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Caitlin Whyte (Host): Hello, and welcome to Checkup Chat with EvergreenHealth. We have Dr. Adam Sangeorzan with us today, a Foot and Ankle Specialist at EvergreenHealth Orthopedic and Sports Care. He is joining us to discuss Achilles tendon tears. So Doctor, to start off our conversation today, tell us what the Achilles tendon is and what does it do?

Adam Sangeorzan, MD (Guest): I think it's a great question and obviously very relevant for our discussion today. The Achilles tendon is one of the largest tendons in the body. For those of us who don't know, a tendon is a soft tissue structure that connects muscle to bone and allows that muscle to work on the bone, or in other words, move the bone.

In this case, the large muscles in the back of your calf, which are called the gastrocnemius and soleus muscle are attached to your heel bone, the calcaneus and these muscles act to plantar flex your foot, which means they point your toes towards the ground and bring your heel up towards your knee, which you can think of as what you would need to do to walk on your tip toes.

The Achilles is very important in normal walking, running, and jumping. And certainly, you know, ruptures, if not treated appropriately can lead to a lot of dysfunction in these things. One other important thing to note is it's not the only muscle that plantar flexes your foot. I do have some patients who come in with an Achilles rupture and say, well, I can't have an Achilles ruptue. I can still point my toes down and that's sometimes led to patients delaying to come in to see me. So it's just important to note that there are other muscles that do that. It's just the most important one are the muscles attached to the Achilles tendon.

Host: I've seen in some movies, some Achilles injuries, and they seem pretty intense. So how can someone prevent an Achilles injury?

Dr. Sangeorzan: Yeah, I think that's a really great question and I wish I had a better answer for that. I can tell you maybe to help is some things that predispose people to Achilles ruptures or at least the type of patients that I tend to see it in is typically a patient who goes from not a lot of activity to a lot of activity, or at least a very intense activity that involves a lot of acceleration and deceleration. We often will call this like a weekend warrior, somebody who doesn't do much during the week, and that goes and plays ultimate Frisbee. Right? So although there's not a lot of data to suggest that stretching beforehand could prevent an Achilles rupture, certainly gradual increase in your activity seems to be a good strategy to try to avoid an Achilles rupture.

Listening to your body. So if you're having a lot of pain or inflammation in the back of your ankle, probably give it a rest. Don't go play. And then finally, there are a couple of things that we associate with Achilles ruptures. One of those is fluoroquinolone antibiotics. So those are antibiotics you may be given if you get a urinary tract infection or maybe a pneumonia. And if you get those and you develop inflammation in your tendon, it would certainly be something to think about. Well, I should probably talk to my doctor and not play this sport. And then finally, I think people who get injections of steroids near tendons have a higher risk of rupture. So I always recommend against getting a steroid injections right into your tendons.

Host: Gotcha. Okay. So if prevention is kind of difficult, what exactly causes an Achilles injury? I mean, can it happen to anyone, anywhere or is it very specific?

Dr. Sangeorzan: The short answer to this is that it can happen to anyone, anywhere. I think, like I said, there is a typical person that this happens to, which is probably somebody between their late twenties and early forties, who's going from not much activity to activity, but you know, I've really seen it in all walks of life. I've, I've seen 18 year olds, you know, who play volleyball every day, get one, I've seen 70 year old patients who are just walking up the stairs and misstep and get them. So it can happen. And I, I, I really, I think the reason for that is that the Achilles is a very large tendon, that sees a lot of force and in certain areas has a very poor blood supply.

And because it has a poor blood supply, it may be that in the area of the tendon that doesn't have a good blood supply, it's more prone to injury. The way it usually happens or it's described by medical professionals is forced dorsaflexion of the ankle, while you're firing your calf muscles. So you can think of, for example, is if you wanted to run forward, you'd put your foot behind you and try to push off that foot.

And that's the motion that happens. It's called an ecentric contraction where the tendon lengthening, even though the muscle is firing and that's what tends to lead to the rupture, but it can happen in many other ways, jumping, skiing, like I said, you miss a step in, you force your toes up towards your face, that all of those things can lead to it.

Host: Well, you mentioned earlier that you had a patient who came in and was like, there's no way I have an Achilles injury, cause I can still move my toes. I mean, how would someone know if their foot pain is something more, if it is an Achilles injury and you know, when is that time to go see a doctor when your foot is hurting?

Dr. Sangeorzan: Yeah, I think that that's a really good question too. And sometimes it's hard to answer. In the specific setting of Achilles ruptures, I think you really need to err on the side of caution because getting in to see someone early can actually affect your overall treatment and recovery. But it might be helpful maybe to go over a scenario that I usually hear for an Achilles rupture.

What you typically hear is the patient's playing a sport. Usually the sport requires accelerations or deceleration, so, you know, tennis, basketball, ultimate Frisbee, football, soccer, something like that. What they usually describe is trying to go fast in one direction, and then they really feel or hear a loud pop in the back of their ankle. And it's not something, and often people around them will hear it, which is, you know, something you'd usually think people would run in to the ER right away but they don't always. And then they also will usually say it's a non-contact injury. So no one ran into them, but they almost always describes feeling like somebody either kicked them in the back of the leg or something hit them in the back of the leg.

And I even had one person who was playing racketball, say he looked up at the ceiling looking to see if a ceiling tile had fallen down and hit him in the back of the leg. And I think, I think, you know, if you have that story, then you should be very suspicious that this is an Achilles rupture. And typically it's a pop, pain in the back of the ankle and swelling.

And if those things happen, you should get in to see a provider soon. I will say though, that some patients will come in, you know, a week after having this injury, and saying, yeah, all those things happened, but it stopped hurting very shortly afterwards. And I was able to kind of walk on it, even though I was limping.

And because, you know, either, like we talked about earlier, they're able to point their toes down in a plantar flex position, or because it stops hurting, they don't come in to see a doctor. So I think if you have the scenario of a pop and swelling in the back of your ankle, even if it doesn't hurt much, I think that's a time to come in to see a physician.

Host: Gotcha. Okay. Well, let's talk about healing. Can an Achilles tendon tear be healed or strengthened without surgery first?

Dr. Sangeorzan: Yeah, I, you know, it's a great question. And a question that's been, the answer has been changing to over the last 20 years. I think the short answer to it is yes. So Achilles ruptures can heal without surgery, if they're treated correctly. In other words, we have some very high level studies, which we call randomized controlled trials, which show when you compare operative repair to non-operative repair, patients tend to have very similar overall strengths, similar re-rupture rates and similar return to sport at one to two years. The important part to note about this is that these studies typically involve a protocol where the patient is almost immediately put into a cast or a boot in a plantar flex position.

And then they're very carefully guided through a rehab protocol by a physician and usually a physical therapist. So what I'll usually tell my patients is if done correctly, even a complete rupture of the Achilles can be managed quite well with non-operative care, but you really have to manage it correctly. So it doesn't mean you don't get to just treat it with nothing. You have to really treat it with rehab. What I do usually tell patients is that operative care, the advantages are, in large study groups, there's a very slightly higher risk of re-rupture in non-operatively treated patients. I think, I think rehab can be done more confidently with operative care because you know, those tendon edges are held together and it allows you to push your motion a little bit more, which anecdotally has led to my patients with operative care, seem to return to sport a little bit faster than non-operative care. However, the data says that at about two years, you're going to be very similar, whether you had non-operative or operative care as long as you did it appropriately.

So I think the important thing or the takeaway is, if you suspect or know you have an Achilles rupture, get immobilized right away and get in to see a doctor soon.

Host: Well, I guess when does that conversation graduate to a surgical level?

Dr. Sangeorzan: Yeah. Sure. So if treated appropriately, you never have to have surgery. The times when I think you require surgery or when I'm much more likely to recommend it, is in a young, healthy person who did not get appropriate early care. So someone who was walking on their rupture for some time. Or someone who wasn't immobilized for some time, I'm much more likely to suggest an operation to them. This is because I think that when you don't immobilize the foot appropriately and plantar flex it, the tendon can heal at a length that is too long.

And if your tendon heals at a length that's longer than it's supposed to be, you'll lose strength and have difficult with function of daily living. And I know with surgery I can appropriately restore the length of that tendon. So typically when I meet someone early on, I leave all doors open. If they've been walking on it for awhile, then I'm more likely to suggest surgery to them.

As far as what surgery looks like, typically you would have a day surgery where you come in for surgical treatment. You'd go home that day. The surgery itself, in my hands is done through a very small incision, which is about two centimeters in length. People typically talk about being in pain for a few days afterwards, but then tend to do quite well. And you are not allowed to put any weight on it for the first two weeks, which is, you know, equivalent to non-operative care where I also would keep you off of it for the first two weeks.

Host: Wonderful. Well, Doctor, as we wrap up our episode here, is there anything else you want patients to know about Achilles injuries, treatment, prevention, anything else?

Dr. Sangeorzan: Sure. I, you know, I think the takeaways are that ruptures are common. If you're worried you have one, don't delay and go see a doctor and get immobilized. The non-operative and operative care both work as long as you do appropriate functional rehab. And that the benefits of surgery in my opinion, are a slight decrease in re-rupture rates and more confident rehab that may lead to a slightly faster recovery.

Host: Well Doctor, thank you so much for being with us today and sharing this information. To learn more or make an appointment, please visit evergreenhealth.com/ortho-sports-medicine, that's evergreenhealth.com/ortho-sports-medicine. This has been Checkup Chat with EvergreenHealth. I'm Caitlin Whyte. Stay well.