Transcription:
Recovering from a Ruptured Achilles Tendon

Melanie Cole (Host):   The Achilles tendon is the largest tendon in the body. It connects your calf muscle to your heel bone and is used when you walk, run, and jump. While it can withstand great stresses from running and jumping, it is vulnerable to injury. My guest today is Dr. Truitt Cooper. He's a board certified orthopedic surgeon whose specialties include caring for patients with foot, ankle and leg injuries at UVA Health System. Welcome to show, Dr. Cooper. Tell the listeners first of all, what is the Achilles tendon? What does it do?

Dr. Truitt Cooper (Guest):  Basically, the Achilles tendon is the bundle of collagen, just like all of our tendons, that connects, like you said, the calf muscle, the gastrocnemius and the soleus muscles, to the heel bone--the calcaneus. It helps us during weight-bearing by letting us push off with the forefoot. Basically, that's its role.

Melanie:  So then, how is it injured? Women wear high shoes, we step off of curbs; we do all sorts of things. What are some of the most common injuries to the Achilles?

Dr. Cooper:   Actually, if you're wearing a shoe with a higher heel, you're probably less likely to injure your Achilles because it's at rest when the foot's flexed like that. The most common injuries are with sort of high-impact cutting sports and jumping sports, when the foot has sort of a sudden and unexpected dorsiflexion, or the foot's forced up when you're landing or trying to decelerate.

Melanie:  Okay. Let's get to this first. Is there a way to prevent these types of injuries, as you say, in sports injuries or kids playing sports, quick movements, deceleration, jumping. Is there something we can do to sort of calm this injury?

Dr. Cooper:  Potentially. The most common group of people that rupture their Achilles tendon would be males between 37 and, say, 42. A lot of these people are sort of what we would call the "Weekend Warrior" where they're sedentary all week and then they go out on the weekend and participate aggressively in sports, and that, I think, is a set up for injury. With the sedentary week, you're developing tightness and potentially weakness in some of those muscles as well as in the tendon itself. So, I think a good overall fitness program that includes strengthening and stretching can help prevent some of those injuries as well as warming before activity.

Melanie:  What would the symptoms be to know? Are they going to hear a pop? Are they going to feel something roll up? What are they going to feel if they've really torn their Achilles?

Dr. Cooper:  With an acute, sudden injury where the Achilles is completely or nearly completely ruptured, it's a pretty dramatic event, usually. It's variable in how much pain one has. Usually, they'll feel a pop. A lot of times people will, if they're playing, say, squash, they'll say they thought that their partner or their opponent hit them in the back of the heel with a racquet. Some people will say they felt like they were kicked in the back of the heel and then they look around and no one's there on the soccer field, or something like that. So, it's a pretty sudden, usually a pretty dramatic pop-type injury. The amount of pain is variable. It’s usually very painful, initially, but often it's not terribly painful within a few hours.

Melanie:   Now, these "Weekend Warriors" that you're discussing, if they don't rupture it but they do strain it, or something happens where it's really just very sore at the bottom of the calf muscle and they know they moved wrong, what do you recommend people do for home treatment?

Dr. Cooper:   Yes, I think with a strain, often the strains occur, like you said, at the bottom of the calf muscle or even up higher in the calf muscle. Those usually respond really well to a period of rest, ice, and then gradual return to activity. If they're more severe, sometimes people will go into a walking boot or not be able to put much weight on it for a few days with those types of injuries. The other issue we run into are the tendonitis-type issues where the Achilles tendon becomes either inflamed or a little bit unhealthy in the tendon itself. Those, often, will respond, again, to rest, ice, good stretching, eccentric-type exercises, which is a particular type of strengthening and stretching exercise which is often done with a physical therapist. Those types of things.

Melanie:  So, people, Dr. Cooper, do calf raises and they think these are just great and they do them off of a stair. Then, they go really, really low and then you hear people at the gym say, "Oh, I ruptured my Achilles," or "I tore my Achilles doing those calf raises too low." Do you tell people not to go below neutral; not to go low-floor height? Or, to do that gently and stretch them long?

Dr. Cooper:  Well, I think it depends a little bit on where the problem is with the Achilles. If you have, say, a tendonitis, or an irritation, where the Achilles actually attaches to the bone, down really low on the back of the heel, I think going down below the stair is definitely harmful and can cause more inflammation with that. If you have like a tendonitis or something that you're trying to treat with some stretching and strengthening activities and it's higher up, in the middle part of the Achilles, then going down a little bit below neutral is okay. But, the people that tend to have a rupture during an exercise like that, or something, usually have a longstanding problem with the tendon where it's actually unhealthy tendon tissue.

Melanie:  What do you do? If someone comes to you and it's swollen and they had that acute event and it was dramatic, then what? Is this a surgical thing? It requires that intervention?

Dr. Cooper:  Yes. There are really two options:  you can treat them either with surgery or without surgery. Probably 20 years ago or 25 years ago, there was a feeling that anyone with an acute Achilles tendon rupture required surgery to fix it or that there were some papers that showed that they had a really high rate of re-tearing the Achilles if they didn't have surgery. They were just treated in a cast. Then, in the last, say, 10 years or so, in America, at least, there have been some good studies that have shown that actually you can treat these without surgery. So, I think that, in certain situations, you can either treat it with surgery and get a good result or you can treat it without surgery and get a good result. They key thing for the people, especially if you're going to treat them without surgery, is not immobilizing them for too long. You can't just put them in a cast and give them crutches for three months because the tendon will heal but it won't heal with the appropriate strength. They do have a higher risk of re-rupturing. So, a lot of patients choose to have surgery for this because there's a feeling that you can get back more of your strength and get back to activities quicker. I think that gap between the two treatments is closing, certainly in America. In some other countries, they're treating almost all of these without surgery.

Melanie:  Yes. It certainly used to be RICE and now it's MRICE, and now there's movement, or RISEM. Now, they add movement in there. When you were talking about that eccentric strengthening protocol, tell the listeners what you mean by that because if they're going to try and really do this and work their Achilles so that they don't injure it, explain what that is.

Dr. Cooper:  First of all I think that in a lot of cases, it's really helpful for people to see a physical therapist maybe one or two times to help develop this program but what eccentric strengthening is, is basically you get on a stair, or something like that, and you go up on your toes fairly quickly. That's not the part of the exercise that matters. So, you do an easy toe raise, and then, the part that matters is coming down very slowly so that the muscle is sort of contracting as it lengthens. That has been shown, in these more chronic situations, to help the tendon heal and improve the structure of the tendon and help it get back more to normal.

Melanie:  Where are shoes and orthotics in this picture? People use them for plantar fasciitis and arch problems but are they involved in the Achilles issues, as well?

Dr. Cooper:  Yes. I think in people with Achilles tendon problems, especially if they have a significant, well, I guess what we would call a “deformity” of the foot, the orthotics can help. It can help take the load off the Achilles and help calm things down a little bit. They probably don't have a huge role in preventing ruptures of the Achilles tendon but some of this chronic situations, I think orthotics can help rest it. As far as shoe wear goes, there's been a lot of shift back and forth both ways as far as running shoes go in the last five to ten years where they went from a shoe with a thick heel to five years ago there was a big push towards the minimal barefoot-type shoe. At that time, I was seeing a lot of people with Achilles tendonitis overuse problems because they switched too quickly. If you have a shoe with a thick heel, it sort of lets your Achilles tendon rest a little bit; it doesn't put as much strain on it. Then, if you switch to the minimal shoe, you Achilles and your calf are doing a lot more work. Now, there's sort of a push back going the other way toward more cushiony shoes. So, I think that the big thing is, you pick the shoe that's comfortable but if you're going to change, you have to change gradually, over time. I think that's where people get into a lot of problems, both with their shoe wear as well as their training. You know, increasing their mileage too quickly or their intensity too quickly.

Melanie:  In just the last few minutes here, why should patients choose UVA orthopedics for Achilles tendon surgery and for their sports medicine care?

Dr. Cooper:   I think here at UVA, we've got a unique situation where we have for foot and ankle, anyway, we have three full-time orthopedic fellowship-trained foot and ankle surgeons. We kind of specialize in the whole pathology of foot and ankle and I think we're very conscientious of each individual patient and their needs, so not everybody that comes in here is going to be pushed towards surgery if it's not right for them. We'll work out a treatment plan that includes physical therapy and other things like that, if that's appropriate.

Melanie:  Thank you so much for being with us. It's great information, Dr. Cooper. You're listening to UVA Health Systems Radio. For more information, you can go to UVAHealth.com. That's UVAHealth.com. This is Melanie Cole. Thanks so much for listening.