The Achilles tendon is the strongest tendon in the body and is also the most commonly ruptured. However, rupture is only one of the problems that can occur with the Achilles tendon. For every torn tendon, I see many more cases of tendonitis and tendinopathy.
Achilles ruptures are often associated with a “pop” and an instant feeling of pain. Patients relate that the pain does not last very long and — although there is swelling on the bag of the leg — the pain often subsides. Some patients may not realize they have an Achilles tendon tear for a while, resulting in a chronic tear that may require additional care beyond a primary Achilles repair surgery.
The point of this article is to share my experience with everything Achilles from tendonitis to tendinopathy and acute to chronic rupture repairs.
How is acute Achilles tendinitis treated?
In my experience, acute cases of Achilles flare-up or tendonitis are often due to overuse and a level of increased activity that results in the tendon being strained and painful. Patients usually experience pain to the touch and pain when moving the Achilles tendon. There may be inflammation and/or grinding of the tendon with pressure.
Several common causes of Achilles tendonitis include pronation deformity of the foot, which results in hyperextension of the tendon and strain on the entire foot/ankle. Furthermore, an increased level of acute activity can place strain on the tendon and cause inflammation. Commonly, rest, ice, anti-inflammatory treatments, physical therapy, and protection will result in improvement.
If pronation is causing your tendonitis, insoles or orthotics may help to reduce strain. Achilles strengthening exercises and gentle stretching after a period of rest will also protect and improve the function of the tendon.
What are the challenges of chronic Achilles tendinopathy?
If acute Achilles tendonitis is not treated in a timely fashion, continued strain and damage can occur. Often when treating Achilles tendonitis, I have found microscopic tears in the tendon with scar formation and more chronic damage.
The inflammation process that heals your damaged Achilles tendon may reduce over a period of three to six months. This results in chronic, noninflammatory scar formation and enlargement of the tendon.
My goal during treatment of chronic Achilles tendinopathy is to convert a chronic, noninflammatory condition to a more acute inflammatory condition. Reducing your tendonitis from chronic to acute, better allows your body to heal the damaged area.
In my experience, rest, ice, and anti-inflammatory treatments do not always help a chronic condition as inflammation is not the primary problem present. However, physical therapy can be very helpful, and often includes scar tissue-focused modalities in the form of Astym (augmented soft tissue manipulation) or Graston techniques. Both techniques focus on breaking down restrictive tissues and restoring normal function.
In truly stubborn cases, shockwave therapy, platelet-rich plasma (PRP), or amniotic fluid injections may provide relief.
Treatments for chronic Achilles tendinopathy
I have used extracorporeal shockwave therapy for years, but in the past three years my office began using the OrthoGold 100 (SoftWave) device. Through a combination of ultrasonic sound waves, light waves, and shockwaves, we break the scar tissue apart in the damaged tendon. This activates the body’s stem cell response to help heal the region.
If the Achilles is very bulbous and needs extra treatments or multiple treatments are difficult for the patient, I have found that PRP injection is a good choice. My clinic uses ultrasound guidance during the injection process and uses a “peppering technique” to break up the scar tissue while injecting small amounts of PRP. After treatment, I often give patients a walking boot to rest the tendon and make them more comfortable.
Amniotic fluid injections have become a mainstay in my treatment of Achilles tendinopathy. Amniotic fluid triggers a stem cell response and causes an inflammatory healing response in the region of injection. In general, amniotic fluid injections are less painful for patients than PRP. Again, peppering and ultrasound guidance are preferable but not essential, and using a boot may be a good option. It is not rare to repeat the PRP or amniotic injection a second time four to six weeks after the first injection in stubborn cases.
More advanced Achilles tendinopathy treatment options
In serious cases, where the tendon does not respond to these treatments, debridement is the next step. While I was in residency, we would perform open surgery to debride the damaged tendon area. Nowadays, we are able to perform debridement with percutaneous means (through several small incisions, instead of a large incision).
Three common debridement probes we use are:
- Topaz (Smith and Nephew)
- TenJet (HydroCision)
- Tenex (Trice Medical)
Topaz is a radiofrequency coblation (low-temperature) device that stimulates healing in the degenerative tendon, creating a local plasma layer that dissolves molecular bonds of soft tissue scarring.
The Tenex and TenJet probes remove scar tissue in a more mechanical manner. Using ultrasound guidance, we insert the probe, break apart the scar tissue, and remove it with suction. TenJet utilizes a power saline jet system that will break up the scar and debride it, while the Tenex system debrides and aspirates by reducing the target tissue to liquid.
What you should know about acute Achilles tears
Most acute ruptured tendons I see in my practice are from “weekend warriors” who are between their early 20s and late 60s and engage in frequent physical activity. Patients may come in complaining they “sprained their ankle,” but under examination, we find weakness to plantar flexion and a palpable gap in the tendon.
While we can usually assess and diagnose a tear with a simple examination, we often turn to imaging to confirm diagnosis. Magnetic resonance imaging (MRI) is a mainstay of imaging, but I have begun to use in-office ultrasound for my testing and radiographic diagnostics. Ultrasound testing is inexpensive, fast, and easy to perform as well as dynamic. An ultrasound can show if the tendon ends approximate with plantarflexion — which I find helpful in planning the treatment course.
How is the treatment of acute Achilles tendon ruptures performed?
It’s rare for me to consider nonsurgical Achilles casting as an option for acute rupture of the Achilles tendon, but it is sometimes worth considering. Depending on what the ultrasound shows, we may have success casting the ankle in a plantarflexed position. However, nonsurgical treatment does come with higher rate of re-rupture and longer recovery time. Casting can also result in a tendon that is weak or not at optimal length.
In the case of Achilles tear surgery, I have started utilizing a minimally invasive repair system almost exclusively. I now find it rare to have to make a large incision in acute cases for an end-to-end repair. Furthermore, a minimally invasive system places the sutures in the non-ruptured region of the tendon — which is likely stronger and of better quality.
If the tear is distal or there isn’t enough quality tendon to do a direct repair, I’ll anchor the sutures to the heel bone. While this technique is more difficult, the repair is stronger.
Achilles surgery recovery
After torn Achilles surgery, we will put you in a cast for five weeks to allow the tendon to heal. At five weeks, we place you in a tall boot with one inch of lift —at this point, you’ll be cleared for weight-bearing and will start physical therapy to recover range of motion. Over three weeks, we slowly remove portions of the lift during follow-up appointments. At 10 weeks post-surgery, protection can be removed and therapy continues.
Full recovery may take three to six months total. During this time, prescription or over-the-counter pain medicine may be used to manage any pain.
How are chronic Achilles tendon ruptures treated?
Chronic ruptures typically occur in patients who continue to function on an injured foot due to lack of acute pain. As a result, the tendon doesn’t heal or heals incorrectly. My primary Achilles tendon repair method for this condition is to repair the Achilles to a functional length.
In my experience, it is rare that a ruptured Achilles tendon can be primarily repaired when chronically ruptured. If there was a high-grade partial tear and the Achilles repaired itself in a lengthened manner, an end-to-end open repair can be performed by removing a tubular section of scar and tendon and re-repairing under anatomical tension.
Often the Achilles tendon and the calf muscles (gastrocnemius and soleus muscles) are weakened and full strength may not return, therefore a flexor hallucis longus (FHL) tendon transfer to the heel can add strength to the Achilles function. The FHL tendon is harvested from behind the Achilles tendon. The FHL will act in sync with the Achilles tendon to add push-off strength.
Recovery from this procedure is usually similar to acute tendon tear repair and extensive therapy will be needed to strengthen the area.
Dr. Bob Baravarian is just one of the expert podiatrists and orthopedic surgeons at the University Foot & Ankle Institute (UFAI). UFAI’s podiatrists are experts in non-invasive and surgical repair procedures as well as sports medicine and physical therapy. Whether you’re experiencing ankle pain or just interested in preventative care, UFAI’s staff are here for you.
Call us at (877) 736-6001 or make an appointmentonline now!
Our podiatrists take patients’ safety seriously. Our podiatry facility’s Covid-19 patient safety procedures exceed all the CDC’s coronavirus pandemic recommendations. Masks are always required in our institutes.
University Foot and Ankle Institute is conveniently located throughout Southern California and the Los Angeles area. Our foot doctors are available at locations in or near Santa Monica, Beverly Hills, West Los Angeles, Manhattan Beach, Northridge, Westlake Village, Granada Hills, Valencia, and Santa Barbara.
Resources
Chiodo CP, Glazebrook M, Bluman EM, Cohen BE, Femino JE, Giza E, Watters III WC, Goldberg MJ, Keith M, Haralson III RH, Turkelson CM. American Academy of Orthopaedic Surgeons clinical practice guideline on the treatment of Achilles tendon rupture. JBJS. 2010 Oct 20;92(14):2466-8.
McCormack R, Bovard J. Early functional rehabilitation or cast immobilization for the postoperative management of acute achilles tendon rupture? A systematic review and meta-analysis of randomized controlled trials. Br J Sports Med. 2015. 49:1329-1335.
Schmitz C, Csaszar NBM, Milz S, et al. Efficacy and safety of extracorporeal shock wave therapy for orthopedic conditions: a systematic review on studies listed in the PEDro database. Br Med Bull. 2015;116:115-138.
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Dr. Bob Baravarian, DPM, FACFAS
Dr. Bob Baravarian is a Board Certified Podiatric Foot and Ankle Specialist. He is currently a member of UCLA Medical Group, Chief of Podiatric Surgery at Santa Monica/UCLA medical center and Orthopedic Hospital and an assistant clinical professor at the UCLA School of Medicine. He also serves as co-director of University Foot and Ankle Institute. He is Editor Emeritus of the international medical journal, Foot and Ankle Specialist.
Dr. Baravarian has been involved in athletics his entire life and played competitive tennis in high school and college. He has an interest in sports medicine, arthritis therapy and trauma/reconstructive surgery of the foot and ankle. He servers as a consultant to the ATP (Association of Tennis Professionals) tour, multiple running organizations and several shoe manufacturers. He is also fluent in five languages (English, French, Spanish, Farsi and Hebrew),
Podiatrist Dr. Bob Baravarian is available for consultation at the Santa Monica, Sherman Oaks and UCLA Westwood offices.
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FAQs
Do all Achilles tendon tears need surgery? ›
You might need Achilles tendon surgery if you tore your tendon. Surgery is advised for many cases of a ruptured Achilles tendon. But in some cases, your healthcare provider may advise other treatments first. These may include pain medicine, or a temporary cast to prevent your leg from moving.
How long does it take for Achilles tendon to heal without surgery? ›You'll wear a cast, splint, brace, walking boot, or other device for several months. Your total recovery time can be up to 6 months.
Can a fully torn Achilles tendon heal on its own? ›If a completely ruptured Achilles tendon is not treated properly, it may not heal or heal with scar tissue in an elongated position, and the person will not regain enough strength in the leg for normal daily activities such as walking, let alone running or other athletic activities.
How serious is an Achilles tear? ›If your Achilles tendon ruptures, you might hear a pop, followed by an immediate sharp pain in the back of your ankle and lower leg that is likely to affect your ability to walk properly. Surgery is often performed to repair the rupture. For many people, however, nonsurgical treatment works just as well.
What is the best walking boot for Achilles rupture? ›VACOped Achilles Injury/Fracture Orthosis Boot is the number one choice of patients and physicians alike for treating Achilles injuries. It has an adjustable, articulating ankle feature for dynamic settings such as plantar flexion and controlled Range of Motion (ROM) thus allowing and enabling an active recovery.
What happens if you tear your Achilles and don't get surgery? ›Take a group of 100 people who have a ruptured Achilles tendon. With surgery, 5 out of 100 will rupture the tendon again within 1 to 2 years. This means that 95 out of 100 will not. Without surgery, 12 out of 100 will rupture the tendon again with 1 to 2 years.
Can you live with a torn Achilles? ›Yes, you usually can. What you feel when you walk with a partially torn Achilles tendon depends on how much of the tendon is torn and how long ago you've torn it. If it's a significant portion, then it may be quite painful to put your heel on the floor, and you may struggle to push off with the front of your foot.
What is the success rate of Achilles tendon surgery? ›Results: At 12 months, 92% of patients were successfully followed up. Of those working prior to injury, 95% had returned to work.
Is walking good for a torn Achilles tendon? ›Researchers recommend early walking in a brace for Achilles tendon rupture.
Can you return to normal after Achilles tear? ›At some point as you recover, your provider will ask you to begin moving your heel. This may be as soon as 2 to 3 weeks or as long 6 weeks after your injury. With the help of physical therapy, most people can return to normal activity in 4 to 6 months.
How long do you have to wear a boot for Achilles rupture? ›
You will need to wear a cast or a walking boot for 6 to 12 weeks after surgery. At first, it may be set to keep your foot pointed downward as the tendon heals. You may be able to put weight on your affected leg after a few weeks. But it will be several months before you have complete use of your leg and ankle.
What helps tendons heal faster? ›Stretching and flexibility exercises to help the tendon heal completely and avoid long-term pain. Strengthening exercises to help you rebuild tendon strength and avoid future injuries. Ultrasound heat therapy to improve blood circulation, which may aid the healing process.
How long can you wait to repair a tendon? ›Delayed tendon repair can be performed within 3 weeks to one month after injury, but the repair is preferably done in initial several days of delay. Direct sheath closure is not advocated in tendon repair in the delayed period.
How can I treat my Achilles tendon at home? ›Home Care. Rest and ice can ease the pain of tendinitis. Stay off your foot or ankle as much as possible and apply ice for up to 15 minutes at a time, three to four times a day. Stretching of the tendon is not recommended until all symptoms have resolved or indicated by your physician.
How do you heal a torn Achilles without surgery? ›Non-operative treatment requires that you use crutches, a walker, or a wheelchair to remove your bodyweight from the injured leg. You will also need guided physical therapy. Slowly, you will progress from the non-weightbearing treatment to walking in a boot with heel wedges.
How painful is a torn Achilles? ›The most obvious sign is pain above your heel, especially when you stretch your ankle or stand on your toes. It may be mild and get better or worse over time. If the tendon ruptures, the pain is instant and severe. The area may also feel tender, swollen, and stiff.
Which is worse torn or ruptured Achilles tendon? ›Any type of tear can cause patients issues but a full rupture is much tougher to bounce back from in the long-term as a great deal of tissue needs to be repaired.
Are compression Socks good for Achilles rupture? ›Now there is evidence that besides helping prevent DVT complications, intermittent compression therapy may actually improve the rate of healing of the ruptured Achilles tendon.
Are compression Socks good for Achilles tendon? ›Medical grade compression improves circulation in the feet by applying targeted compression over the mid-foot and ankle. The compression directly reduces superficial swelling by supporting the Plantar Plexus network of veins while directly stabilizing the Achilles tendon.
Should I wear a short or tall walking boot for Achilles tendonitis? ›Short or Tall Boot? Always use the tall walking boot for tendonitis. The muscles start high up in the leg and to best rest these muscles the boot must go up high on the leg.
Do you get a cast for a torn Achilles? ›
Traditionally, patients with an Achilles rupture have been treated with serial plaster casts over several weeks. The cast provides maximum protection for the tendon as it heals, but immobilisation might increase calf muscle atrophy, ankle joint stiffness, gait abnormalities, and the risk of blood clots.
Do you need a cast for a torn Achilles? ›Treating an Achilles tear
A tear can be treated either with casting or with surgical repair. Cast treatment requires 6-8 weeks of non-weight bearing cast immobilization, followed by several weeks in a walking boot, to make sure the tendon is completely healed in proper position.
This can result in residual symptoms of discomfort which can often be exacerbated in different weather conditions, and problems with balance, altered gait, poor strength of the affected leg resulting in over-compensating with the uninjured leg, and issues with mobility.
How long is hospital stay after Achilles surgery? ›You will normally be able to leave the hospital or clinic within three to four hours after surgery. Make sure to have someone available to drive you home, as you will be unable to drive a car.
What are the 3 types of Achilles tendon surgeries called? ›- Percutaneous repair, open repair, and tendon transfer are different types of surgery for Achilles rupture. ...
- If physical therapy does not help heal Achilles tendinitis, your doctor may recommend surgery. ...
- Your doctor may recommend using biologics to enhance healing from a procedure.
Patients with rupture of the Achilles tendon can still walk. Patients with rupture of the Achilles tendon can still actively move the ankle up and down. Patients with an Achilles tendon rupture may even manage to stand on tiptoes (on both feet together — though not on the injured limb alone).
How do you know if you need Achilles tendon surgery? ›5 Signs You Need Surgery on Your Achilles Tendon
Pain — possibly severe — and swelling near the heel. A snapping or popping sound when the injury occurs. Inability to bend the foot forward or push off of it when you walk. Inability to stand on tiptoes.
Grade 1: Mild, with few torn tendon fibers. It produces some tenderness and sometimes minor swelling. Grade 2: Less than half of tendon fibers torn, causing pain, tenderness and some swelling. Most activities (walking, running or jumping) are accompanied by pain.
Do you sleep in boot after Achilles surgery? ›Sleep with the boot on until you feel confident to take it off at night (normally approximately 4-6 weeks).
Do you need an MRI to diagnose a torn Achilles tendon? ›MRI is unnecessary for diagnosing acute Achilles tendon ruptures: clinical diagnostic criteria. Clin Orthop Relat Res.
How do you shower with a torn Achilles? ›
Washing & Bathing:
Once your splint is removed, many patients are advanced into a walking boot; it is OK to shower directly over your Steri-Strips (they won't come off for several days). The splint is used for up to 2 weeks after surgery, so be patient, it will be a while before you get that shower.
Left untreated, injuries like partial tendon tears can become full ruptures that leave no connection between bones and muscle. Achilles tendon ruptures and ACL ruptures can disable your ability to put weight on your legs, bend or straighten your knees, stand on tiptoe, or walk with a normal heel-to-toe stride.
Can you live with a torn tendon? ›Although fairly uncommon, a tendon rupture can be a serious problem and may result in excruciating pain and permanent disability if untreated.
Can a torn tendon get worse? ›Movement or mild exercise of the joint usually reduces the stiffness. But a tendon injury typically gets worse if the affected tendon is not allowed to rest and heal. Too much movement may make existing symptoms worse or bring the pain and stiffness back.
What cream helps tendonitis? ›What is the best cream for tendonitis? Mild tendonitis pain can be effectively managed with topical NSAID creams such as Myoflex or Aspercreme.
How long should I rest my Achilles? ›With rest, Achilles tendonitis usually gets better within 6 weeks to a few months. To lower your risk of Achilles tendonitis again: Stay in good shape year-round. Drink plenty of water to flush out inflammation, and eat healthy whole grains, vegetables, and fruits to decrease inflammation.
What painkillers are best for Achilles tendonitis? ›Paracetamol and ibuprofen can help to ease pain. They may also recommend a nonsteroidal anti-inflammatory (NSAID) cream or gel you rub on your skin.
Is it okay to walk with a torn Achilles tendon? ›Patients with rupture of the Achilles tendon can still walk. Patients with rupture of the Achilles tendon can still actively move the ankle up and down. Patients with an Achilles tendon rupture may even manage to stand on tiptoes (on both feet together — though not on the injured limb alone).
Should you walk on a torn Achilles? ›Yes, you usually can. What you feel when you walk with a partially torn Achilles tendon depends on how much of the tendon is torn and how long ago you've torn it. If it's a significant portion, then it may be quite painful to put your heel on the floor, and you may struggle to push off with the front of your foot.
What is the average recovery time for a torn Achilles tendon? ›If you sit at work, you may be able to go back in 1 to 2 weeks. But if you are on your feet at work, it may take 6 to 8 weeks. If you are very physically active in your job, it may take 3 to 6 months.
What happens if you don't fix a torn Achilles? ›
Take a group of 100 people who have a ruptured Achilles tendon. With surgery, 5 out of 100 will rupture the tendon again within 1 to 2 years. This means that 95 out of 100 will not. Without surgery, 12 out of 100 will rupture the tendon again with 1 to 2 years.
What happens if you don't treat a torn Achilles tendon? ›It can cause pain down the back of your leg and around your heel. You might notice that parts of your tendon are getting thicker, and hardening, because of tendonitis. This will get worse if you don't treat it.
What's worse a rupture or tear? ›Tears to tendons and ligaments are common among people who play sports, and they can be extremely painful. Ruptures are less common but when they do occur they can be excruciating and can result in permanent damage if left untreated.
How can I speed up my Achilles recovery? ›With the help of physical therapy, most people can return to normal activity in 4 to 6 months. In physical therapy, you will learn exercises to make your calf muscles stronger and your Achilles tendon more flexible. When you stretch your calf muscles, do so slowly.
How long do you have to sleep in the boot after Achilles surgery? ›Sleep with the boot on until you feel confident to take it off at night (normally approximately 4-6 weeks).