A complete tear or rupture to the Achilles tendon at the back of the lower leg is a rare but serious injury requiring urgent surgery followed by months of careful rehabilitation. Many athletes have recovered from such a serious injury and gone on to do amazing things but prevention is always the best cure.
So, are there any warning signs or things you can do to prevent a Achilles tendon rupture from happening in the first place?
Who is most likely to suffer a complete rupture of the Achilles tendon and what early warning signs should you look out for?
Men over the age of 40
Achilles ruptures affect men roughly 10 times more than women and usually occur 30 to 40 minutes into a training session rather than at the start. That is not to say they never happen to women so it is still important to notice the warning signs. Ladies who wear high heels all day (shortening the calf muscles at the back of the leg) and then put flat running shoes on may be putting excess stress on the Achilles tendon.
As you get older, wear and tear on tissues increases and they may become less elastic. Be aware that if you have been a professional athlete or trained hard over many years, then the wear and tear (called degeneration) might just occur a little sooner than it might otherwise do.
Do you play sports where sharp changes of direction are needed, such as racket sports, boxing, rugby or football? These place huge and sudden demands on the Achilles tendon. It is very common for athletes who suffer a ruptured Achilles tendon to think they have been kicked by an opponent (football) or hit by a racquet (in squash) and yet when they turn around, there is no-one nearby. The explosive forces that are transmitted through the tendon are significant but combined with a twisting or torsional force, the strain might be even higher and cause a rupture.
Achilles pain that is ignored
Pain in the Achilles tendon (at the back of the ankle) which niggles and may have come on gradually over a number of days or even weeks or months should be taken seriously. Achilles tendonitis (or more accurately Achilles tendinosis) is a common injury and one that many people can carry on playing sport with. Classically, pain and stiffness is usually worse in the mornings and then tends to wear off when you get moving and the tendon warms up and therefore the athlete will often continue to train with it. The advice for this condition is to listen to your body, especially as you get older. The days of your body learning to do as it is told may be in the past for us more ‘experienced’ athletes.
Recent ankle injury as a factor?
A recent injury to the ankle may cause alterations or compensations in the way you walk, thus putting excessive strain on the Achilles tendon. The pain felt from the ankle injury may “mask” any of the early warning signs associated with a grumbling Achilles injury and the resulting changes in force direction might be the 'final straw' to cause the tendon to snap.
“Overpronation” is a condition where the foot flattens or rolls over too much when in contact with the ground. It is a very common condition and people who have it are often referred to as having ‘flat feet’. There is some evidence to suggest that athletes who have flat feet are more prone to Achilles injuries compared to athletes that have higher arches in their feet. The reason for this is that as the foot rolls over or flattens as it makes contact with the floor, it causes the ankle to roll inwards and change the angle of pull on the Achilles tendon. The forces that are transmitted through the Achilles are significant enough but with the addition of a twisted or torsional force as well, this may lead to ruptures.
Having a thinner Achilles tendon
A literature review has shown that there is moderate evidence that decreased tendon fibril (fibres that make up the tendon) size increases the risk of a rupture. This could have developed over a number of years as a result of playing a sport or could just be an anatomical characteristic that you were born with.
Other factors include being overweight (the heavier you are the greater the forces through the tendon), taking certain medications such as quinolone (an antibiotic) or the use of oral corticosteroids.
So, what can I do if I am at risk?
Ok, so here are a few things to think about if you believe you are more at risk of suffering an Achilles tendon rupture:
Don’t ignore the warning signs
If you are experiencing occasional or persistent Achilles pain, then seek help from a therapist to improve the healing. See our page on 'Achilles tendonitis' for more information but applying heat to a chronic injury can be beneficial and ensure stretching and strengthening exercises are part of your normal training routine. The key to treating is tendinopathies is NOT to rest them completely but to change the amount of load that goes through them and then carefully progress the load, as demonstrated by Hakan Alfredson's protocol for treating Achilles injuries including the heel drop exercises.
Get your foot biomechanics checked
A podiatrist can carry out a full biomechanical analysis and advise on whether you may need support in your shoes, called “orthotics” or if you need to do specific exercises to improve foot posture. Many “specialist” running shops will offer a similar service when advising on the most appropriate footwear for your foot type and running style to buy.
Improve flexibility. If you suffer from tight calf muscles, then this can also affect how the foot and Achilles tendon work together and may be a contributing factor in suffering an injury. Regular calf stretching exercises can help with this or for a more drastic option, you may consider a night splint.
The Hakan Alfredson's heel drop protocol is a 12-week intensive strengthening program that has been shown to be successful in rehabilitating chronic Achilles tendon injuries. The exercise regime gradually increases the load placed on the tendon, making it more resistant to injury, although you are advised to seek professional advice from a therapist first to confirm this is appropriate for your own situation.
Get a regular sports massage
Although not guaranteed to prevent an Achilles rupture, massage can help keep the calf muscles in good condition and manipulate the Achilles tendon. An experienced massage therapist may be able to detect areas of tightness or abnormalities that may be potential risks for injury.