Massage Therapist Treatment For An Achilles Tendon Rupture
“I heard a loud pop and it felt like somebody hit me in the heel.”
I’ve had a few friends and patients over the years that ruptured their achilles tendon.
It just sounds terrible and I hope I never have to experience it.
The last time I heard a story about it, the guy was playing tennis and lunged after a ball. He just dropped to the ground.
He knew he shouldn’t move because the foot didn’t feel right and when you hear something like that, the last thing you want to do is move the injury.
Fortunately keeping still was the right thing to do.
First Aid For An Achilles Tear
I would treat this the same as I would for a fracture.
The person may still be able to limp or walk because the peroneals and other muscles deep in the leg compartment that remain in tact do not require push off with the superficial calf muscles.
Once that tendon is ruptured, immobilize as soon as possible, you want to do everything possible to prevent the calves from balling up.
Make sure to immobilize in the position found. Since the gastrocs cross the knee, do not straighten it because that motion would place more tension on the calf muscles and could further complicate the injury. However this is just my opinion from experience in dealing with things like this on an acute level (this study says that knee position does not affect the tendon gap at the injury site).
Once immobilized check the pulse distal to the injury to make sure circulation is okay.
If you’re not sure whether the injury is a rupture there is a few signs and symptoms to look for:
- visible separation in the tendon
- unable to stand or balance on the affected leg
- swelling and bruising around the ankle
- excessive dorsiflexion of the ankle
- positive Thompson’s test.
While all of those signs and symptoms and the Thompson’s test are quality things to look for, I would be hesitant to have someone try to stand on the injured side or perform the test for fear of causing further damage. You are much better off to look at the mechanism of injury and let the doctors at the hospital perform any further testing that is required.
Achilles Tendon Rupture: Surgical Or Non-Surgical
I had no idea that there was a non-surgical procedure for this injury until just recently.
In doing research, there is quite the debate over which is better between surgical and non-surgical procedure and both have their advantages and disadvantages. It seemed like I could find just as many pro or against for either treatment.
In the non-surgical treatment the foot is braced in plantar flexion and three weeks later progresses to weight bearing exercise and manual therapy. Scar tissue fills the space between the ends of the torn tendon, which lengthens it and gives the patient less push off strength. It takes longer to recover, longer immobilization time and has a higher risk of a deep vein thrombosis.
There are a few different methods to the surgery but it comes with the risk of wound closure problems, infection and nerve damage.
One systematic review looked at seven articles from the last ten years and found:
- there wasn’t a significant difference in re-ruptures of the tendon
- more soft tissue injuries from the surgery (we could probably help out here)
- better function after surgery
- quicker rehab after surgery
The review also points out the difference between surgical and non-surgical treatments were minor so the importance lies in the rehab.
How To Rehabilitate An Achilles Rupture In The Massage Clinic
Your approach to helping rehab this injury is going to vary depending on when the patient comes to see you and what type of repair was done to the tendon.
There are two approaches to rehab, the conventional approach and an early remobilization approach.
Getting a good history from your patient will be crucial to providing the appropriate care (as it always is).
When the conventional approach is used, somewhere around the 4 week point (after the operation) the person is usually put into a walking cast (ankle is placed in neutral) with some weight bearing exercises are started. Around the 8-10 week mark, the walking cast is taken away and range of motion exercises begin. After 12 weeks things are getting back to normal and full weight bearing activities are okay again.
When the early remobilization approach is used, weight bearing and range of motion exercise starts immediately (or within 2 weeks) after surgery while wearing a brace that holds the ankle in plantar flexion. Full weight bearing happens gradually at 3-6 weeks with orthotics in place that allow more dorsiflexion.
With either approach, weight bearing exercises are used around that 6 week mark. At this point it is also okay to start some Massage Therapy work around the tendon and the calf muscles. The biggest thing we want to do is help with increasing the ankle range of motion. Using some techniques like joint mobilizations, mild stretching, active and passive range of motion and manually stripping out the gastrocs will all help contribute to these goals.
The next goal should be strengthening the calf muscles. After being in a splint, brace or cast for that long there will be some wasting of the muscle. I had a knee surgery back in 2005 and had to wear a full length leg splint for 3 months after the surgery. My leg looked like it belonged to a 10 year old kid compared to the other one.
Because weight bearing is allowed in both approaches at the 6 week mark, strengthening should be tolerated as well. If you’re not comfortable setting up exercise programs, reach out to someone in your network that is and get some help with it. Chances are the patient will already have exercises in place, either prescribed by the surgeon or from a physio they have been referred to.
Whichever rehab approach is being used will be dictated by the doctor or surgeon. Reach out to them and find out which approach is being used and get some feedback on what they have seen success with. Sometimes with surgery structures are taken from flexor hallucis longus, plantaris, peroneus brevis or parts of the fascia from the gastrocs. Getting that kind of information from their doctor is valuable information and may alter your treatment. If you’re dealing with an acute achilles rupture, even though they may be able to limp on it, get them down on the ground and splint the ankle in place. Do whatever you can to prevent any further injury or complications. When a person is coming in to your clinic for rehab, do a little research on what works best for a successful outcome and have some open communication with the persons other practitioners. And hopefully the next time you’re out exercising it never feels like someone kicked you in the back of the heel.
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I’m confused by this article’s assertion that the linked systematic review showed no difference in re-rupture rates when it clearly states the opposite – “When
the data from each of these randomized controlled trials were pooled and meta-analyzed, the incidence of reruptures was found to be significantly higher with nonoperative management when compared with open surgical repair.”
Thanks Ken, in the abstract it mentions “there were no significant differences in re-ruptures between the two treatments” and further into the article mentions that “re-rupture rate between the surgery and non-surgery group in many new studies has equalized”. Then in the discussion at the end it points out “Furthermore, although no significant difference in re-rupture rates was seen in this review, there was still a clinical difference in favor of surgery treatment, which also advocates for surgery” and also says “We found no significant differences in re-rupture rate between surgical and non-surgical treatment of Achilles tendon rupture, although a tendency to favoring surgery that could be of clinical importance was presented.” So there is a tendency favoring surgery which had to do with rehab, infection and other complications. I read through the study a couple of times again (it’s been quite a while since I wrote it) and couldn’t find the exact quote you mentioned, so my apologies if I missed it again, thanks for bringing it to my attention.