Surgery or immobilization? What is the best option when it comes to a full recovery after a ruptured Achilles tendon?

As our population continues to stay active as they age, the number of Achilles injuries seen in emergency rooms and doctors’ offices is increasing. What I see most often is the rise of Achilles tendon ruptures in my middle-aged males who are participating in activities that include explosive movements, like basketball, tennis, and soccer.

The Achilles tendon is the largest tendon in the body and is used when you walk, jump or run. It attaches the calf muscle to the heel bone and controls the movement of the foot. The Achilles tendon can undergo a considerable amount of pressure and stress, but at times it will strain or tear. In fact, it is the most frequently injured tendon in the lower half of the body.

The two main forms of Achilles injuries are Achilles tendonitis and a ruptured Achilles tendon.

• Achilles tendonitis is a strain or inflammation of the Achilles tendon that will cause pain along the back of the leg near the heel. Most often, treatment for Achilles tendonitis is nonsurgical, though surgery is an option if pain persists six months after nonsurgical treatments.
• Ruptured Achilles tendon is a tear or separation of the fibers in the Achilles tendon. In some cases, this comes after a period of tendonitis, which weakens the tendon. During a rupture, patients often describe feeling and hearing a pop in their heel, followed by pain and loss of function. Patients will commonly say it felt like someone kicked them from behind.

An orthopedic physician can perform several tests to diagnose if your Achilles tendon has ruptured. I usually perform one of the following tests to confirm the level of an Achilles injury:

• Thompson test is an easy way to see if the Achilles tendon is ruptured. The patient will lie on his or her stomach with the injured leg in the air. The physician squeezes the calf muscle to examine the reflex that should flex the foot. If the foot does not flex, the Achilles tendon is most likely ruptured.
• Palpation of the tendon will usually reveal a defect at the rupture site.
• Not uncommonly, you can see a ‘divot’ where the tendon is ruptured.
• Ultrasound is an option if the diagnosis is questionable.
• Magnetic resonance imaging (MRI) is another diagnostic option that is useful if the diagnosis is in question or if the rupture is chronic and the tendon retraction level needs to be evaluated.
• 99 percent of the time, the diagnosis can be confidently made without any type of imaging study and is determined through physical examination alone.

If your doctor has confirmed that you have ruptured your Achilles tendon, the next step is to consider a treatment plan. Nonsurgical treatment has received some attention recently, but surgical treatment is still the preferred option by most surgeons and the vast majority of patients. Both types of treatments have a lengthy healing process with required rehabilitation.

Nonsurgical treatments

This involves immobilization of the ankle. Immobilization involves wearing a brace or boot that will help protect the tendon while healing. This is the more common treatment for older, medically unstable or inactive patients.

Nonsurgical treatments are less invasive than surgery, but the recovery time tends to takes longer and the chance of re-injuring your tendon again in the future increases. Because of this, I tend to lean away from this nonsurgical option, especially if you are an active individual.

Surgery for Achilles tendon repair

Surgery is the more common treatment for a ruptured Achilles tendon. Typically, surgery entails making an incision on the back of the heel and sewing the tendon back together using nonabsorbable sutures. Surgery may include using minimally invasive techniques that rely on smaller incisions and allow for faster recovery. If you have an experienced orthopedic surgeon who frequently repairs ruptured Achilles tendons, this is the treatment option I would choose.

Rehabilitation

No matter if you choose a surgical or nonsurgical treatment, you will need to complete physical therapy rehabilitation to improve the strength of the tendon and restore functionality.

When deciding what plan is best for you, it is important to meet with an orthopedic specialist to discuss the best treatment option for your particular injury. And because many times patients go to the emergency room upon sustaining the injury, they may not be referred to an orthopedist who specializes in these repairs. A ruptured Achilles tendon is very serious and should not be taken lightly. By not seeing a doctor, you can unconsciously make your injury worse over time.