The Achilles tendon is the largest tendon in our body, a massive structure capable of withstanding loads greater than ten times the body weight. This tendon was the star of the latest episode of Sky Sport Doctor, aired on Sky Sport.
What is the Achilles tendon made of?
It is the distal tendon of the calf muscles, formed by the convergence of the medial gastrocnemius, lateral gastrocnemius, and soleus muscles. It is divided into three parts: a proximal, broad portion (fan-shaped), a second, narrower area (the most prone to rupture), and a third part, which is its insertion into the calcaneus (the posterior bone of the foot).
How does it rupture, and which sports are most at risk?
The Achilles tendon most often ruptures during acceleration from a stationary position or during sudden changes in direction (Stop & Go movements). The sports most at risk are those involving intermittent activity, where these movements are more frequent. Classic examples include basketball, American football, soccer, as well as tennis, and particularly padel, a sport that, as we know, has become very popular in recent years.
At the moment of injury, the patient is in an acceleration phase (either from a stationary position or already in motion). At this point, the torso (or trunk) is bent forward, the hip and knee extend, and all forces are directed onto the ankle (which is maximally dorsiflexed). This position, combined with the contraction of the calf muscles, generates forces that exceed the tendon’s rupture threshold.
What happens when it ruptures?
Typically, a loud noise is heard, like a snap. Often, the patient looks back, convinced someone has hit them, and simultaneously falls to the ground. At this point, the patient will be unable to walk, and a defect in the tendon can be felt upon palpation.
Are there any predisposing factors for rupture?
The number one predisposing factor is Achilles tendinopathy, a chronic condition of the Achilles tendon that causes pain but also alters its structure, making it less resistant.
This is not present in all cases; even a healthy tendon can rupture if subjected to sufficient forces. However, screening for early symptoms can be important to identify an initial issue.
What should I do if I think I’ve ruptured my Achilles tendon?
It is crucial to seek medical attention as soon as possible to confirm the diagnosis and proceed with treatment, which is very often surgical.
What is the treatment of choice for athletes?
After an Achilles tendon rupture, especially in cases involving athletic functional demands, the treatment of choice is surgical. The repair procedure involves “rejoining” the two ends of the ruptured tendon. The surgery is typically performed early, within the first few days after the injury.
How is rehabilitation managed after an Achilles tendon rupture?
With immense patience, dedication, and consistency. It is a long and demanding process (spanning several months) that should not be underestimated.
It involves a functional recovery program with progression based on objective recovery criteria. A “traffic light” approach, where achieving specific goals allows for increasingly complex functions.
We have identified five:
- Walking without crutches
- Running on a treadmill
- Starting functional exercises (in dedicated spaces we call the Green Room)
- Starting on-field rehabilitation
- Rejoining the team
There are some priorities and key points:
- In the initial phase, it is crucial to pay close attention to the surgical wound (which should be dressed and monitored by dedicated personnel) and to avoid forcing the ankle into dorsiflexion (pushing the toes upward). This is to prevent excessive stretching of the reconstructed tendon until walking without crutches is possible.
- In the intermediate phase, the patient will begin working more intensively on muscle strengthening and basic sports exercises. Functional tests are performed.
- Strength tests to objectively assess the recovery of calf muscle strength.
- Movement analysis tests to evaluate compensations and load imbalances between the two limbs (often present).
- Tests that assess cardiovascular fitness.
This phase is very delicate because the primary challenge is to avoid the feeling of a “flat tire” (acceleration deficit) that these patients often complain about due to reduced strength and function in the calf.
Once the deficits are resolved, in the advanced phase, on-field work should focus specifically on accelerations to retrain their intensity and volume. Recovering the sport-specific movement is the final step.
When is it possible to return to play?
The decision to return to sport must be based on objective data and not solely on time. Specifically, these are the criteria we use:
- Surgeon’s approval
- No pain during on-field activities
- Full strength recovery
- Excellent movement control without significant compensations toward the healthy limb
- Full recovery of cardiovascular fitness
- Complete on-field rehabilitation
The timeline is not short; on average, professional soccer players take nine months to return to play.
