by G. John Mullen, DPT 2011 | email@example.com
Achilles’ tendon injuries have been present since the time of the Greek Gods and Goddesses, (remember Achilles from Greek Mythology?). Achilles’ is the burly, handsome warrior from the Trojan War legends who could only be harmed by a lethal blow to his Achilles tendon…and the name was born. Contrary to popular belief, this warrior’s surname was not Pitt. What we really want to know, however, is how does the Achilles tendon affect us today?
We all witnessed the devastating loss Michigan State suffered to underdog, Butler University, in the men’s NCAA basketball tournament. The Spartans put in a valiant effort despite the season-ending loss of Kalin Lucas, a pivotal player averaging 12.3 points per game. Lucas tore his Achilles’ tendon during the game against Maryland (tragic, we know). Achilles’ tendon tears are not unique to the collegiate super-athlete; weekend warriors are just as susceptible to Achilles’ tendon tears as the pros. An Achilles’ tear is debilitating, requiring surgery and extensive rehabilitation in most cases. Successful surgery and rehabilitation of a torn Achilles’ tendon requires a thorough understanding of the anatomy, cause of the injury, patient’s unique health condition & lifestyle and patient’s athletic activities. These factors are essential to preventing a re-repture of the tendon.
Stat Fact: Most Achilles’ tears occur 2-6 cm above the Achilles’ insertion into the calcaneus, the heel bone in the foot (3).
The Achilles’ is a complex tendon whose rarity is secondary to the fact that the tendon crosses two joints. Multi-joint crossing places increased stress on the Achilles’, resulting in the tendon’s high injury rate. Everyday activities like walking place repeated stress on the tendon. The tendon is the composite of two muscles in the calf: the gastrocnemius (the medial and lateral heads which cross the back of the knee) and the soleus (the bulk of the calf). The tendon is surrounded by two sheaths (which are called “paratendon” and “mesotenon”). The mesotenon is responsible for the nourishing blood flow to the tendon. Diminished blood flow is seen at the bottom of the Achilles’ tendon and is responsible for the high rate of tears in this region. The majority of the tendon is made of Type 1 collagen (4).
Stat Fact: The Achilles’ tendon twists in a spiral motion as it wraps around the foot and inserts into the calcaneous.
Types of Achilles’ Tears and Risk Factors
Athletic Achilles’ tears are typically acute injuries caused by a “high rate of loading” associated with specific movements which include landing, pivoting or sweet juke moves on the field…talk about all-time backfires! Acute injuries commonly occur at the distal portion (i.e. the point farthest towards your heel) of the tendon where blood flow is diminished. Out-of-shape athletes returning to high-impact sports make up the largest portion of these injuries. Trauma from a foreign object is another common cause of an acute Achilles’ tear (i.e. Tonya Harding action to the back of your ankle). These injuries are not pretty, but if you’ve seen the movie, Saw, you may remember one of the hostages having their Achilles’ sliced to prevent escape. Uncommon but horrific to say the least. Tears during motor vehicle crashes are more typical and can be equally debilitating. Chronic Achilles’ tendon injuries can also eventually lead to tears. Nagging Achilles’ tendonosis (chronic inflammation of the Achilles’ tendon) transforms the molecular properties of the tendinous collagen making the tendon soft and pliable. Pliability is the Achilles’ kryptonite (not arrows as Hollywood would have you believe)! As we age, we are more prone to tendon tears. Two factors lead to increased Achilles’ tears as we age: 1) the transformation that takes place in your tendon’s cartilage and 2) hypovascularity (impaired blood flow) making previously injured, older athletes more prone to Achilles’ tears.
Stat Fact: The Achilles’ tendon is the strongest tendon in the body, absorbing up to 8x our body weight in force during athletic movements (2).
Surgery and Rehabilitation
Surgery is always the last option. Debate surrounds the efficacy of surgery and rehabilitation in Achilles’ tears. Studies show conflicting evidence in terms of recovery speed and re-rupture rates for individuals with and without surgery (5). There is further debate on the first phase of rehabilitation for both groups. One theory of rehabilitation promotes 6-8 weeks of immobilization via casting. Casting is typically done in plantar-flexion (with your foot bent at 90 degrees to your calf) or in the neutral position (imagine your foot’s position as your leg hangs over the edge of the bed). Immobilization is thought to allow collagen repair following surgery increasing stiffness and strength of the tendon. The other accepted method of rehabilitation is the exact opposite of immobilization: early mobilization. Early mobilization is believed to promote revascularization of the injured tendon. Revascularization is believed to enhance strength (4). More importantly early mobilization is associated with similar functional gains and a low re-rupture rate (5). These positive attributes make early mobilization an important variable for surgical and non-surgical treatment of Achilles’ tendon tears.
Rehabilitation regimens vary depending on the surgeon’s approach (early mobility vs. early immobilization). Early mobilization seems to be gaining momentum with recent publications. A typical early mobility rehabilitation protocol is listed below:
Postoperative Exercise Program (1)
Group 1 (early mobilization)
Time: 0-3 wk
Flexion and extension of the toes in a supine position; 25 × 3 series
Plantar flexion of the ankle and dorsiflexion to neutral in supine position
Extension of the knee in a sitting position (hold 2 s); 10 × 3 series
Flexion of the knee in a prone position; 10 × 3 series, 3 times daily
Extension of the hip in a prone position (hold 2 s); 10 × 3 series
Time: 3-6 wk
Same as week 0-3
Time: 6-9 wk
1. Ankle flexion and extension exercises with manual help
2. Rotation of the ankles in both directions; 30 × 3 series, 3 times daily
3. Standing on the toes and heels alternately; 30 × 3 series, 3 times daily
4. Ankle extension exercises against a rubber strip; 20 × 3 series, 3 times daily
5. Ankle stretching exercises to flexion with the help of a rubber strip; 30 s × 5 series, 3 times daily
6. Stretching of the calf muscle by standing with the leg to be stretched straight behind and the other leg bent in front and leaning the body forward, with support from a wall or chair; 30 s × 5 series, 3 times daily
7. Stretching exercises for the toes and ankle against the hand in a sitting position; 30 s × 5 series, 3 times daily
Time: 9 wk
1. Raising and lowering of the heel, first with both feet at the same time and later with 1 foot; 20 × 5 series, 3 times daily
Exercises against a rubber strip for
Ankle extension 20 × 5 series, 3 times daily
Ankle flexion 20 × 5 series, 3 times daily
Ankle abduction 20 × 5 series, 3 times daily
Ankle adduction 20 × 5 series, 3 times daily
Stretching of the calf muscle against the wall; 30 × 5 series, 3 times daily
Standing with the knee somewhat flexed; 30 × 5 series, 3 times daily
With any surgery, you must take note of the potential complications. At the same time, the re-rupture rates in Achilles’ tendon tears are significant in the conservative non-surgical group. A notable complication with Achilles’ Tendon surgical repair is sural nerve dissection. The sural nerve is damaged in approximately 6% of Achilles’ tendon repairs. Sural nerve damage can lead to impaired sensation to the dorsal (back) aspect of the heel (2).
Stat Fact: Non-surgical Achilles’ Tendon treatment has a re-rupture rate of 12.6%, nearly 4x the 3.5% re-rupture rate seen in the surgical repair group (2).
While many people believe that stretching is the key to preventing Achilles’ tendon rupture, this may not actually be the case. Stretching may reduce the number of tendon injuries, but a more thorough approach is needed to further minimize your risk of injury. Most Achilles’ tendon tears are caused by high force movements. As your coach always said, “Practice like your play!” It only makes sense to practice these high force movements via plyometrics to train your body to adapt to these high levels of strain. Therefore a stretching regimen in combination with a light plyometric routine makes perfect sense. A simple plyometric routine (for example, ankle hops progressing to higher impact squat jumps and then repeated hops) can be utilized before exercise to minimize your risk of injury. Who doesn’t want strong enough Achilles’ tendons to dunk like Dwight Howard?
Questions? E-mail G. John Mullen: firstname.lastname@example.org
1. Kangas J, Pajala A, Ohtonen P, Leppilahti J. Achilles tendon elongation after rupture repair: a randomized comparison of 2 postoperative regimens. Am J Sports Med. Jan 2007;35(1):59-64.
2. Molloy A, Wood E. Complications of the treatment of Achilles tendon ruptures. Foot Ankle Clin. Dec 2009;14(4):745-759.
3. Park D, Chou L. Stretching for prevention of Achilles tendon injuries: a review of the literature. Foot Ankle Int. Dec 2006;27(12):1086-1095.
4. Strom A, Casillas M. Achilles tendon rehabilitation. Foot Ankle Clin. Dec 2009;14(4):773-782.
5. Twaddle B, Poon P. Early motion for Achilles tendon ruptures: is surgery important? A randomized, prospective study. Am J Sports Med. Dec 2007;35(12):2033-2038.