Achilles Tendon ruptures

Who Was Achilles, and Why Is It Called the Achilles Tendon?

The Achilles tendon is named after Achilles, the legendary Greek warrior from Homer’s Iliad. According to myth, his mother, Thetis, dipped him in the River Styx to make him invulnerable—except for the heel where she held him. In battle, he was fatally wounded by an arrow to this unprotected spot, now known as the Achilles tendon, some say the thickest and strongest tendon in the human body.

Despite its strength, the Achilles tendon is also prone to rupture, particularly during explosive movements like jumping or sprinting.

Who Gets Achilles Tendon Ruptures?

Achilles tendon ruptures most commonly occur in active men aged 30-50, especially those who engage in recreational sports that involve sudden acceleration, jumping, or pivoting (e.g., basketball, soccer, and tennis). However, ruptures can also occur in:

Older individuals due to age-related tendon degeneration.
Sedentary individuals who suddenly engage in high-impact activity.
People taking corticosteroids or fluoroquinolone antibiotics, which weaken the tendon.
Diabetics and smokers, who have impaired tendon healing.

Nonoperative vs. Surgical Management

Achilles tendon ruptures can be treated either nonoperatively (without surgery) or with surgical repair. Both approaches follow a similar rehabilitation protocol, known as the Achilles Tendon Accelerated Functional Rehabilitation Protocol (AFRP), which emphasises early weight-bearing and controlled movement to optimise healing.

Key Differences Between Surgery and Nonoperative Treatment

The primary difference between the two approaches is that surgery involves directly repairing the torn tendon before beginning rehabilitation, whereas in nonoperative treatment, the tendon is left to heal naturally with controlled immobilization.

One major consideration when deciding between the two treatments is re-rupture risk. Some studies suggest that surgery lowers the re-rupture rate to around 5%, while nonoperative treatment carries a re-rupture risk of 10-12%, particularly if rehabilitation is not followed correctly. However, when using a modern functional rehabilitation approach, the re-rupture rate for nonoperative treatment has improved significantly and is now closer to that of surgical repair.

Tendon strength and function may also differ between treatments. Some research indicates that surgical repair results in greater mechanical strength, which may be beneficial for athletes or those engaging in high-impact sports. Some studies suggest that patients who undergo surgery regain slightly better plantar flexion strength at one year post-injury. However, long-term differences in function appear to be minimal if nonoperative rehabilitation is properly followed.

The time to return to activity can be similar between both approaches if early mobilisation protocols are used. However, return to sport and explosive movements may be slightly faster in those who undergo surgery due to potentially better tendon strength.

While surgery may offer advantages, it also carries risks, including infection, wound healing complications, sural nerve injury (leading to numbness or pain in the outer foot), and deep vein thrombosis (DVT) due to post-op immobilisation. These risks must be weighed against the benefits when considering treatment options.

Who Should Consider Surgery?

Surgery may be a better option for:
✔ Athletes or active individuals who require maximum tendon strength.
✔ Cases where the tendon is not well-aligned in a functional position when immobilised.
✔ Re-ruptures after failed nonoperative treatment.

Risks of Surgery

While surgery offers potential benefits, it also carries risks, including:

Wound healing complications (higher in diabetics and smokers).
Infection (1-5% risk).
Sural nerve injury (can cause numbness or pain along the outer foot).
Complex Regional Pain Syndrome (CRPS)
Deep vein thrombosis (DVT) due to post-op immobilisation.

Optimizing Healing: The Role of Vitamin C

To support tendon healing, we recommend taking Vitamin C 500 mg daily until you return to sport. Vitamin C plays a crucial role in collagen synthesis, the primary structural protein of tendons. Studies suggest that adequate Vitamin C intake may help promote stronger tendon repair and reduce the risk of re-injury.

Achilles Tendon Accelerated Functional Rehabilitation Protocol (AFRP)

Regardless of treatment choice, a structured rehabilitation program is critical for a successful recovery. This protocol emphasises early weight-bearing and progressive loading to ensure optimal tendon healing while minimising the risk of re-rupture.

Rehabilitation Timeline

0-2 Weeks (Immobilisation Phase)

Boot in full plantar flexion (~30°-40°, 3-4 heel wedges in CAM boot)
Non-weight bearing with crutches
Begin gentle isometric contractions for the calf

2-6 Weeks (Early Mobilisation Phase)

Adjust boot gradually to a neutral position (remove 1 heel wedge every 2 weeks)
Begin protected weight-bearing in boot at 2-3 weeks
Seated heel raises and active dorsiflexion up to neutral

6-12 Weeks (Strength & Balance Phase)

Transition from CAM boot to normal footwear from 8 weeks
Progressive loading with calf raises (seated → standing)
Single-leg balance and proprioception training -gradual from week 10

12+ Weeks (Return to Activity Phase)

swimming as normal
Plyometrics & sport-specific training at 4-6 months
Return to full activity at 6+ months (based on strength and function tests)
Progressive running drills at 6 months

Key Notes for Physiotherapists and Patients

Avoid excessive stretching in the first 10-12 weeks to prevent tendon elongation.
Progress based on strength, not time—patients should meet strength goals before advancing.
Monitor for swelling or pain, which may indicate overloading.

This structured rehabilitation plan, combined with Vitamin C supplementation, ensures optimal tendon healing, minimises re-rupture risk, and promotes a safe return to activity. If you have any questions about your Achilles injury, feel free to book a consultation.