Katdazzle, the queen of her domain

Poor Danny- he tore his Achilles tendon due to being on ladder too long doing the remodeling of the kitchen and then he actually tore it when he fell into a hole in the ocean. Dr. George Arungio at Sports Docs said that it is a partial rupture. He has a boot brace on now for 6 weeks but he then has to get surgery. The doc said Danny can choose to have surgery right away if he wants to or wait 6 weeks and then se how he's doing. The question in our minds is this "Is surgery the best way to handle this?" So here's the research on Achilles tendons and the surgery to lengthen it.

This picture shows the back of a right heel, the outside of the ankle and a few of the small toes. The red dotted line outlines the Achilles tendon. This is the area within the tendon where we are most likely to find an acute tear of the Achilles tendon or tendonitis. The red circle shows the area where the Achilles tendon inserts into the calcaneus and is the location of chronic Achilles tendonitis. This are will often become hypertrophied (enlarged) as the result of spurring that forms on the posterior heel at the insertion of the tendon. The red circle is also the area where we would find pain associated with retrocalcaneal bursitis. The blue area is on the outside, or lateral aspect of the heel. The blue area is where we would find the symptoms of Haglund's Deformity or a pump bump.

Treatment of acute and chronic Achilles tendonitis

Knowing that the single greatest contributor to acute and chronic Achilles tendonitis is equinus (see the biomechanics section below for more information on equinus), we know that we need to weaken the calf muscle to allow the Achilles tendon an opportunity to heal. This can be done by elevating the heel with heel lifts or by high heel shoes. Inflammation of the tendon can be calmed by ice, both before and after activities. Anti-inflammatory medications, casting or ultrasound treatment can also be used. Steroid injections are typically not used to treat Achilles tendonitis since injecting the tendon has a tendency to weaken the tendon resulting in a possible rupture.

Manipulation techniques are also helpful to increase the range of motion of the ankle. One new technique involves manipulation of the fibula (smaller outer bone of the ankle and leg) to allow greater excursion of the talus (foot bone of the ankle).
This technique must be performed by someone other than the patient and is performed as follows;

1. The patient is placed in a sitting position with the hip and knee flexed. Standing on the side of the chair opposite to the leg that will be manipulated, place the index and middle fingers of both hands over the head of the fibula (That's just below the knee on the outside of the leg). Using a firm and rapid motion, manipulate the head of the fibula anteriorly (towards the front of the leg). A slight shift or pop may or may not be noted.

2. Next, with the patient sitting and the hip and knee extended (straight) place traction on the foot with the ankle slightly plantar flexed (toes pointing down and away from the leg). Continue traction for 30-45 seconds. Then dorsiflex the ankle (move the foot/toes towards the shin). Complete a series of range of motion of the ankle with the patient.

3. Repeat as needed.

In cases of chronic Achilles tendonitis, patients who do not respond to heel lifts, manipulation and anti-inflammatory medications require a lengthening procedure of the Achilles tendon with or without a partial resection of the posterior heel. In cases with minimal hypertrophy of the heel, lengthening of the tendon will suffice. Lengthening of the Achilles tendon may be performed through three 0.5cm incisions but does require a period of casting. Full recovery may take 6-18 months.

Achilles Tendon Ruptures

First, there's a pop or a snap. Then an immediate sharp pain in the back of your ankle and lower leg that makes it impossible to walk properly. It almost feels like you've been kicked, or even shot.

These are the sensations typical of an Achilles tendon rupture. The Achilles tendon is a large, strong fibrous cord that connects the muscles in the back of your lower leg to your heel bone (calcaneus). Your Achilles tendon — also called your heel cord — helps you point your foot downward, rise on your toes and push off your foot as you walk. You rely on it virtually every time you move your foot.

If you overstretch your Achilles tendon, it can tear (rupture). An Achilles tendon rupture can be partial or complete. Usually the rupture occurs just above your heel bone, but it can happen anywhere along the tendon.

Although other problems affecting your Achilles tendon — such as bursitis and tendinitis — often improve with home treatment, an Achilles tendon rupture usually requires surgical repair.

Pain and swelling near your heel and an inability to bend your foot downward or walk normally signal that you may have ruptured your Achilles tendon. If you've ruptured the tendon completely, you won't be able to rise on your toes on the injured leg. The pain can sometimes be severe.

Often people report hearing a popping or snapping sound when the injury occurs. With a partial rupture, you may still be able to move your foot, and you may experience only minor pain and swelling.

A full rupture is more severe, but less common, than a partial rupture.

A full rupture splits the Achilles tendon so that it no longer connects the calf muscle to the heel: the calf muscle can no longer cause the foot to “push off”, so normal walking is impossible. If it is a full rupture, then lightly pinching the Achilles tendon with the forefinger and thumb will reveal a gap in the Achilles tendon.

Chronic Achilles tendonitis is not a symptom to be ignored based upon the knowledge that Achilles tendonitis is often a precursor to an Achilles tendon rupture. A rupture of the Achilles tendon can be a debilitating injury. The actual rupture of the tendon is described by most patients as feeling as if they were hit in the back of the leg. An audible pop is often described. Most ruptures occur 2-4cm proximal to the insertion of the tendon into the calcaneus (heel bone).

The repair of Achilles tendon ruptures may be conservative or surgical. Orthopedic and podiatric literature abounds with articles that compare the merits of conservative vs surgical care of Achilles tendon ruptures. Re-rupture of the tendon is not uncommon regardless of the method of correction although, statistically, re-rupture does seem to occur less in those patients that undergo surgical repair. These findings may also reflect the nature of patient that would be a surgical candidate. Typically we would assume that those patients that were in poor health (eg elderly, diabetic, immune compromised) would not become surgical candidates and therefore may contribute to the increased rate of re-rupture seen in those treated with conservative care.

Recent articles have advocated a surgical approach for repair of ruptured Achilles tendons that employs both an open and percutaneus technique of repair. The most popular method was described by M. Kakiuchi of The Osaka Police Hospital in 1995. This technique involves the use of an open procedure at the site of rupture to enable debridement of the ruptured tendon. Kakiuchi also employs a closed technique to suture the tendon to allow for proper healing.

partial or complete Achilles tendon rupture requires immediate immobilization, or in the very worst cases, immediate surgery to reconnect the tendon. Note that this treatment is the complete opposite of the treatment for Achilles tendinosis.

Strengthening, stretching, and relative rest followed by gradual increases in exercise will help Achilles tendinosis, but would be detrimental to an Achilles tendon rupture. Activity causes Achilles tendon ruptures to get worse, making them more likely to require surgery.

What is the treatment for Achilles tendon rupture?
Achilles tendon rupture is most often treated surgically to reattach the tendon to its normal position.

Nonoperative management can be undertaken, generally people who live sedentary lifestyles or who may have problems with wound healing. Nonsurgical treatment of an Achilles tendon rupture is accomplished by casting the Achilles tendon for several months. In these patients, the number of reruptures is higher compared to those patients who have surgical repair. In patients who have surgery for an Achilles tendon rupture, less than 3% experience a rerupture of the tendon.

How is surgery done for treatment of an Achilles tendon rupture?
The surgery to treat an Achilles tendon rupture involves an incision along the back of the ankle. Usually the incision is made just to the side of midline so shoes will not rub on the site of the scar. The torn ends of the Achilles tendon are identified and strong sutures are placed in both ends of the tendon. These strong sutures are then tied together to repair the tendon.

What are the complications of Achilles tendon repair?
The most common and worrisome complications following an Achilles tendon repair are problems with wound healing. The skin over the Achilles tendon sometimes does not heal well. Therefore, careful wound management is of utmost important following surgical repair of an Achilles tendon rupture. Other potential problems include infection, ankle stiffness, and rerupture of the tendon.

What is the rehab following Achilles tendon repair?
Rehabilitation following Achilles tendon repair is a controversial topic. Traditionally, patients were casted after surgery for a period of 4 to 8 weeks and after that time, patients were allowed to gently move the ankle.

More recently, studies have shown that patients do well and heal faster with more rapid mobilization. If a solid repair is attainable, patients may not be casted at all, and allowed to begin motion immediately after surgery. These patients will use a removable boot when walking for several weeks.

How long might you be out of training for?