Every year, surgeons in the UK repair 10,000 ruptured Achilles tendons. Gavin Thow, 33, a buying and production manager from South London, underwent a new technique with a speedier recovery time, as ADRIAN MONTI reports.
On the last evening of my holiday in Lanzarote in August, I was playing in a five-a-side football match at my hotel. About half way through, I quickly changed direction to reach the ball. Suddenly, something ‘went’ in the back of my left ankle and I fell to the ground.
A doctor said she thought I’d torn my Achilles – a tendon at the back of my heel – and used an ice pack to help reduce the swelling before bandaging it up. I borrowed crutches and my partner Penny helped me back to our room.
Every year, surgeons in the UK repair 10,000 ruptured Achilles tendons. Gavin Thow, 33, a buying and production manager from South London, underwent a new technique with a speedier recovery time, as ADRIAN MONTI reports
Once we landed at Gatwick the next day, I went straight to A&E, still using the crutches.
The doctors said by touch they could feel the tendon had totally ruptured – an operation would be my best option. This would ideally be done in under two weeks on the NHS, but could take longer.
My foot was put in a cast with the toes pointing downwards to bring the snapped two ends of the tendon closer together, which would help when they were stitched together in surgery.
Because I’d flown for more than four hours there was a risk of deep vein thrombosis, so I was given blood thinners to take during the next five weeks.
I saw consultant orthopaedic surgeon Kumar Kunasingam at St Anthony’s Hospital in Surrey two days later using my private health insurance. He said with usual tendon surgery – where they stitch the two ends of the torn achilles tendon back together – it can be up to a year before you can play sport again.
I play hockey competitively, so that was a blow. But he was also using an innovative method with a shorter recovery time. It involved using a muscle that allows movement of the big toe and stitching it to the Achilles tendon after it’s repaired.
What are the risks?
- There is a small risk of infection. This is greatest during the two weeks when it is in a cast while it heals. This is no higher a risk than the standard procedure.
- When the leg is in plaster there’s a higher risk of blood clots, so patients are given blood thinning injections to prevent this.
- ‘A ruptured Achilles is usually easy to repair with good outcomes reported in both traditional and newer techniques,’ says Barry Rose, a consultant orthopaedic surgeon at Eastbourne District General Hospital.
‘There are some advantages to this new technique such as a slightly improved blood supply that could aid in the tendon’s healing.
‘Having seen and used the technique myself, I feel that there is little to lose by incorporating it, although with little evidence to back it up, there might be some scepticism as to the actual benefit.’
This would increase blood to the tendon, speeding up my recovery. It sounded good to me. I had the 30-minute operation ten days after the injury, under general anaesthetic.
When I woke up, I was wearing a cast. I was in hospital for less than 24 hours. I felt an occasional tingling sensation in my Achilles over the next two months – this was the tendon healing and scar tissue moving and wasn’t uncomfortable.
After ten days the cast was removed and I wore a boot with four wedges in the heel that altered the angle of my foot. When I started wearing it, my toes pointed downwards, but the wedges were removed over the next eight weeks, returning my foot to its normal position.
I also had physio for eight weeks. Last month, I stopped wearing the boot. I am now wearing trainers with a gel support in the heel, to soften any impact while my leg muscles regain their strength. I have finished physio and will be re-assessed after Christmas. In March I hope to go skiing, and be able to play hockey again.
Mr Kunasingam thinks this will be possible if things continue going well. That will be exactly seven months from when I tore my Achilles – a great recovery time.
Kumar Kunasingam is a consultant orthopaedic surgeon at the Spire St Anthony’s Hospital, Cheam, and Croydon University Hospital in Surrey.
Our Achilles tendon connects the calf muscle in the lower leg to the heel. It’s made up of strands of tough, fibrous tissue in a sheath called the paratenon. It keep us upright and propels us forward by pushing the foot down when the calf muscle flexes.
Despite being robust, it’s susceptible to injury because it handles at least four times our body weight when we move.
The surgeon: Our Achilles tendon connects the calf muscle in the lower leg to the heel. It’s made up of strands of tough, fibrous tissue in a sheath called the paratenon. It keep us upright and propels us forward by pushing the foot down when the calf muscle flexes. Despite being robust, it’s susceptible to injury because it handles at least four times our body weight when we move
Although ruptured Achilles are associated with sporty people, they can tear during everyday activities such as walking up steps when you push off and engage your lower leg suddenly and the tendon cannot cope.
It affects all ages, but especially younger men, as they often do sports such as football which can put them at risk of it. Patients often hear a ‘pop’. The pain is dull, rather than excruciating, but will leave you unable to bear weight on the injured leg.
You should go to A&E – quicker treatment means a more successful recovery. The test is squeezing the calf muscle. If the toes stay still, a rupture has happened. An MRI or ultrasound scan will confirm this.
Although ruptured Achilles are associated with sporty people, they can tear during everyday activities such as walking up steps when you push off and engage your lower leg suddenly and the tendon cannot cope
Some people ignore a ruptured Achilles, but they won’t have sufficient control over their foot as the tendon never heals properly, leaving them with a limp.
The traditional surgery involves making a 10 to 15cm incision.
The surgeon cuts through tissue to reach the tendon, before bringing the two ends of it together, stitching back up the paratenon and closing the incision. This takes about 45 minutes. After six weeks in a cast, the patient spends six weeks wearing a rigid boot. After these three months they start physiotherapy – it can be a slow process.
The new method speeds this up by ‘stealing’ the blood supply to the flexor hallucis longus – the muscle in our ankle that allows us to move our big toe. As this has a better blood supply than the Achilles tendon, and sits near the repair, it is ideal to use.
Some people ignore a ruptured Achilles, but they won’t have sufficient control over their foot as the tendon never heals properly, leaving them with a limp. The toe gets an adequate supply of blood, so can spare some. This reduces the recovery period by around four weeks.
An MRI scan of the rupture is used to pinpoint where to make my incision. Guided by this, I make a 3cm cut in the back of the leg. I lift up the affected leg and bend it at the knee, before resting it on a bolster to make the tendon poke out.
I ensure the toes are pointing down, making the gap between the two parts of the snapped tendon closer. I stitch the two ends together, tucking all the Achilles fibre strands neatly in the paratenon, so when it heals there is no scar tissue to stop the tendon moving smoothly.
After repairing it I lift it up to access the flexor hallucius longus – that sits directly in front of the Achilles – and make a 2cm incision into this muscle. I then lift up the cut part of the muscle, which is so close by I don’t have to stretch it and attach it to the Achilles using stitches.
An MRI scan of the rupture is used to pinpoint where to make my incision. Guided by this, I make a 3cm cut in the back of the leg. This allows it to steal some of the blood supply to the muscle to speed up its recovery – our blood is rich in nutrients that promote healing.
Diverting a small amount of blood from the big toe doesn’t affect its movement, and having the muscle attached to the Achilles doesn’t appear to cause any problems in the long term. Patients wear a cast for two weeks, then a boot for six weeks – this crosses over with the period when the patient starts physiotherapy.
Gradually the wedges in the heel of the boot are removed until the foot is flat at 90 degrees, and patients continue physio – vital to the surgery’s success. I believe this could be a more standard way of repairing ruptured Achilles in the future.
The operation costs £4,800 privately, while a standard Achilles repair costs about £3,500-4,500 to the NHS.