, physiotherapy should also be used as a supportive measure. In order to check the success of the therapy, regular progress monitoring should be carried out by means of ultrasound. In this way, surgical treatment can be initiated at an early stage if necessary.

Surgical therapy

In surgical therapy, the tendon is reconnected with a special suture. This suture can also be strengthened by involving adjacent muscle membranes (fascia). The operation can be performed either open or minimally invasive. The minimally invasive variant naturally has the advantage that the tissue is spared and thus a faster healing can be achieved.

Afterwards, the entire foot is immobilized by means of a plaster splint. During this time, the blood must be thinned with medication to prevent the formation of a blood clot. As with conservative therapy, the aim is to mobilise the foot as quickly as possible. The special shoe with the raised heel is also used here.

With professional care, the prognosis of the Achilles tendon rupture is very good. Only rarely do infections, circulatory disorders or restrictions of mobility in the ankle occur. In order to optimise the healing process, sporting activities should not take place for at least twelve weeks. Sporting competitions should be avoided for at least six months.

Particularly with conservative therapy (non-operative), re-rupture (renewed tearing of the tendon) occurs relatively frequently, more precisely in 5 to 18% of cases. In the surgical variant, re-rupture occurs in only 2% of cases. Due to the better prognosis, surgical therapy is also considered the treatment of choice.