Achilles tendon injuries: Causes, symptoms, and recovery

In his latest online article, Mr Hisham Shalaby gives us his insights into Achilles tendon. He talks about what causes an Achilles tendon injury, risk factors, symptoms, diagnosis, available treatment, recovery time, prevention and exercises or rehabilitation programs to reduce the risk of future injuries.

What causes an Achilles tendon injury, and what are the risk factors?

The Achilles tendon stands as the body's strongest tendon, pivotal in various daily activities such as walking, running, jumping, and balancing on tiptoes. Composed of resilient collagen fibres, this tendon smoothly glides within its sheath, supporting substantial weight effortlessly.

Tension in the tendon correlates with the tightness of the calf muscles, constituting a primary risk factor for injury. Additionally, pre-existing tendinopathy or inflammation heightens the vulnerability to rupture. Ignoring pain and swelling in the tendon can lead to severe complications. An abrupt surge in physical activity, especially engaging in a new sport without prior conditioning, increases the likelihood of tendon overstretching and subsequent rupture. Although less influential, factors like inadequate or unstable footwear also contribute to this risk.

What are the symptoms of an Achilles tendon injury, and how is it diagnosed?

The primary symptom of an Achilles tendon injury, often the most common and distinctive, is a sudden popping or snapping sound accompanied by a sensation similar to being kicked from behind, despite no physical contact or impact. This occurrence is highly indicative of an Achilles tendon rupture.

This injury typically brings about significant initial pain, localised swelling around the heel, and occasionally, bruising. Additionally, affected individuals might experience difficulty bending forward, bearing weight on the leg, or standing on tiptoes. These signs collectively suggest an Achilles tendon injury or a partial tear.

When diagnosing this type of injury, patients are advised to seek evaluation at an urgent care facility or minor injuries clinic. A thorough examination and patient history are conducted to identify potential Achilles tendon damage. The assessment involves palpating the tendon for specific tender areas, possibly identifying a noticeable gap within the tendon. Furthermore, specific tests are employed to determine the tendon's continuity.

The calf squeeze test stands as the most common evaluation method, involving squeezing the calf muscles and observing foot movement. Movement equivalence to the uninjured side indicates an intact tendon, while a lack of movement typically signifies a rupture. Other tests assess the range of motion and compare the tightness of the calf muscles on both sides. These diagnostic procedures are routinely performed by doctors to ascertain the integrity of the tendon.

What are the available treatment options for Achilles tendon injuries, both non-surgical and surgical?

Determining the appropriate management of an Achilles tendon injury is a decision best made by an experienced clinician. This decision hinges on factors such as the injury's severity—whether it's partial or complete—and the size of the gap within the tendon. Other crucial considerations include the patient's age, their physical activity level, any pre-existing Achilles tendon issues, comorbidities (such as diabetes or smoking), and the timing of the injury. These aspects significantly influence the chosen management approach.

Regarding treatment options, the primary choices are conservative treatment or surgery. Conservative treatment involves immobilising the leg in a cast or boot with the foot positioned downward. This method aims to bring the tendon ends closer, allowing them to heal without excessive stretching, gradually restoring the calf muscle's strength. The protocol usually involves a period with the foot downward, transitioning gradually to a more neutral position, and ultimately shifting to regular shoes with a slight heel raise to reduce tendon tension.

Surgical options encompass various techniques, ranging from open direct repair to minimally invasive methods using specific sutures to bring the tendon sides together. In cases of an old injury or a significant gap in the tendon, reconstruction techniques may be employed.

What is the typical recovery timeline for an Achilles tendon injury, and can it be prevented?

Regarding the timeline, Achilles tendon ruptures managed conservatively with a boot or plaster typically involve approximately eight weeks in the boot. This period begins with four weeks with the foot pointed downward, gradually transitioning each week until the foot reaches a neutral position. This immobilisation phase lasts around eight weeks. A similar recovery protocol is followed after surgery, if needed initially to repair the tendon. Additionally, part of the recovery process involves physiotherapy, typically commencing after the immobilisation period. Physiotherapy focuses on core muscle strengthening, improving range of motion, and incorporating stretching and strengthening exercises for the calf muscles.

In terms of prevention, the recovery itself cannot be prevented as it is a natural process. However, to prevent Achilles tendon injuries, there are several key measures to consider. Firstly, it's crucial not to overlook any pain in the Achilles tendon; prompt assessment and proper examination are necessary when experiencing pain. Addressing inflammation in the tendon is essential, and patients should be advised on appropriate treatments, whether it involves physiotherapy or other interventions. Ignoring pain can often lead to more severe issues such as tendon rupture.

Another preventive measure involves regular stretching exercises to prevent tightness in the calf muscles. Staying physically active is equally vital, as an active lifestyle can reduce the likelihood of developing tight calf muscles. Managing weight is also essential to avoid putting excessive strain on the tendons. Lastly, gradually introducing physical activities and avoiding sudden spikes in activity levels can significantly decrease the risk of these injuries.

Are there specific exercises or rehabilitation programs to strengthen the Achilles tendon and reduce the risk of future injuries?

The primary exercises in rehabilitation programs focus on stretching and strengthening the calf muscles. Various exercises involve using bands to stretch the foot, performing lunges that engage the calf muscles, or standing on the edge of stairs to slowly lower the heel, all of which aid in tendon flexibility and strength. Additionally, gradually increasing physical activities in small increments, not exceeding 10% of the previous day's activity, is crucial to prevent injury. Adequate warm-up before exercise and choosing appropriate supportive footwear—featuring good arch and heel support with a wider base for stability—are equally important factors.

Allowing sufficient time for tendon recovery is essential, as tendons typically require about 48 hours to recuperate. High-intensity training should not be performed daily; it's advisable to alternate it with low-impact exercises to provide the tendon with a chance to recover. For instance, following intense training, engaging in activities like swimming or cycling, which offer a different, less impactful workout, is recommended.

Understanding the significance of pain is crucial. Pain acts as the body's alarm system, signalling that the tendon is overloaded and needs attention. Ignoring pain might lead to a potential tendon rupture.

Mr Hisham Shalaby is an esteemed orthopaedic surgeon with over 20 years of experience. You can schedule an appointment with Mr Shalaby on his Top Doctors profile.