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The Basic Anatomy & Physiopathology Of The Achilles Tendon
The Basic Anatomy
The Achilles tendon is a strong, fibrous cord in the lower leg. The tendon runs down the back of the lower leg and connects the calf muscle to the heel bone. It is the largest tendon in the body. Also called the heel cord, the Achilles tendon facilitates walking by helping to raise the heel off the ground to walk, run, and jump. A sheath surrounds the tendon, allowing it to glide easily as the ankle moves through its range of motion.
The Achilles tendon receives its blood supply from many sources. Small blood vessels cross the tendon sheath to provide blood and nutrients to the tendon as well as the sheath. However, there is a relative lack of blood supply in the lower part of the tendon just above where it inserts into the heel that is usually associated with the site of the tendon rupture.
The Basic Physiopathology
An Achilles tendon rupture is a complete or partial tear that occurs when the tendon is stretched beyond its capacity. Forceful jumping or pivoting, falling or tripping, or sudden accelerations of running, can overstretch the tendon and cause a tear. A ruptured tendon can cause pain and swelling near your heel. You may not be able to bend your foot downward.
Rupture of the Achilles tendon is not uncommon in healthy, active individuals. The rupture is typically spontaneous and most commonly observed in individuals in between 24-45 years of age. Ruptures are most often seen in typically middle-aged people participating in sports in their spare time. Less commonly, illness or medications may weaken the tendon and contribute to ruptures. The Achilles tendon can also degenerate. This is also known as tendinitis or tendinopathy.
A previous ruptured Achilles tendon increases the risk for another, both on the initially hurt as well as the unaffected sides. Sometimes the tendon does not fully rupture but only partially tears. The symptoms are the same as a complete tear, and a partial tear can progress to a complete rupture. While the Achilles tendon rupture usually occurs near the insertion in the heel, it can occur at any location along the course of the tendon, mostly in men than women in the ratio 6:1.
The Causative Agents Of Achilles Tendon Rupture
Several underlying illness or disease may contribute to the risk of Achilles tendon injury. The following factors serve as example:
The Responsible Diseases:
- Thyroid Disease
- Kidney Failure
- Rheumatoid Arthritis
- Systemic Lupus Erythematosus (SLE, Lupus)
The Responsible Other Factors:
- Older Age
- Activities Or Sports That Involve Running And Jumping
- Lack Of Flexibility
- Excessive Activity Causing Overuse
- Sudden Changes In Intensity Of Exercise
- Poor Conditioning
- Corticosteroid Use
- Consumption Of Antibiotics Of Fluoroquinolone Group
- Poorly Fitting Shoes
- Jogging Or Running On Hard Surfaces
- Hill Climbing Or Stair Walking
- Previous Achilles Tendon Injury
- Family History
The Associated Signs & Symptoms Of The Achilles Rupture
A person with a ruptured Achilles tendon may experience one or more of the following indications:
- Sudden Stabbing Pain in the back of the ankle or calf, often subsiding into a dull ache
- A Popping Or Snapping Sensation in the form of intense pain
- Swelling on the back of the leg between the heel and the calf
- Difficulty In Moving, especially walking upstairs or uphill and rising up on the toes
- Palpation Of A Gap Or Defect in case of complete rupture
- Loss Of Range Of Ankle Motion resulting in difficult foot and ankle movement
The Contraindications Of Achilles Tendon Rupture
Your orthopedic healthcare specialist would not recommend you to undergo a surgical procedure if you:
- are having active infection or unhealthy skin at or around the Achilles tendon rupture site
- are not healthy enough to undergo surgery
- are suffering from diabetes
- are habitual to smoking follow a sedentary lifestyle
- are a steroid user
- are unable to follow postoperative instructions
The Diagnostic Procedure Of The Tendon Rupture
The diagnostic approach employed by your podiatric specialist at their orthopedic clinic for managing Achilles tendon rupture would follow the following sequence:
- Taking Down Patient’s History
- Examining The Foot & Ankle Area That Suggests A Tear
- Evaluating & Comparing The Range Of Motion Against The Healthy Side
- Confirming The Extent Of Tendon Damage Via Imaging Techniques Like:
- Plain X-rays
Treatment Options For The Rupture
Treatment options for an Achilles tendon rupture include both conservative and surgical approaches. Each has its benefits and risks, and decisions of proceeding with a certain approach rests with the patient’s clinical situation, underlying medical background, the extent of the injury and the expectation of future activity.
The Conservative Approach
The conservative, nonsurgical approach features the following characteristics which should be borne in mind prior to going with it:
- Generally associated with a higher rate of re-rupture, nearly in 40% cases
- Selected for minor ruptures and tears
- Chosen for patients leading a less active lifestyle
- Opted for the ones with certain medical conditions that prevent surgery
The conservative procedure comprises of the following:
- Resting The Injured Foot for swift healing
- Applying Ice Massage Frequently to relieve discomfort
- Taking NSAIDs to relieve pain & swelling
- Using A Cast Or Brace to immobilize the affected limb temporarily
- Scheduling Physiotherapy for faster healing & proprioception
The Surgical Approach
Regaining Achilles tendon function after an injury is critical for walking. The goal of Achilles tendon repair is to reconnect the calf muscles with the heel bone to restore push-off strength.
Surgery is the recommended treatment for the young, healthy and active individuals; for athletes, surgery is often the first choice of treatment. Following the conservative method, if symptoms persist even after several months, your podiatric healthcare provider might advise surgery.
There are a variety of surgical ways to repair an Achilles tendon rupture. The most common method is an open repair that may take several hours, following the following steps sequentially:
- Spinal anesthesia and/or sedation would be administered.
- Your orthopedic surgeon would be monitoring your vital signs (heart rate and blood pressure) during the surgery.
- The surgeon would make an incision through the skin and muscle of your calf. The incision is smaller if you have minimally invasive surgery. A tiny camera with a light may then be used to aid the surgery.
- Your surgeon would then make an incision through the sheath surrounding the tendon. Parts of your damaged tendon would be removed or the rip in the tendon repaired.
- Your surgeon may remove another tendon from your foot to replace part or all of the damaged Achilles tendon.
- Your surgeon would make any other repairs that are deemed necessary.
- The surgeon would finally close the layers of skin and muscle around your calf with sutures.
The Postsurgical Caring Phase
- The patient is placed in a splint or cast from the toes to just below the knee to keep it from moving.
- The patient will not be allowed to walk or move around.
- The patient is advised to remain non-weight bearing for a couple of weeks.
- The patient is permitted to remain mobile while using crutches, walker, knee scooter or wheelchair.
- The patient is recommended to keep the operated leg elevated above heart level to decrease swelling and pain.
- The splint or cast is removed after 2 weeks’ time and the surgical incision evaluated.
- Stitches are usually removed at the same time.
- The patient is usually allowed full weight bearing out of the cast or boot after about 6 weeks.
- Physiotherapy is begun which is aimed at restoring ankle range of motion and strengthening of the calf muscles.
- The patient is usually able to resume full activity by six months and full recovery within a year.
The Probable Risks & Complications
The potential complications of Achilles tendon surgery include:
- Bacterial Infection In The Wound
- Damage To Nerves & Blood Vessels
- Excessive Bleeding
- Blood Clot Formation
- A Bad Reaction To The Anesthesia
- Stiffness & Numbness Near The Incision Due To Nerve Injury
- Delayed Wound Healing
- Possible Occurrence Of A Re-rupture
- Possible Scarring Of The Tendon
- Possible Thickening Of The Surgical Scar