default header

Ruptured Ankle Tendon

Background & Etiology (Cause)

The ankle is made up of two joints. These joints need to be strong because they support the weight of the entire body. The ankle is one of the most versatile joint complexes in the body. It is built for weight bearing, mobility, adaptability and stability. The foot and ankle allow us to walk, stand, run and jump, and serves as our connection to the ground. The ankle must be able to withstand the stress of our body weight, and also be able to adapt to, and react quickly to changes in environment and walking surface.

Tendons are connective tissues that attach muscle to bone. They are strong, fibrous structures that are responsible for transferring the forces generated by the muscle to the bone, thus producing movement at the joint. When a tendon becomes irritated or inflamed it becomes painful, causing tendonitis. The tendons in the ankle region are subject to significant stress, and can rupture under extreme pressure.

Tendon Rupture

When a tendon ruptures it can be extremely painful and cause a disability of the foot that then subsequently causes damage to the ankle joints. The tendons in the ankle include: The peroneals (peroneus brevis, peroneus longus,) anterior tibialis, posterior tibialis, and Achilles tendon. Any of these structures can become ruptured, which is a serious condition that will typically require surgery to fix.

Achilles Tendon

The Achilles tendon is the largest tendon in the body. It is formed when the gastrocnemius muscle and soleus muscle of the calf join together. It runs from the calf muscles to the heel bone. The Achilles tendon plays a significant role in the ability to walk, run, and jump. Because the Achilles tendon is used for activities that can put great stress on the tendon, it one of the most often ruptured tendons in the body. Pain from Achilles tendon rupture commonly occurs along the back of the leg in the vicinity of the heel.

Posterior Tibialis Tendon

The posterior tibialis tendon is located along the inner side of the ankle. It connects the posterior tibial muscle (located at the back of the shin bone) to the foot. Problems with this tendon typically occur underneath the prominence of the medial malleolus (inner ankle bone) because the blood supply to this area can be poor. This makes it easier for overuse injuries to cause a tendon rupture. Pain with this type of injury typically occurs along the inside of the foot and ankle.

Peroneal Tendon

There are two peroneal tendons, the peroneus longus and the peroneus brevis. These tendons run along the outside of the ankle and are subject to the repetitive forces from walking and standing. Pain with this condition is typically located along the posterolateral area of the ankle.

Anterior Tibialis Tendon

The tibialis anterior is a muscle located along the front of the tibia (shin bone). It is attached to the foot by the tibialis anterior tendon. This structure is responsible for the dorsiflextion of the foot and ankle. The anterior tibialis muscle plays a large role in dorsiflextion and deceleration of the foot when walking and running. Stress from a variety of movements including walking, running, kicking, or kneeling can cause the tibialis anterior tendon to rupture. Pain with this condition is typically concentrated along the front of the ankle or foot.

Causes

Common causes of an ankle tendon rupture include:

  • The progression of or the final result of longstanding tendonitis of the involved tendon or an overuse injury.
  • An injury to the ankle or a direct blow to the tendon.
  • From a fall where an individual lands awkwardly or directly on the ankle
  • Laceration of the tendon
  • Weakness of the associated muscle in people with existing tendonitis places increased stress on the involved tendon.
  • Steroid use has been linked to tendon weakness
  • Certain systemic diseases have been associated with tendon weakness.
  • A sudden deceleration or stopping motions that cause an acute injury of the ankle.
  • Injection of steroids to the involved tendon or the excessive use of steroids has been known to weaken tendons and make them susceptible to rupture.

Symptoms of Ankle Tendon Ruptures

  • Ankle pain and swelling or feeling that the ankle has “given out” after falling or stumbling.
  • Possible audible pop when the ankle is injured.
  • Patient may have a history of prior ankle pain or tendonitis, and may be active in sports.
  • Swelling, tenderness and possible discoloration or ecchymosis in the ankle region.
  • Indentation above the injured tendon where the torn tendon may be present.
  • Difficulty moving around or walking.
  • Individual has difficulty or is unable to move their ankle with full range of motion.
  • MRI can confirm disruption or tear in the tendon.
  • Immediate pain at time of injury.

Treatment of Ankle Tendon Rupture

Early diagnosis and treatment is the key to a successful outcome for a rupture of any of the tendons in the ankle. If diagnosis or treatment is delayed the integrity of the healing tissue can be compromised as a result of scarring and decreased blood flow. Surgical repair followed by structured and aggressive physical therapy is the treatment of choice for complete ruptures. In the case of a small partial tendon tear conservative treatment without surgery is an option.

Partial (small) Tendon Tear

  • Immobilization of the ankle for 3-6 weeks to rest and promote healing. Individual will be placed in an immobilizer or brace and will move around with crutches to keep weight off of the leg.
  • Physical Therapy: following the period of immobilization your physician will decide when you are ready for physical therapy. Treatment will emphasize gradual weaning off the immobilizing device, increasing weight bearing, restoration of ankle range of motion and strengthening of the associated muscles. It is important that the physician and therapist communicate during the early stages and progress your recovery program based on the principles of healing so as not to compromise the injured tendon.
  • Patient will be progressed to more functional activities as normal ankle range of motion and strength is restored.

Treatment of Complete Tendon Ruptures

  • Immediate surgical repair of the tendon is indicated in complete tears. Delaying surgery can lead to shortening of the tendon, formation of scar tissue and decreased blood flow, which can lead to a poor outcome.
  • Following surgery your ankle will be put in an immobilizing device and you will be instructed to use crutches to limit weight bearing and protect the joint.
  • Over the next 2-4 weeks weight bearing will be increased and physical therapy will be initiated.
  • The surgeon will determine the physical therapy timeline and program.
  • Physical Therapy: treatment will emphasize gradual weaning off the immobilizing device, increasing weight bearing, restoration of ankle range of motion and strengthening of the associated muscles. It is important that the physician and therapist communicate during the early stages and progress your program based on the principles of healing so as not to compromise the involved tendon.
  • Patient will be progressed to more functional activities as normal ankle range of motion and strength is restored.

Physical therapy for a tendon rupture must remain conservative at the onset in order to protect the repair. Emphasis will be on rest, tendon protection, reducing the inflammation and increasing the blood circulation for healing. Following the surgeon’s timeline and protocol, a program of progressive weight bearing, stretching and strengthening will be initiated.

Physical Therapy Interventions

Common Physical Therapy interventions in the treatment of Ankle Tendon Rupture include:

  • Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, stretching and joint mobilization of the ankle by a physical therapist to improve joint mobility and range of motion of the ankle. Use of mobilization techniques also helps to modulate pain.
  • Therapeutic Exercises (TE) including stretching and strengthening exercises to regain range of motion and strengthen the muscles of the ankle and lower extremity.
  • Neuromuscular Reeducation (NMR) to restore stability, retrain the lower extremity and improve movement techniques and mechanics (for example, running, kneeling, squatting and jumping) of the involved lower extremity to reduce stress on the tendons in daily activities. Taping, strapping or bracing may be indicated to rest the tendon and promote healing.
  • Modalities including the use of ultrasound, electrical stimulation, ice, cold, laser and others to decrease pain and inflammation of the involved tendon and bursa.

Prognosis

If repair and treatment are initiated immediately, individuals with a rupture or tear of any of the tendons in the ankle generally do well. Delay can result in the formation of scar tissue and retraction of the tendons. Other factors that can affect recovery are:

  • Age: Older individuals are generally weaker and take longer to heal affecting the functional outcome.
  • Strength: Individuals who are strong and in good condition prior to the injury generally do better following surgical repair.
  • Tissue: Tissue quality prior to the surgical repair will effect healing and recovery following surgery. Poor circulation and presence of scar tissue will interfere with the healing process.

The healing time for a tendon repair will take up to 8-12 weeks but restoration of function and ability to accept full activity, load and stress can take up to one year.