Should You Have Surgery on Your Ruptured Achilles Tendon?
There is considerable debate about whether a ruptured Achilles Tendon should be treated with surgery. Personally, I believe that patients should be offered the choice of surgery – specifically minimally invasive Achilles Repair Surgery. The reasons for this are
allows movement immediately after surgery
allows smooth movement of the tendon
prevents loss of push off power from elongation of the tendon
gives additional security and confidence – no need to wear an orthotic boot in bed
has a lower rate of re-rupture
shorter time in a boot before returning to normal shoes
definitely no plaster casts involved
full weight bearing and lower risks of DVT
The ruptured ends of the tendon look like a horse’s tail – stringy and disheveled. For a solid surgical repair, a Krakow suture repair or an Achillon type repair are the most reliable. They do not rely on the stringy ends, but use the healthy tissue away from the rupture to hold on to the tendon.
Previously, there were concerns about the wound healing from Achilles Tendon surgery. The technique I use, which is minimally invasive, eliminates the concerns about wound healing and also has lower risks of injury to the nerve adjacent to the Achilles Tendon.
Some surgeons opt for conservative treatment. This means treatment in a plaster cast or a plastic boot without surgery. You should definitely not be treated with a plaster cast alone – this is old fashioned. Conservative treatment nowadays is with an airboot. Not having surgery will require that you wear the boot almost continuously and certainly in bed. The boot has to be worn for a longer period overall, and this means longer before you are walking independently and usually longer before you can drive.
When the Achilles tendon is ruptured, it is inevitable that the muscles of the calf will waste away to some extent. Having a solid surgical repair allows early exercises to be performed to minimise this, and also the gliding of the tendon and active movement has benefits for the healing tendon. A year after the injury, the muscle will have regained most of it’s power, but with surgery, the power to push off is better than without surgery.
How Do You Know That You Have Ruptured Your Achilles Tendon?
An Achilles Tendon rupture causes a sudden pain in the Achilles area behind the ankle at the bottom of the calf muscle. Usually, patients describe that it feels like they have been kicked or struck from behind, but when they turn around, nobody is there. Typically, they were running or pushing off on their affected leg when it happened. Often, it occurs during sport – football, cricket, squash, tennis, table tennis or even running.
The pain prevents normal walking, or sometimes even weight bearing. Without treatment, the tendon can elongate, with scar tissue forming between the torn ends. This can result in noticeable weakness of the calf in walking.
Sometimes, there has been a low level ache in the Achilles area for weeks or months prior to the rupture. This suggests that there is a background area of wear and tear, which has finally ruptured due to activity that has suddenly stretched it. This tends to occur in a middle and older aged group.
Although an MRI scan or ultrasound scan can confirm the diagnosis, I do not routinely use these – it is usually very clear if the Achilles Tendon has ruptured. See the video below on clinical examination for a rupture.
If you have an Achilles Rupture, you should see an orthopaedic surgeon who specialises in surgery of the foot and ankle – they should be able to offer you a complete range of modern treatments. You should certainly not be treated with plaster alone, and you should know if your surgeon is up to date with minimally invasive techniques.
What Happens During Surgery?
This is a daycase procedure – you will go home the same day. You will normally have a general anaesthetic. You will also have an injection behind the knee to numb the nerves that go into the calf, so that there is no pain for around 24 hours following surgery.
A cut is made in the skin at the level of the tendon rupture. This is a side to side cut, around 3cm long. The tendon ends are grasped with stitches using a special device called an Achillon. This allows the stitches to gain a hold in the healthy part of the tendon, well away from the damaged area of tendon. These stitches can be tied together to form loops of stitch which bring the ends of the tendon back together, and prevent stretching of the repairing tendon.
The skin is stitched, and a dressing is applied. Immediately after the procedure, a boot is applied to the leg, and this contains three wedges, which keep the foot pointing downwards.
See the video below for more details of surgery
What happens after surgery?
You will go home the same day as the operation. You should have no pain as you will have had an injection to stop the nerves working. However, this will wear off within 24 hours, so you should take regular painkillers, whether it is hurting or not.
You will be prescribed blood thinning injections, although weight bearing through the leg will decrease the risk of developing a blood clot.
The boot allows you to put all your weight through the leg. However, you cannot put any weight through it without the boot. You will need crutches for balance. The boot can be removed at night and to perform exercises. From two weeks, you will be able to shower normally. Until then, the dressings will remain in place.
For the first two weeks, you should perform exercises. These consist of flexing the foot down and then relaxing back to a neutral position. You should not lift the foot upwards (dorsiflexion) as this will risk stretching the repair.
You can perform this exercise as often as you feel comfortable. If it is too painful, you can manipulate your foot instead using your hand. The aim is to keep the tendon moving, so that it does not scar down to the surrounding tissues. This is also good for the tendon as it repairs.
You can also use an exercise bike with no resistance.
At two weeks, you will be reviewed and the dressings removed. If the wound is well healed, no further dressings are required. You can get the wound wet in the shower, or even a swimming pool, although you should still avoid full weight bearing.
The bottom wedge inside the boot is removed at two weeks. At four and six weeks, the other wedges are removed. At each stage, you can increase the resistance on your exercise bike to light resistance and moderate resistance.
At six weeks, you will be allowed to pull the foot upwards (dorsiflexion). The physiotherapist will work on developing a better range of movement, and start working on power and endurance.
It can take up to a year to return to normal levels of power, but most of the power should be back within six months. I would expect you to be able to return to your previous level of sport/recreation.
When you return to normal shoes, a 1cm wedge is placed inside the shoe to protect the Achilles tendon from excess stresses. When you go up and down stairs, you should lead with the uninjured foot and go up and down one step at a time.