Which treatment is better for an Achilles tendon rupture?

The Achilles tendon is one of the most powerful tendons in the body. It connects our calf muscles to the heel bone, so transmits the forces from the calf through to the foot for walking and running. One big anatomical disadvantage of the Achilles tendon is that it and the calf muscles are a two-joint structure. This means that the tendon and the muscle crosses two joints – the knee and the ankle. If during activity the two joints are moving in opposite directions, in this case the ankle joint is dorsiflexing at the same time that the knee joint is extending, then the load on the tendon is pretty high and if there is some weakness or issue with the tendon it may tear or rupture. This can happen in sports like basketball or boxing where there is a sudden stop and start motion.

When the Achilles tendon does rupture it can be quite dramatic. Sometime there is an audible snap, but other times there might be no pain and the athlete just falls to the ground as they loose all power from the calf muscles through to the foot. There are plenty of videos of the Achilles tendon rupturing in athletes available in places like YouTube. A simple search there will find them. The videos show how dramatic the rupture is, just how easy it appears to occur and just how immediately disabling it is in the athlete as soon as it happens. Clinically a rupture of the Achilles tendon is pretty obvious to diagnose and assess, as when they contract the calf muscles, the foot will not move. When standing they can not raise up on to the toes. The Thompson test is a test that when the calf muscle is squeezed, then the foot should plantarflex. If the tendon is ruptured, then this does not happen.

The first aid treatment for an Achilles tendon rupture is ice and pain relief and for the athlete to get off the leg, usually in a walking brace or splint. There are mixed opinions on the definitive treatment for an Achilles tendon rupture. One option is surgical, and the other option is to using a walking brace. The research comparing the two methods is pretty clear in showing that there is no difference between the two regarding the long term outcomes, so you can be comfortable in knowing that whichever treatment is used, then the long terms outcomes are the same. In the short term, the surgical approach does get athlete back to sport quicker, but as always, any surgery does carry a small anesthetic risk and surgical site infection risk. That risk must be weighed against the need to get back to the sport quicker.

What is probably more important than the choice of the surgical or non-surgical treatment is the rehabilitation after. The evidence is quite clear that the sooner weight bearing and movement is done, the better the outcome. This has to be done gradually and slowly to allow the tendon and the muscle to build up strength before the return to sport.