The Achilles Tendon

The Achilles tendon is one of the largest tendons in the body.  It connects the calf muscles, the gastrocnemius and soleus, to the foot via the calcaneus bone.  The Achilles tendon functions to plantar flex the foot, or more easily conceptualized, the act of putting your foot down onto a gas pedal.  The Achilles tendon is vulnerable to tearing due to extreme pressures it experiences over a lifetime.

I felt a "POP" behind my ankle when I landed.

Pop. 
We hear it almost every time.  Athletes such as basketball players will say that when they landed they felt an immediate pop.  The athlete will usually fall down and be unable to put pressure on the leg.  The back of the ankle swells quickly and patients often go to the ER.  "It felt like someone kicked me in the back of the ankle," said one of our patients.  Another said "it felt like I got a charley horse immediately after I landed."  These are two of the more common complaints patients with Achilles injuries experience. 

Surgery?  Or not?

Contrary to popular belief, not all Achilles tendons need to be fixed.  Although current guidelines recommend that we repair Achilles tendon in young athletes, those who are older and over 60 may benefit from wearing a special walking boot that lets the Achilles tendon heal in place.  To our knowledge, data suggests that surgical repair has a lower retear rate than conservative management, however, surgery does have its risks as well.  Each patient is individualized for their care and the surgeon will determine which management will be best for you.  Factors such as age, activity level, history of diabetes and weight all factor into the decision to do surgery.

A demonstaration of what an Achilles tendon tear looks like.

Surgical Repair

Achilles tendon repair is most commonly performed in healthy athletes.  Most patients under 50 will opt to have their tendon repaired.  Nonsurgical repair and surgical repair the same immobilization period and due to lower retear rates with surgery, most patients prefer to have their Achilles tendon fixed.
Fixation is usually performed with stitches into the tendon then putting it back together.

A drawing representing how Achilles tendons are stitched back together in surgery.

Picture of a torn Achilles tendon during surgery. Note the plantaris tendon, the white tendon, is intact. This was a difficult repair as it was a chronic tear.

Rehabilitation

Achilles tendon repairs take a long time to recover from.   We routinely keep Achilles tendon repairs in plantar-flexion in order to reduce the stress on the repair for the first few weeks.  Around 4 weeks, protected weight bearing is initiated.  Casting or using a boot are options for the first 4 weeks after surgery.  After protected weight bearing, patients at 6 weeks are allowed to put all of their weight on their surgical leg.  Between 4-6 weeks, and depending on the repair, therapy is initiated.  Therapy early in the postoperative period focuses on increasing motion and later on excercises to strengthen the calf muscles. 

A boot used after Achilles tendon repairs