Why does the largest tendon in your body rupture & how do you fix it?
Updated: Mar 26
So I am now 9 weeks post Achilles tendon (AT) rupture and from the 1st blog we now know what the AT does (ultimately we can’t live without it! DOH), how and when rupture occurs. I wanted to dive into the possible reasons to why a spontaneous rupture happens. What are the risk factors that could make it more likely and whether I can learn from this, if it was ultimately my fault ignoring signs or symptoms. Was it just bad luck? To cut this blog super short, for those that don’t want to carry on reading, I still have no definitive fecking clue to why it happened…. For those that are interested then the following info gives a bit of context of potential contributing factors.
For some, especially me, I wanted to know why this injury had happened, to almost justify if logically, to be able to move forward in the recovery/rehab and to ensure it doesn’t happen again. Honestly if it re-ruptured, which is possible in the rehabilitation process, I would seriously struggle in handling it (I would probably crawl under a stone, hide and eat cake, for a very long time). This post will also look at the assessment of the injury and then common treatment options for a full AT rupture.
As stated in the last blog AT rupture can occur within active and non-active populations and doesn’t always correlate to engaging in sport. This is one of the main reasons why a lot of research has been done on the risk factors in AT rupture as it may not just be the mechanical overload of the tendon that caused it to snap, there are potentially other factors which make this more likely to happen.
Ok so the run down of who’s at risk:
Men (Yep I’m male)
Aged between 30-50 (Yep I’m 35)
Playing high intensity, explosive sport (Yep I was playing squash… maybe I should give up.. on second thoughts I am too stubborn to give it up)
And other risk factors to AT injury can be systemic diseases such as gout, infections, diabetes, collagen deficiency, chromic renal failure, lupus, thyroid disorders and rheumatoid arthritis. Also foot problems that increase AT injuries include Cavus foot, insufficient gastroc-soleus strength, limited ability to perform ankle dorsiflexion, tibia vara and Varus alignment with functional hyper pronation. (Shamrock and Varacallo, 2021)
Of the above I would consider myself as having none of these factors, that I am aware of. Reading around the issue and risk factors the hallmarks of AT problems seem to be damaged (history of tendinitis, commonly inflamed acute tendon injuries, and or tendinosis, long term overuse with tissue degeneration, commonly presenting with little or no symptoms), weak, elastic tissue (poor tensile strength properties).
Considering I use to performed eccentric calf raises with high load to increase strength, twice a week as part of my Strength and conditioning, and stuck to a structured running training plan to balance volume, intensity of running with the S & C work. I have previously suffered from minor tendonitis in my right Achilles after my 3 peaks cycle but apart from that it’s my left Achilles that I would consider my dodgy one! Maybe I had prolonged overuse degeneration (tendinosis) of the right AT? Or maybe I was lacking relevant/specific plyometric loading in my S & C program for explosive sports such as squash. These exercises were in there but they just weren’t structured per se.
It is thought that the reason for the rupture of an AT is likely to be multifactorial rather than for one sole reasons (Shamrock and Varacallo, 2021). There is some evidence suggesting that genetics plays a large part in the structure & make up of tendons and could be one of these multifactorial factors. Also a lot of the info, books and studies that I have read seem to neglected the consideration of other factors that could play a part in injury that aren’t purely biological/ mechanical. If you think of the biopsychosocial model of individuals interactions you can potentially see how psychological and social factors could effect the biological and influence the presentation of injures. Studies have shown a potential link between the rates of injury and sleep, one of which was in children (Owens et al., 2005), possibly poor nutrition effecting potential to injury (Close et al., 2019) and stress and rates of injury (Nippert & Smith, 2008). These potential interactions of the biopsychosocial aspects could effect likelihood of injury. Maybe you slept bad and so felt fatigued or low in mood or stressed due to work or an argument with a friend which meant you hadn’t recovered, rested, slept as well the night before. All these small things, interactions could play a part. Maybe its not just purely biology and mechanics behind the why. The complex interactions leading to why it occurred aren’t ever going to be clear cut so I have to see the potential holes in my training and plug them for the future.
So how do they diagnose an AT rupture? Well you would think it can’t be missed, but it can. Symptoms are pain (however 1/3 don’t experience pain), pain on passive dorsiflexion (point toes up), limited or no planta flexion (point toes down), swelling, bruising along with an audible pop or snap heard. The most common ways to test if it’s a AT rupture is to do the Thompson test. Lay face down on a couch or kneel on a couch with the toes over the edge. By squeezing the calf muscle there should be movement in the foot. No movement = positive and complete rupture. Also looking for a more dorsiflexed position of the foot whilst at rest in comparison to the other side and possibly palpating for a gap in the tendon but isn’t always obvious. A more certain way to confirm these tests is to have an ultra sound to locate the rupture exactly and measure the gap. This isn’t always performed to confirm diagnosis or needed for an effective treatment to be administered. My rupture was 5 cm up from the heel and 12mm
So the possible treatment options as far as I am aware are fairly simple but the questions is to operate or not to operate? This depends on a few possible variables. From my understanding a tendon gap below 10mm they are more likely to leave and treat conservatively (no op), over 20 mm gap they definitely operate as its too far apart to repair to bridge that gap, and between this its more down to the individual circumstances.
Being an active, fit and healthy individual which relies on a strong recovery / repair in regaining their quality of life and with my work relying physically on a good recovery there was a conversation about an operative approach. However, if an individual had a non-physically active job and not going to ask too much of the AT after recovery in daily life and activity then they are more likely to take a conservative approach.
With the research I had done I found a meta-analysis by Ochen et al. (2019) that showed very little between the two approaches but a smaller chance of re-rupture with a surgical fix 2.3% vs. a conservative approach 3.9%. Having said this the operation does come with more risks, 4.9% chance of complications like infection, DVT and nerve damage etc with non operative only being1.6%.
What swayed my decision was twofold. Whilst having the conversation with the doctor about my concerns about the strength of my calf post recovery he said there is some evidence suggesting a better recovery to preinjury strength, to around 80% strength with operative intervention, rather than 60% if conservatively treated. I haven’t been able to find this info/ research but after speaking to several physios and friends that have sustained the same injury it is perceived as a stronger and preferred repair for active individuals. The doctor said within a day to day living you wouldn’t notice the difference between 60% & 80% of preinjury strength but if you are a keen amateur sports person, like myself, the likely hood is you would notice the difference during sporting activity. This along with the perception that an operation will give a stronger repair because its sewn together. BUT having done a lot of reading they can’t actually sew the ends together, they just get pulled together so they are close enough to heal. There are multiple ways to perform the surgery from different methods of incision, methods of sutures which all comes down the surgeons preference. Importantly my confidence in believing an operation was a stronger fix was a powerful factor in my decision.
Regardless of the decision op or not to op, you are in a boot for 6-10 weeks and gradually building the weight bearing in the boot and then out of the boot after that time. Again there is still a great deal of debate about the most effective recovery protocol so each consultant/specialist will have their views and professional opinions on when to use op vs no op and also in how early to get you out of the boot and into rehab exercises. This again this isn’t your choice but just depends on who you see.
In hindsight would I do the same given the option, probably solely based on the potential to regain as much pre injury strength as possible. Having an operation sucks and would always avoid if I could due to the fascia/ connective tissue of the area being disturbed and impacted. I am now seeing this first hand in my rehab coming out of the boot, the other lower leg tendons aren’t moving as freely due to the laying down of scar tissue and restricting their movement which you may not get as much of in the non invasive conservative approach.
So 9 weeks in and I have been signed off from orthopedics at 8 weeks and started the hard work of what I class as structured rehab after 7 weeks under private physio advise. I am going to write another blog about my rehab but I am going to see how the next month or so goes to give you a good over view of the process. It can take 6 months up to 12 month and possibly even 2 years for a full return to play recovery.
A little hint though, don’t snap your Achilles as it’s a ball ache to do the most simple of daily task… carrying a cup of coffee – impossible until week 6-7. Unless your very good at hopping on one leg and not spilling the contents. So top tips:
1. Have a structured well rounded training program including plyometrics, especially if you are doing explosive sports like squash. Ensure you had adequate rest in your program if you are feeling physically or even mentally fatigued. Train to feel within a structured program.
2. The mind is as important as the body. Take care of both and into consideration when training and especially in recovery. I will chat more about this in my next blog.
3. We don’t completely know why AT ruptures occurs, they are most likely multifactorial in nature. It’s very unlikely to occur, but don’t worry about it if you are nailing all the other aspects of a well-balanced training program in and out of the gym. 4. If it does occur treatment options are surgery or non surgical with good reasons for each option and the research is showing very little difference in outcomes short and long term. However you have to also ask what are your expectations of each option, do you already have an underlying bias towards one than the other, what do you feel is right and that combined with the evidence is the most important aspect.
References (I have always hated doing references so don’t judge me incorrect format I have them below)
Judith A. Owens, Sandra Fernando & Melissa Mc Guinn (2005) Sleep Disturbance and Injury Risk in Young Children, Behavioral Sleep Medicine, 3:1, 18-31, DOI: 10.1207/s15402010bsm0301_4
Graeme L. Close, Craig Sale, Keith Baar, and Stephane Bermon (2019). Nutrition for the Prevention and Treatment of Injuries in Track and Field Athletes in International Journal of Sport Nutrition and Exercise Metabolism DOI: https://doi.org/10.1123/ijsnem.2018-0290 Volume 29: Issue 2 Page Range: 189–197
Angela H. Nippert, Aynsley M. Smith, (2008) Psychologic Stress Related to Injury and Impact on Sport Performance, Physical Medicine and Rehabilitation Clinics of North America, Volume 19, Issue 2. Accessed on 4 February 2022 https://www.sciencedirect.com/science/article/abs/pii/S1047965107001350
Ochen Y, Beks RB, van Heijl M et al. (2019) Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis. BMJ. 2019;364:k5120. Downloaded from: https://www.bmj.com/content/bmj/364/bmj.k5120.full.pdfon 4 February 2022
National institute for Health and Care Excellence (2020) Achilles Tendonopathy https://cks.nice.org.uk/topics/achilles-tendinopathy/background-information/prevalence/#:~:text=Achilles%20tendon%20rupture%3A&text=Has%20an%20annual%20incidence%20of,years%20%5BUquillas%2C%202015%5D.