Overview An Achilles tendon rupture is a complete or partial tear that occurs when the tendon is stretched beyond its capacity. Forceful jumping or pivoting, or sudden accelerations of running, can overstretch the tendon and cause a tear. An injury to the tendon can also result from falling or tripping. Achilles tendon ruptures are most often seen in ?weekend warriors? - typically, middle-aged people participating in sports in their spare time. Less commonly, illness or medications, such as steroids or certain antibiotics, may weaken the tendon and contribute to ruptures. Causes The exact cause of Achilles tendon ruptures is hard to say. It can happen suddenly, without warning, or following an Achilles tendonitis . It seems that weak calf muscles may contribute to problems. If the muscles are weak and become fatigued, they may tighten and shorten. Overuse can also be a problem by leading to muscle fatigue . The more fatigued the calf muscles are, the shorter and tighter they will become. This tightness can increase the stress on the Achilles tendon and result in a rupture. Additionally, an imbalance of strength of the anterior lower leg muscles and the posterior lower leg muscles may also put an athlete at risk for an injury to the Achilles tendon. An Achilles tendon rupture is more likely when the force on the tendon is greater than the strength of the tendon. If the foot is dorsiflexed while the lower leg moves forward and the calf muscles contract, a rupture may occur. Most ruptures happen during a forceful stretch of the tendon while the calf muscles contract. Other factors that may increase the risk of Achilles tendon rupture include. Tight calf muscles and/or Achilles tendon. Change in running surface eg: from grass to concrete. Incorrect or poor footwear. A change of footwear eg: from heeled to flat shoes. It is thought that some medical conditions, such as gout, tuberculosis and systemic lupus erythematosus, may increase the risk of Achilles tendon rupture. Symptoms Symptoms usually come on gradually. Depending on the severity of the injury, they can include Achilles pain, which increases with specific activity, with local tenderness to touch. A sensation that the tendon is grating or cracking when moved. Swelling, heat or redness around the area. The affected tendon area may appear thicker in comparison to the unaffected side. There may be weakness when trying to push up on to the toes. The tendon can feel very stiff first thing in the morning (care should be taken when getting out of bed and when making the first few steps around the house). A distinct gap in the line of the tendon (partial tear). Diagnosis A physician usually can make this diagnosis with a good physical examination and history. X-rays usually are not taken. A simple test of squeezing the calf muscles while lying on your stomach should indicate if the tendon is still connected (the foot should point). This test isolates the connection between the calf muscle and tendon and eliminates other tendons that may still allow weak movement. A word of caution, Achilles tendon rupture is often misdiagnosed as a strain or minor tendon injury. Swelling and the continuing ability to weakly point your toes can confuse the diagnosis. Ultrasound and MRI are tests that can assist in difficult diagnosis. Depending on the degree of injury, these tests can also assist in determining which treatment may be best. Non Surgical Treatment Not every torn Achilles tendon needs an operation. Recent studies have shown that even a conservative treatment, i.e. immobilizingt the leg can lead to satisfactory healing successes. This requires, however, that the patient is fitted with a cast (immobilization splint) and/or a special boot for a period of approximately 6 - 8 weeks. After that, the boot must be worn during the day for about two more weeks. An intensive physiotherapy will start after about six weeks to train the calf muscles so that the initial coordination can be restored. Running training on flat ground can be started again after another 10 - 12 weeks. Studies show that the danger of a recurring torn tendon is higher after a conservative treatment opposed to an operative treatment. Depending on the type of treatment, about 10 - 15 percent of those affected can expect at some point to again suffer from a tear of the Achilles tendon. Moreover, in the non-operated cases, we see more often a significant permanent weakness of the footprint, particularly restricting the ability to participate in sports. Surgical Treatment Referral to a surgeon for open or percutaneous repair of the tendon is often necessary, followed by an immobilisation period. Functional bracing and early mobilisation are becoming more widely used postoperatively. There is no definitive protocol for this and it may differ, depending on the surgeon. Operative treatment has a reduced chance of re-rupture compared with conservative treatment (3.5% versus 12.6%) and a higher percentage of patients returning to the same level of sporting activity (57% versus 29%). The patient's desired functional outcome and comorbidities that affect healing will be factors in the decision to operate.