There has been a debate in medicine lasting many decades about the benefits of surgery vs conservative treatment of a ruptured tendon. Initially the surgery required a large scar which posed risks of post-op infections. The alternative was plaster casting with pointed toes and allow the tendon to heal over a period of 3 months. This lead to a large lump in the tendon and quite often a not particularly strong repair. This also lead to very weak calf muscles and a stiff ankle. Both techniques have improved dramatically.

In this post I explain the healing process for a tendon and why this is important for an Achilles Rupture.
It is quite a technically complicated article but I have tried to make it easy to understand.

Basically you have two options:-

1. SURGERY
2. NO SURGERY

Surgery

There a several variations on the surgery and post-surgical care available see Surgical Repair of Achilles Tendon Rupture

Non-Surgical

There have been great advances in the non surgical treatment of ruptured Achilles over the past 30 years.
This extract is taken from a medical journal in 1979 “Twenty patients with total rupture of the Achilles tendon were treated by immobilisation in plaster in the gravitation-equinus position (foot down) for eight weeks. After removal of the plaster, seven patients had a re-rupture, four of whom were treated by operation, whilst two others sustained a deep vein thrombosis (blood clot).
At follow-up, 16 patients had no complaints and the remaining four had only minor problems. The range of motion in the ankle joint was normal in all patients and the strength in the affected calf was restored to normal in the majority. Because of the high complication rate we consider plaster treatment inferior to surgical treatment of Achilles tendon rupture.”
THAT WAS 30 YEARS AGO

However in 2009 this was published:
One hundred patients were randomly assigned to surgery with early mobilisation or to early mobilisation alone with the removable orthosis and without prior surgery.
In every other respect, all the patients in the study had the same treatment.
The thesis shows that there is no difference in the re-rupture rate.
A year after the injury, there was no difference in the patients’ own impression of symptoms and function,
but irrespective of which treatment the patient received, the function tests showed that there remained a substantial difference between the healthy and the injured foot.
“I have concluded that not everybody needs to have surgery, but it is important that those who suffer an Achilles tendon rupture discuss the treatment options with their orthopaedic
surgeon,” says surgeon Katarina Nilsson Helander

The key difference in the 30 years between the two articles is the phrase “early mobilisation alone with the removable orthosis”
There is a picture of one of these orthoses opposite.
This is a removable boot which is set to control the amount of ankle movement that can take place.
This allows the tendon to be protected as it heals but also allows it to be progressively stressed.
Stressing the repair site improves the quality of the scar which results in a better and more functional tendon.

For more on Tendon Healing click here

Relevance of Tendon Healing

It is the early mobility and then gradually stressing the healing tendon that has resulted in the dramatically reduced recovery times from a ruptured Achilles tendon. This applies to the surgically treated patients as well.

The secret of effective rehab is to apply the appropriate amount of stress – enough to encourage this alignment of the cells and fibres of the tendon. Applying too much stress at the wrong time results in re-rupture of the healing tendon.
Wearing the orthosis pictured above allows for the early application of these stresses which produce the excellent results now being achieved.

What Decision Do You Make?

That depends on your Doctor and their preferences although you should have input to the decision making. If you are serious about your sports then I would suggest that the Surgical approach is more likely to allow an earlier return to sport and probably with less calf muscle wasting. This is because you can start your rehab earlier after the surgery option.
However having said that, the results with non-surgical repairs are so good now that this option is becoming much better and there are none of the risks associated with surgery.
I just hope that you don’t have to make the decision!
If you do – good luck with whatever option you choose.

Other Achilles Related Posts

This post explains the

• anatomy of the calf and Achilles
• structure of the Achilles Tendon
• factors affecting rupture of the tendon

What is the Achilles Tendon?

Well it’s the long cord that attaches your calf muscles to the heel bone (Calcaneum) at the back of your lower leg.

It comes in all shapes and sizes – from long and thin to short and thick but they all do the same job – transfer forces from the calf muscles to the foot and vice versa. I say muscles because you have two muscle groups in the calf and they both perform slightly differing functions.

Gastrocenmius muscle gives the calf its distinct shape. This muscle itself has two distinct parts (heads) to it – medial and lateral.

These heads are attached to either side of the back of the knee and actually cross the knee joint to be attached to the lower end of the thigh bone (femur) by strong flat tendons.

The medial head is larger than the lateral which can sometimes be absent although I don’t think I’ve ever seen it.  The terms medial and lateral are explained in the Medical Terms Explained post.

The two heads come together about half way down the lower leg and blend with a sheet of fibrous tissue (aponeurosis) which joins onto the tendon of the third muscle –Soleus.

Soleus is attached to the upper ends of two lower leg bones namely the tibia and fibula and so is deep to the gastrocnemius muscle. From here its fibres pass posteriorly to its tendon which blends with the gastrocnemius and other fibres extend further down the leg to attach directly to the Achilles tendon almost to its lower end.

Achilles tendon (or more correctly tendocalcaneus) is the thickest and strongest human tendon. It begins near the middle of the lower leg and reaches up to 15cm long before attaching to the heel bone (calcaneus).

This diagram shows the back of the leg with the gastrocnemius muscle cut away to show the deeper Soleus muscle in its entirety.

The Gastrocnemius muscle sits over the upper part of the Soleus. There is another muscle which is small and this called Plantaris (this can be absent in many people).

Plantaris is not shown in the diagrams but it starts on the lateral side of the femur and passes obliquely down the leg to attach to the medial side of the Achilles tendon or directly onto the medial aspect of the heel bone (calcaneus).

STRUCTURE OF ACHILLES TENDON

The tendon consists of budles of connective tissue fibres called type 1 collagen fibres. Collagen is the main structural protein in the body which provides the strength to the tendon. Collagen is present in bone, tendons, cartilage and scar tissue. The tendon is between 4mm and 6mm thick, it does not contract and it can handle forces up to 12.5 times bodyweight. By my calculations that is over a ton for someone weighing just under 13 stones!!

RUPTURE OF ACHILLES TENDON

This generally takes place 2 – 5 centimetres above the insertion of the tendon into the calcaneum. It generally ruptures with and audible ‘snap’ and patients report being struck on the back of the leg by an object and turn to find nothing and no-one there. There is actually not a great deal of pain with a total tear. If it is painful then that may be a sign that the tear is only partial.

Factors contributing to rupture of the Achilles Tendon are

• high velocity sports – to otherwise healthy tendons
• pre-existing damage to the tendon
• age related degenerative changes in tendon
• rheumatoid arthritis
• Certain antibiotics (Fluoroquinolones are often used for genitourinary infections)

You now have an understanding of where the Achilles Tendon is and what it is made of, and what muscles are attached to it.
You know where the tendon ruptures and what factors may cause a rupture.

Other Achilles Related Posts