The Cause and Recovery of Achilles Tendon Injuries

Have you seen the instant replay of Kobe Bryant’s season-ending (maybe career-ending) Achilles tendon injury? He attempted to move against his defender and drive to basket. This was “a move that I have done a million times,” said Kobe. He crossed over, planted his left foot to change directions and push off towards the basket. Suddenly Kobe fell to the floor and grabbed the back of his ankle. “I thought I had been kicked in the back of the leg.” He was unable to walk without a limp or continue playing. The next day Kobe had surgery to repair a complete tear of the Achilles tendon.

What is the Achilles Tendon?

The Achilles tendon (also referred to as “heel cord”) is located in the back of the ankle. This thick, “leather-like” cord of tendon tissue connects two primary muscles (Gastrocnemius and Soleus) to the Calcaneous (heel bone). It’s responsible for transmitting their contraction forces to the foot/ankle complex. The Gastrocnemius and Soleus (together are referred to as “the Calf muscles”) are connected to the Calcaneous and are capable of generating enough force to lift or lower the heel to or from the floor. The Plantaris muscle tendon is part of the Achilles tendon, but if it is injured it does not cause the drastic functional deficits that occur when the other two are injured.

These muscles are “active” when we walk, run or jump. During the course of the day, these muscles contract to either lower the heel to the floor in a controlled manner (eccentric contraction) or contract in a concentric mode (shortening) and literally lifting the heel off of the ground to help propel the body forward or upward.

Injuring the Achilles Tendon

Most people who rupture their Achilles tendon are not world-class athletes. They are often middle age men who are not in great physical condition and spend most of their “spare” time playing the game but not conditioning to play the game. Sports such as tennis, racquetball, volleyball and basketball are common activities that lead to these kinds of injuries. It typically happens when they attempt to perform a quick, explosive motion with the ankle. Some antibiotics (Fluoroquinolone) have also been linked to an increase in Achilles tendon ruptures.

The diagnosis is quite easy for a trained healthcare professional. When someone ruptures his Achilles tendon, he often says, “I thought I got kicked in the heel, but when I turned around to see who did it there was no one near me!” The torn Achilles tendon will most likely not have the same appearance as the opposite, non-involved side. The “cord-like” appearance will be gone in the ruptured side.

A positive Thompson Test reveals that the tendon is ruptured. The patient lies in a prone position and the healthcare professional squeezes the medial and lateral aspect of the calf complex. If the foot does not move into plantar flexion, the test is considered positive. The severity of the damage to the tendon cannot be fully ascertained with the physical examination; therefore the patient will be scheduled for a MRI or a diagnostic Ultra Sound. If the patient attempts to walk on the injured ankle, they will be unable to push off and they will have a severe limp when they walk.

Treating an Achilles Tendon Rupture

Surgical and non-surgical treatments of Achilles tendon ruptures can be successful. The non-surgical approach is used when the tear is not complete, the person is relatively sedentary, and/or there are other mitigating factors (health or personal) that will not allow the person to undergo a surgical procedure. These patients will be placed in a cast or range of motion limiting “boot” for 8-12 weeks. There is a non-weight-bearing stage and then the patient is progressed to partial weight bearing in the boot. Physical therapy can be started as soon as the doctor has removed the cast. If the patient is placed in a “boot,” physical therapy treatments can begin immediately.

If surgery is performed, the surgeon might opt to wait for several days prior to performing the surgery to allow the swelling to reduce. The ruptured Achilles tendon is “sewn” back together and will heal over the course of approximately 8-12 weeks. Physical therapy treatments can begin within a few days of surgery. Many surgeons will put the surgically repaired Achilles tendon in a cast or posterior splint for 1-2 weeks prior to beginning physical therapy treatments.

Physical therapy treatments are similar during the surgical and non-surgical rehabilitation process. The reduction of pain and swelling are the primary concern in the first 2-3 weeks of treatment. Regaining motion and muscle strength are secondary. Once the pain and swelling have been reduced or resolved, the rehabilitation efforts can transition to regaining the strength, proprioception, and motion in the involved limb. Due to the non-weight bearing phase of rehabilitation (3-4 weeks standard) the entire limb is affected. Exercises to engage the core and all lower extremity musculature are essential if the patient is to regain full functional use of the involved limb. The physical therapist and patient must be careful to avoid passive dorsiflexion greater than neutral for the first 4-6 weeks. Aggressive mobilization or stretching into a dorsiflexed position greater than neutral can cause the healing tissue (new cells) to be elongated and become non-functional. If the new cells are “over-stretched,” their non-elastic nature does not allow them to “recoil” to their original length. The elongated cells lose their ability to generate sufficient force and the calf complex never regains full functional ability.

The sight of Kobe Bryant falling to the floor and clutching his left ankle reminds us that these injuries can occur in anyone. No one knows if there was an underlying problem with his Achilles or if the injury to his left knee earlier in the same game had any influence on the eventual injury to the Achilles, but Kobe Bryant is in tremendous shape and performs the most advanced training techniques.

Reducing the Likelihood of Injury

For the general public, there are a few things that can be done to help to avoid this type of injury. Before participating in a new activity, it is important to prepare by training for that specific activity. Performing the activity only once a week without training in between events will not sufficiently prepare the musculoskeletal system is for high-level activity.

A well-rounded training program should include agility and plyometric (bounding/jumping) exercises. These exercises can be as simple as jumping rope or hopping up and down in one place for several minutes. Agility movements such as lateral shuffling, running backwards and various movements that incorporate rotational hip and lower extremity motions (carioca and figure 8 running) help to place “game-like” actions throughout the musculoskeletal system of the lower extremities. The intensity of these exercises should mimic the required intensity needed to complete the activity.

The worst type of Achilles tendon injury is a rupture. Not all ruptured Achilles tendons are surgically repaired, but the rehabilitation process for any ruptured Achilles tendon is extensive and can take approximately one year to complete. There is no clear-cut way to totally avoid this type of injury, but training and preparing for an activity can help reduce the probability of rupturing an Achilles tendon.