I have seen a few Achilles Tendon (AT) ruptures over the last few months, so I decided to write a blog about this injury. I hope it guides patients that have experienced this type of injury and explains how to reduce the risk of recurrence or reinjury if you have already suffered from an Achilles rupture.

Those that have experienced a rupture can confirm it is a long recovery process that can range anywhere between 6-12 months post rupture. The most common mechanism of injury in both the sporting and non-sporting environments are eccentric contraction of the calf muscle group (calf is on stretch as the heel hits the ground) and when the trunk of a person's body is opposite to the direction in which the person's foot is planted, e.g. when they change direction suddenly.

The Achilles tendon anatomy and Risks for Achilles rupture

A: Muscle tendon Junction (MDT): where the calf attaches to the tendon

B: Mid portion (the middle part of the tendon)

C: Insertional (part of the tendon that inserts onto the heel bone)

Achilles Tendon (AT) ruptures commonly occur in the active individual with underlying Achilles tendinopathy that they were unaware of (2/3 of people had no experience of pain prior to the rupture). Patients will commonly report they heard or felt a pop at the ankle when ruptured but this symptom is not always reported. Many described this as "feeling as though they were shot from behind". This is most commonly pain free at the time of the incident.  Those that do experience pain during or after the rupture, will commonly report pain starting at the ankle acutely and then migrating towards the calf over the next few days. Patients will usually complain of weakness and an inability to stand, walk, or run on their foot as they could prior to the rupture.

Males are more prone to AT ruptures and unfortunately, we do not know why however, females with an absent menstrual cycle, on hormone replacement therapy (HRT) and over 40 are also at a greater risk.

Higher risk individuals to AT rupture also include people within the age group of 30- 40 and 60-75 years old. Other factors that predispose you to tendon injuries are those that are:

• Taking regular medication - steroids, quinolone, or HRT (hormone replacement therapy)
• Genetic factors
• History of a previous rupture (this is the largest risk factor)
• Previous cortisone injection into a tendon for pain relief! Please DON'™T DO THIS EVER! Cortisone has been shown to weaken a tendon!

Most tendon ruptures occur at the mid-portion of the Achilles and this is usually due to existing tendon degeneration however, this can occur in individuals with NO tendon pathology too.  As mentioned before, this is usually the group that does not have pain with their tendon prior to rupture as most people that suffer from tendinopathy pain seek treatment and therefore begin rehabilitation that builds strength and capacity in their calf and Achilles complex and therefore their risk of rupture is reduced. So remember if you are someone who is struggling with Achilles tendon pain that has been persisting for a short or long period of time ensure you seek an assessment of this from someone who is experienced in tendinopathy pain so that you can get this on the right track. It is important you do this rather than being afraid your tendon may rupture as that is extremely unlikely in your case.

It is less common that a healthy tendon will rupture unless it has been exposed to a significant external force in which case rupture at the MDT portion of the Achilles will occur.

Management of AT ruptures

These can be managed conservatively or surgically but in New Zealand, the majority of these injuries are treated conservatively. This, at times, differs in the elite athlete population but research shows us that after 18 months post rupture the outcomes of surgical vs conservative care are largely the same. The conservatively managed population has a slightly higher risk of re rupture and the surgically managed group has a higher incidence of infection, but overall results are relatively even, and good function regained. Other things that may be taken into account when considering surgical vs conservative management are whether the injury is acute (5 days) or chronic (3-6weeks); the size and location of the tear, and the Orthopaedic surgeon's availability and assessment of the individual.

Overall, there is little difference in recovery and return to play with the 2 approaches. The main difference is that with operative management, the person may regain functional use of the foot a few weeks earlier than conservative BUT with all approaches, there are risks and benefits for each. As a physiotherapist, I would always encourage my patients to consider a conservative approach.

The most important contributing factor determining the success to a full return to function is the quality of the REHABILITATION post rupture.

 Both surgical and conservative approaches protocols include;

A: Immobilisation in serial casting in a plantarflexed position (pointed foot position)  for (2-3 weeks) whilst using crutches to avoid putting weight through the tendon.

B: At 3 weeks they are put in a moon boot with wedges keeping the foot into a pointed position and 1 wedge is removed on a weekly basis until the patients' foot is in a neutral (flat foot) position. The Doctor will advise on when gradual weight bearing can occur.

C:  Ideally from around 6 weeks the patient will be able to gradually start weight bearing and commence light exercise (guided by Doctor and Physio).

D: At 10 weeks post rupture, the patient is usually allowed to remove the boot and walk, gradually increasing walking time and distance.

The important thing during this initial phase of recovery is that we allow the tendon to heal properly and develop sufficient stiffness!  A long Achilles repair leads to less function as the final outcome.

The immobilisation period is important as it bridges the gap of the Achilles and promotes the tendon healing in a shortened rather than lengthened position. A tendon that heals in a lengthened position is less likely to be able to develop appropriate strength and force which leads to a less than satisfactory outcome including a greater likelihood of re-rupture.

Rehabilitation post rupture

As a physiotherapist, we want to ensure that we regain ankle and forefoot mobility, regain and optimise your calf and foot endurance, strength and proprioception of BOTH legs.

We also aim to achieve proximal strength through your hips, core and the remainder of your lower limb as this will facilitate recovery and a greater overall outcome.

We will guide you through sport specific training and return to play programmes to reduce the risk of re-rupture and ensure not only a return to play but more importantly over time a return to performance.

I always advise my patients to start physiotherapy ASAP as there is a lot we can do to help facilitate recovery without affecting the injured area. When you are out of the serial casting and put in the moon boot, we will then start with hands on treatment to regain ankle and foot mobility whilst protecting the AT.

It is comforting to know that 80% f people return to full sporting activities following a rupture and that the Achilles tendon can tolerate the force being put on it! With each running step the AT has a load of 6 X bodyweight put on it!

With appropriate rehab, you can feel confident and enjoy a return to sport without being afraid to re-rupture, provided you have done your homework.

If you have any questions or concerns regarding any Achilles pain you are having or have had, please contact us to talk to a qualified Physiotherapist

Written by Dunia Mouneimne Senior Physiotherapist

Editors note: If you are an athlete who is post-partum there is a section further down below that is important for you to read.

Over recent years we have seen an emerging social phenomenon with successful return to sport of many elite athletes. Guidelines and important points for athletes and non-athletes returning to exercise post childbirth are included in this blog.

Ideally seek medical guidance prior to returning to exercise post-partum. If you have had an uncomplicated pregnancy and birth your physiotherapist is one of the best suited professionals to seek advice from at this point.

The general guideline is that healthy women gradually return to physical exercise aiming to accumulate 150 to 300 minutes per week. Low impact endurance training should start gradually but can start early as desired as there is minimal impact on the pelvic floor. Return to high impact exercises and strength training may need to be delayed several months. Some exercises need to be more gradual especially exercises increasing intra-abdominal pressure. The initial focus should be on strengthening pelvic floor muscles.

Important points to be aware of for athletes and non-athletes:

• The pelvic floor is weak and injured in most women postpartum and will require rehabilitation to return to its "normal" functions. Those who struggle to perform the above exercise guidelines and those that have not completed pelvic floor muscle training prior to the birth may need an individualised and supervised programme to regain appropriate strength and control.
• Any physiological changes that occur during pregnancy and persist for four to six weeks post birth, such as elevated hormone levels, may mean your joints are more mobile than normal so take care with activities that require large amounts of movement, flexibility and dynamic exercises.
• Certain birth types may lead to complications. For example, C sections are more likely to cause abdominal pain postpartum.  Pain management and wound healing are therefore important prior to any return to exercise.
• Low back pain is common so must be considered prior to return to exercise. An assessment of this with a specific treatment and rehabilitation programme may be required.
• Stretched, weakened or separated abdominal muscles (Diastasis recti abdominis) may also delay or impede exercise ability.
• Increase energy and fluid intake if breastfeeding when returning to exercise.  Ensure particularly when breastfeeding that nutrition demands of both lactation and training are met. The caloric cost of breastfeeding is estimated to be around 600 kilocalories per day.
• Adequate intake of calcium and vitamin D during breastfeeding is essential.
• Ensure adequate hydration throughout the day.

• Consider psychological readiness to return to exercise as this is important post childbirth. Fear of movement is common particularly post C section and has been associated with restricted postpartum physical activity.
• Exercising after breastfeeding will likely be more comfortable to avoid engorged breasts.
• Take care with those exercises that cause high gravitational load on the pelvic floor or high impact activities in early stages.
• Complicated births such as a forceps delivery or levator ani avulsions are likely to slow down return to exercise post-partum and potentially lead to elevated complication rates of pelvic floor dysfunction and pelvic organ prolapse if time is not given to heal appropriately and rehab is not completed.
• Ensure that return to exercise is gradually increased.
• Consider the importance of individualized breast support support rather than compression is important from a comfort perspective.
• If an obvious Diastasis Rectus Abdominis (gap in between abdominal muscles) see a physiotherapist for an assessment to have a programme prescribed at the correct level and to ensure safe return to exercise without complications
• Sexual dysfunction is common postpartum. Those suffering may benefit from pelvic floor rehabilitation to improve this.

Stress incontinence (involuntary emission of urine when pressure within the abdomen increases suddenly, as in coughing, running or jumping) is one common post-partum complication. Pelvic floor rehabilitation post childbirth can be used successfully in resolving this issue in a large percentage of the population. If you or anyone you know is suffering from any stress incontinence, please contact the clinic and book in for a pelvic health assessment as this is often an extremely limiting condition that can be resolved relatively easily.

• Factors that may predispose you to post-partum stress incontinence are:
  • Giving birth,
  • Increasing age,
  • Vaginal delivery,
  • Pregnancy stress incontinence,
  • Running related pre pregnancy incontinence,
  • Partaking in high impact activities,
  • Women with multiple children, and/or
  • Return to high impact activities before the body has healed i.e., running.

Exercise guidelines:

• Research highlights that all post-natal mothers, regardless of delivery mode, should be offered pelvic health assessment from six weeks post-natal to comprehensively assess the abdominal wall and pelvic floor. In NZ this is uncommon and requires the mother to generally access private health providers for this. There is currently a movement for this to change so all mothers in NZ can access private pelvic health physiotherapy assessment and rehabilitation in the future which we believe is essential to the long term health and wellness of mothers in NZ.
• High impact activities, such as running, are associated with a sudden rise in intra-abdominal pressure and load the pelvic floor as a result.  For this reason, it is advised that you return to low impact activities post-partum prior to a return to running.
• Low impact exercise can be implemented within the first three months post-natal followed by a return to run between three to six months.

Key signs or symptoms of pelvic floor and or abdominal wall dysfunction:

• Urinary and or faecal incompetence,
• Urinary or faecal urgency that is difficult to defer,
• Heaviness pressure bulge dragging in the pelvic area,
• Pain with intercourse,
• Obstructive defecation,
• Pendular abdomen, separated abdominal muscles and or decreased abdominal strength and function, and/or
• Musculoskeletal lumbar-pelvic (low back) or pelvic pain.

Risk factors for potential issues returning to running and sport:

• Less than three months post-natal,
• Pre-existing hypermobility conditions i.e., Ehlers-Danlos,
• Breastfeeding,
• Pre-existing pelvic floor dysfunction or lumbar-pelvic dysfunction,
• Psychological issues that may predispose a post-natal mother to an inappropriate intensity or duration of running as a coping strategy,
• Obesity,
• C-section or perineal scarring, and/or
• Relative energy deficiency in sport (RED S).

A referral to a pelvic health physiotherapist is further highlighted if any of the following signs and symptoms are experienced prior to or after attempting returning to run:

• Heaviness or dragging in the pelvic area,
• Leaking urine or inability to control bowel movements,
• Pendular abdomen and or noticeable gap along the line of your abdominal middle,
• Pelvic or lower back pain, and/or
• Ongoing or increased blood loss beyond eight weeks post Natal that is not linked to your monthly cycle.

An inability to exercise may affect both your mental and physical wellbeing. It can be socially isolating not being able to complete exercises as you previously had. Please ensure that you reach out to us for an assessment if this sounds like you.

To book a pelvic floor assessment please call 07 576 1860 or email reception@buretaphysio.co.nz.

Exercise in Athletes Post Partum

Across the board, athletes return to sport sooner than non-athletes with a greater percentage within six weeks post-partum. Research also highlights that a large percentage of those athletes returning to elite sports post childbirth return to the same if not a higher level of performance. If you are intending on returning to competitive sports post pregnancy, ensure you include a multidisciplinary team in your planning.

Be aware that just as if you were returning to running or sport post injury, when you had a significant reduction in your training load, this is a period that exercise must be gradually resumed. Ideally, this would start with pelvic floor rehabilitation, alongside low impact activities, prior to a gradual reduction in high impact activities and those that result in significant increases in intra-abdominal and pelvic pressure such as lifting weights.

Moderate to vigorous physical activity in sport will not negatively affect breastmilk volume, alter the composition of breastmilk or affect infant growth if there is appropriate food and fluid intake.

Note that post-natal women with a history of RED-S (relative energy deficiency in sport) are at increased risk of stress fractures, pelvic dysfunction and fertility issues so must have appropriate multidisciplinary involvement regarding their return to training.

Things to take note of:

• Regaining functional control of the abdominal wall to manage intra-abdominal pressure and load transfer should be achieved prior to return to run or sport, otherwise overload and compensatory strategies may occur.
• Return to running with a diastasis if it is functional i.e. it is present but there are strategies to control intrabdominal pressure and transfer load across the abdominal wall that are adequate.
• Shoe/boot size can alter permanently with pregnancy and footwear previously worn should not be presumed to be the correct fit.
• Sleep deprivation in athletes is associated with increased injury risk. Sleep is key for recovery from both physical and psychological stress and is frequently restricted in the postpartum period. Utilise naps as able to optimise sleep quantity.
• Utilise sleep hygiene guidelines to optimise sleep quality.
• Similar to post injury situations, build training volume prior to increasing training intensity.
• Minimise large and sudden increases in load.
• Take note of key individual signs that need to be monitored during your return to run/sport i.e. heaviness, dragging, incontinence or moderate to severe pain may suggest excessive training distance or intensity.
• Mild musculoskeletal pain 0-3/ 10 which settles quickly after a run with no pain lasting into the next day is often acceptable; as is used in the management of tendinopathy and other conditions.
• If running with a buggy it must be a buggy that is specifically designed for running. Two handed technique where it is possible should be utilised and ideally your baby is greater than six months old as per buggy manufacturers guidelines. Note also that pushing a buggy has an increased energy cost when compared to running independently.

In summary:

Post-natal women will benefit from individualised assessment and guided pelvic floor rehabilitation for the prevention and management of pelvic organ prolapse, the management of urinary incontinence and for improved sexual function post childbirth.

Return to running is not advised prior to three months post-natal or beyond this if any symptoms of pelvic floor dysfunction are identified prior to or after attempting return to running.

Until recently, sport culture has generally positioned motherhood into a woman's post athletic life. But in recent years many examples of elite sportswomen have demonstrated a successful return to sports performance at the highest level.

Research has confirmed that vigorous physical activity has no adverse effects on the course of the pregnancy, the labor, or on the fetus and is not associated with an increased risk of preterm birth or reduction in gestational age at delivery by women who were well trained pre pregnancy. Well trained women can benefit substantially from training at high volumes during an uncomplicated pregnancy. Such training has also been shown to facilitate a successful and quick return to competitive sport after pregnancy.

Whilst this is the case there is a lack of easily obtainable information regarding specific forms of exercise such as strength training while pregnant.

Athletes should have their exercise regime overseen by an expert health provider to ensure the safety and wellness of the mother and her unborn child. This is particularly important with the fetus as small for gestational age.

• There are a number of forms of sport that are generally considered more unsafe and should be avoided while pregnant. These include:
  • abdominal trauma or pressure ie weightlifting, contact or collision sports such as rugby or martial arts 
  • those that involve projectile objects or striking implements ie hockey or cricket
  • sports involving falling ie judo, skiing, skating, horse riding
  • extreme balance coordination and agility sports ie gymnastics, water skiing
  • sports that involve significant changes in pressure ie scuba diving, skydiving
  • heavy lifting greater than submaximal high intensity training
  • altitudes greater than 2000 meters
  • exercise in the supine position or even motionless supine posture after 28 weeks of gestation

Some modifications to exercise techniques or programs may be required to accommodate anatomical and physiological changes as your body changes throughout the pregnancy.

All pregnant women are advised to do pelvic floor exercises to improve the tone of the pelvic floor muscles reducing the complications of pelvic floor weakness post birth including but not limited to urinary incontinence.

• Avoid large increases in body temperature during exercise. Remain well hydrated, avoid hot or humid exercise environments where possible.
• Use controlled stretching only.
• Avoid wide squat lunges or unilateral leg exercises that place excessive shearing forces on the pubic synthesis and case pubis pain.

Come and see one of our physiotherapists that work in this field if you are suffering from pelvic pain, lumbar spine or other musculoskeletal pain during your pregnancy. We can also help you with designing an exercise programme that is suitable for you during your pregnancy as well as get you started on an appropriate pelvic floor exercise programme to reduce many of the complications that are common post childbirth.  

Also don't forget to discuss your post-partum plan with your physiotherapist so you are comfortable regarding what you need to look out for, when and how you can start and what you can do to ensure the most problem free return to exercise possible post birth.

To book please call 07 576 1860 or email reception@buretaphysio.co.nz.

In the general population, in the absence of contraindications, all pregnant women are encouraged to be physically active for at least a minimum of 150 minutes per week. This should consist of moderate intensity aerobic activity. Depending on your usual volume of exercise it is common for this total volume to be reduced in the first and third trimesters due to a number of pregnancy related issues such as fatigue.

The below guidelines are a great starting point for exercising during pregnancy. These guidelines relate to those women who have an uncomplicated pregnancy. If you have additional health or pregnancy related concerns, please ensure you speak to your health care provider prior to undertaking exercise when pregnant.

• Exercise during pregnancy does not increase the risk of adverse pregnancy or birth outcomes

• Research says that pregnant women who were inactive prior to pregnancy should be encouraged to be active during pregnancy commencing low intensity activities such as walking and swimming and progressing to the lower end of the range recommended and national guidelines of 150 minutes per week or 30 minutes per day of activity on most days. If you are unsure throughout, please seek advice from your health care practitioner.

• There is strong evidence to support the benefits of physical activity for pregnant women including improvement or maintenance of:
  • muscle strength and endurance
  • cardiovascular function and physical fitness
  • decreased risk of pregnancy related complications such as hypertension
  • reduced back and pelvic pain
  • improved fatigue levels
  • improved mental health including reduced  stress, anxiety, and depression
  • reduction in excessive gestational weight gain and postpartum weight retention
  • fewer delivery complications
  • to aid in the prevention of urinary incontinence

• Those who should be cautious with or complete low level exercise only with professional collaboration with medical personnel include those with a history of:
  • previous spontaneous abortion
  • history previous preterm birth
  • mild to moderate cardiovascular or respiratory disorder
  • anemia
  • malnutrition or eating disorder
  • twin pregnancy after 28th week
  • obesity  BMI >30
  • intrauterine growth restriction
  • other significant medical conditions such as poorly controlled type one diabetes or hypertension

• There are contraindications to physical activity during pregnancy and these include those women who have below:
  • ruptured membranes
  • signs of preterm labor
  • hypertensive disorders of pregnancy
  • incompetent cervix
  • growth restricted fetus
  • high order multiple gestations eg  triplets
  • placenta previa after week 28

• Woman who have experienced the following symptoms should seek advice from antenatal care provider before continuing exercise:
  • abdominal pain
  • amniotic fluid leakage
  • calf pain or swelling
  • chest pain tightness or palpitations
  • decreased fetal movement
  • dizziness or presyncope
  • dyspnea (shortness of breath) before exertion
  • excessive fatigue
  • excessive shortness of breath
  • muscle weakness
  • pelvic pain
  • preterm labor
  • severe headaches
  • uterine contractions
  • vagina bleeding

• If any of the above complications relate to you please ensure you discuss any planned or proposed exercise regime with your lead health professional.

Our Pelvic Floor Physiotherapists can ensure you get an exercise plan that works for you and your pregnancy. To book please call 07 576 1860 or email reception@buretaphysio.co.nz.