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Warning: This article contains graphic photographs taken during a real medical surgery. For those of you who are not squeamish, roll your mouse over the small pictures to make them pop up large.
Having experienced the pain and more than anything, annoyance of an all but fully ruptured Achilles tendon, I wanted to give you all a more simplistic and practical look at the injury, its treatment, rehabilitation and associated problems.
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What Is the Achilles Tendon?
It is amazing what you learn about anatomy when you actually live through a serious injury. The common belief amongst athletes and non-medical folk is that the Achilles tendon is a thick rubber band-like tissue which connects the heel of the foot to the calf. Some may even think it is a bone or cartilage due to its apparent hardness. The first assumption is almost accurate. It is in fact a whole bunch of spaghetti-like strands of elastic tissue connecting the heel to the calf.
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Tendonitis or a rupture is when some, or all, of these strands are damaged or snapped (broken). The good news is that with this multiple strand scenario, if one or two snap, there are still lots more to keep you on your feet. With time, scar tissue will grow to create it's own "bridge" across where the broken strands used to be, or in milder cases of tendonitis, rest brings about a healed tendon.
The more elastic these strands are, the more resistant to straining or snapping they are. What makes the tendon (as these strands are collectively called) elastic? Blood flow. When you are young you naturally have better circulation than when you get older.
How Do Achilles Ruptures Occur?
Most Achilles ruptures occur in athletes in their mid to late 30s or early 40s The reason being is that they have not yet fully felt the effects of aging other than perhaps a longer recovery time for injuries. So, they go and start a work out session with a warm up and stretching routine which is the same as the one they did when they were twenty. This can be particularly deadly if the athlete is coming off an extended period of not training regularly. Errr... humm.... yup, that's how I did it.
I retired at age 35 from competitive kumite, not so much because I wasn't competitive anymore but more because I no longer possessed the drive and interest to train four hours a day every day. Injuries took longer to heal, and it took more time and effort to maintain the same level of fitness and performance. Bottom line was that I had done it for a long time and it was time to move on. When I retired I took some time off from training altogether, playing some other sports and occasionally just running.
After a marriage and two kids, I was wanting to feel that adrenaline pump again. Not from competition, but just from sparring and pushing myself to the highest level I could. On my very first focus pad session, where I got some obliging fitness gym employee to hold them for me, the inevitable happened.
The drill was simple and not demanding: bouncing back and forth in a fighting stance, moving in for a quick single jab, quick leg switch and move in for a single jab with the other hand.
On about the third leg switch, I stepped back (bouncing) to switch and heard a loud "POP" which sounded like an extremely loud champagne cork popping. I felt like I had backed into a chair. When I looked, there was no chair...
It took me a few seconds to figure out something was wrong. I was still standing, still had use of my leg albeit limited, and felt no pain. The look of horror on the guy holding the pads however was my first warning that something might seriously be wrong. My leg felt stiff and numb. I knew from experience that "numb" was not good. I sat down. As I felt blood drain from my head I asked my partner to get me some water afraid that I was going to pass out. Still no pain.
I'll cut this story a bit short. As amazing as it sounded later to my doctors, after my drink, I got up, alone, and walked to the changing rooms where I showered, dressed and left the gym. From my car I called a friend whom I knew had ruptured an Achilles and asked him what the symptoms were. At this point I was hoping for a partial rupture...
The Treatment
After 24 hrs of hobbling around and icing my leg, I reluctantly drove myself to the Emergency Room of a nearby hospital. After 3 hours, the diagnosis was "quick". A probable total rupture. X-rays and an MRI followed. These confirmed the doctors' worst fears. The doctors who immediately put me in a leg brace and gave me crutches could not believe I had "walked" in. Furthermore everyone kept asking me if I was in a lot of pain. It seems that Achilles ruptures are supposed to be very painful. The truth is that aside from some occasional sharp pains if I did something stupid it was just mostly uncomfortable and ached. Still, I was not supposed to be able to walk on it. I guess somehow I found a way of walking that did not use the Achilles. Hurray for the Martial Arts training! Adapt, adapt, adapt!
So I was given my options: 1. Put it in a cast for a few months and let the scar tissue form an artificial tendon., or 2. Surgery to repair and reattach the tendon. (Gulp!) After much discussion about what I planned to do after I healed, it was decided that surgery was the best option. The surgery, which could not be performed for two weeks until all the swelling disappeared, lasted 4 1/2 hours. Apparently a tendon repaired through surgery is stronger and far more elastic than scar tissue. Therefore if you plan to be athletically active, surgery may be your best bet.
However, my tendon was virtually completely ruptured as you can tell from the above picture which shows one single strand remaining. Most ruptures are partial, not complete like mine. It is important to note that many people refer to these as "full" or "complete" meaning the tendon snapped completely as opposed to just got damaged. What they mean is part of the tendon ruptured "completely" as opposed to a "complete rupture" which means all of the tendon ruptured. There is a big difference in treatment and recovery time between these two.
The more common partially ruptured tendon usually does not require surgery. In fact, in many cases the surgery will slow down the recovery time and lead to more muscle atrophy. Case and point: 5 time World Champ Geoff Thompson (GBR), my former coach. He suffered an Achilles rupture, went the non-surgical route and was back to full strength and ability within months. I was on crutches or in a leg brace for the better part of a year.
While there was probably a difference in the severity of our two injuries, it illustrates the vast difference in treatment and recovery times depending on the injury and your individual needs.
Rehabilitation
The most important advice I can offer here is to take it easy. The re-rupture rate after the tendon has supposedly healed is quite high, so beware. Take your rehabilitation slowly and very seriously. There is probably a lot of atrophy, which means your tendon is "working without a net" so to speak - bearing all the pressure. ("Atrophy" means your muscle has wasted away from lack of use.)
Your doctor or physical therapist will almost certainly prescribe exercises where you push with the ball of the foot into the equivalent of standing on your toes. This can be done by doing just that, standing slowly on your toes and then lowering, or with a weight machine. (See illustrations below) Initial stretching exercises will include the "pushing the wall" exercise. Lean forward slowly with your hands on the wall and your foot flat, stretching the Achilles as you lean forward. This will hurt. Do Not bounce! Do not push beyond mid level pain.
What you are in effect doing here, believe it or not, is trying to gently rip away some of the scar tissue which grew when your foot was in its cast. This is excess scar tissue. Its kind of like removing the training wheels on a kid's bike for more freedom and mobility.
Once you have regained the mobility of your foot, it is time to build up the lost muscle around it. The following was sent to me by our Director of Sports Medicine & Science, Dr. Rafael Arriaza to help me build my muscles up again:
Eccentric Training Routine (In English y Español)
By Dr. Rafael Arriaza
Patients perform the exercise twice a day, 7 days a week, for 12 weeks. During this period, walking and light jogging or "trotting" was authorized for those patients who experienced only discomfort but not pain.
Los pacientes realizaron el trabajo dos veces al día, 7 días por semana, durante 12 semanas. Durante este periodo se autorizó a caminar y trotar a los pacientes si aparecía tan sólo una molestia, y no dolor.
Two types of eccentric exercises were used, one with the knee bent and one with it straight, performing 3 X 15 repetitions of each. In both cases raise the body by lifting off the ball of the foot.
Initially only body weight was used achieving only an eccentric phase and using the healthy leg to lean on to create the concentric. It was explained to patients that it would be normal to feel discomfort for the first two weeks.
Se utilizaron dos tipos de ejercicios excéntricos, con la rodilla flexionada y con ella extendida, realizando 3 x 15 repeticiones de cada uno de ellos. Inicialmente, sólo se utilizaba el peso corporal, realizando sólo una fase excéntrica y apoyándose en el miembro sano para realizar la concéntrica. Se les explicó a los pacientes que era normal sentir molestias durante las dos primeras semanas.
Once patients were able to perform this eccentric phase without pain, weight was gradually added using either a backpack or a weights machine.
Una vez que eran capaces de realizar la fase excéntrica sin dolor, se comenzaba a añadir peso por medio de una mochila o de una máquina de pesas.
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