The Achilles tendon is the largest and strongest tendon in the body. It connects your calf muscles (the gastrocnemius and soleus) to your heel bone (calcaneus) and is essential for walking, running, jumping and pushing off the ground.

When the Achilles tendon tears, it is called a rupture. If a rupture is not treated within the first four to six weeks, it is described as a chronic Achilles tendon rupture. Over this time the torn ends draw apart, the gap fills with weak scar tissue, and the calf muscle begins to shorten and waste away. This makes a chronic rupture harder to repair than a fresh one, which is why it is important to be seen by a specialist.

A surprising number of Achilles ruptures are missed at the time of the injury — up to one in four are not picked up straight away — so it is not unusual for people to come and see us weeks or months later, still feeling weak. Being seen by a Consultant Foot & Ankle Surgeon such as Mr Matthew Welck in London gives you the widest choice of repair options.

The Achilles is the most frequently ruptured tendon in the body, and it has become more common over recent decades as more adults stay active into middle age. Acute ruptures most often occur in men aged 30 to 40 during sport or sudden exertion.

A chronic rupture usually develops for one of the following reasons:

• Missed diagnosis — the original tear was thought to be a sprain or calf strain and was never treated
• Late diagnosis — help was not sought until weeks after the injury
• Treatment in a boot that did not work — the tear healed in a poor position
• Re-rupture — a previously healed or repaired tendon that tears again

Whatever the trigger, the underlying problem is the same. Once the tendon ends separate, they pull apart and are joined only by weak, disordered scar tissue. The longer this is left, the bigger the gap becomes and the more the calf muscle wastes away — and both of these affect which operation is best for you.

Compared with a fresh rupture, a chronic rupture is often less painful but has a bigger effect on what you can do. Typical features include:

• Weakness pushing off — difficulty walking briskly, climbing stairs or standing on tiptoes
• Inability to perform a single-leg heel raise on the affected side
• A gap or dip you can feel in the line of the tendon (although scar tissue may fill this in)
• A thinner, wasted calf
• An altered, flat-footed or limping gait
• Fatigue and aching in the calf after activity

Many people manage for months, but it is the ongoing weakness and limp that usually bring them to see a specialist.

Diagnosis involves listening to your history, examining you, and using scans to measure the gap and plan the repair:

• Clinical examination — including the Simmonds (Thompson) calf-squeeze test: if the tendon is torn, squeezing the calf will not move the foot. We also look at how the foot sits at rest
• Ultrasound — a quick scan that shows the tear and can measure the gap while your ankle is moved
• MRI scan — the most detailed test. It shows the size of the gap, how healthy the tendon ends are and, importantly, whether the calf muscle has become fatty and wasted after a long delay

MRI is especially useful in long-standing cases, because fatty change in the calf muscle may affect whether another tendon is used to support the repair.

Non-surgical management has a limited but real role in chronic ruptures. It is usually chosen for people who are older, less active, or not well enough for surgery, or who have adapted well and do not need to do a great deal on their feet.

• A made-to-measure brace or ankle splint (an ankle-foot orthosis, or AFO) to support push-off and help you walk better
• A heel raise inside the shoe, to reduce the work the tendon has to do
• Physiotherapy to build up as much calf and leg strength as possible

It is only fair to be clear about the trade-off: without surgery, a large gap will not close and your calf will stay weaker. For active patients seeking a return to sport or a normal walking pattern, surgical reconstruction is usually recommended. We talk every option through openly and decide together.

The best operation depends mainly on the size of the gap between the tendon ends once the scar and unhealthy tissue have been cleared away. Surgeons use a standard grading system based on gap size as a guide, and the tendon ends are always trimmed back to healthy tissue first.

Patients preparing for surgery may find our downloadable Preparing for Foot & Ankle Surgery guide (PDF) and the Guide to Risks of Ankle & Hindfoot Surgery (PDF) a helpful next step.

Because the injury is long-standing, full recovery usually takes 9 to 12 months. Modern rehabilitation encourages early, protected movement, which improves the final result without making it more likely that the repair will tear again. A typical pathway is:

• Weeks 0–2: a splint or cast, and keeping your weight off the leg to protect the repair
• Weeks 2–6: a walking boot with heel wedges, starting gentle movement with guidance
• Weeks 6–10: putting more weight through the leg, with the wedges gradually taken out as movement returns
• From about 10 weeks: coming out of the boot into supportive shoes and building strength
• Later on: returning to higher-impact activity once you can do repeated heel raises and hops on one leg

Your rehabilitation is supervised by specialist physiotherapists and is tailored to the operation you have had.

Mr Matthew Welck is a Consultant Orthopaedic Foot & Ankle Surgeon at the Royal National Orthopaedic Hospital (RNOH) Stanmore — a specialist orthopaedic hospital — and Honorary Associate Clinical Professor at UCL.

He runs a specialist practice devoted entirely to problems of the foot and ankle, with particular expertise in complex reconstruction, revision surgery, sports injuries and total ankle replacement. He has written more than 50 published research papers, has completed two specialist fellowships including training abroad, and remains active in research. Patients are seen from across London, the UK and overseas.

Patients are assessed across North and Central London with quick access to ultrasound, MRI and weight-bearing CT scans. All of the options are discussed with you, and a plan that suits you is agreed together. Visit matthewwelck.com to learn more.

If you have ongoing calf weakness, difficulty standing on tiptoes, or you think an Achilles rupture may have been missed, seeing a specialist can make a real difference to your outcome. Being seen early by an expert gives you the widest choice of repair options and the best long-term result.

Book a private or NHS consultation with Mr Matthew Welck, Consultant Foot & Ankle Surgeon.

• Email: secretary@matthewwelck.com
• Call: 07547 395 270
• Website: matthewwelck.com