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Zeeshan S. Husain, DPM

Charles G. Kissel, DPM

Michael S. Schey, DPM

Board certified by the 
American Board of 
Podiatric Surgery.


Fractures

Fractures and Tendon Ruptures

Subtopics

  1. Toe and Metatarsal Fractures

  2. Fifth Metatarsal Fractures

  3. LisFranc Injuries

  4. Calcaneal Fractures

  5. Ankle Fractures

  6. Achilles Ruptures

 

1. Toe and Metatarsal Fractures

The structure of your foot is complex, consisting of bones, muscles, tendons, and other soft tissues.  Of the 26 bones in your foot, 19 are toe bones (phalanges) and metatarsal bones (the long bones in the midfoot).  Fractures of the toe and metatarsal bones are common and require evaluation by a specialist.  A podiatric foot and ankle surgeon should be seen for proper diagnosis and treatment, even if initial treatment has been received in an emergency room.

What Is a Fracture?

A fracture is a break in the bone.  Fractures can be divided into two categories: traumatic fractures and stress fractures.

Traumatic fractures (also called acute fractures) are caused by a direct blow or impact like seriously stubbing your toe.  Traumatic fractures can be displaced or non-displaced.   If the fracture is displaced, the bone is broken in such a way that it has changed in position (dislocated).  Treatment of a traumatic fracture depends on the location and extent of the break and whether it is displaced.  Surgery is sometimes required.  Signs and symptoms of a traumatic fracture include:

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You may hear a sound at the time of the break.

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“Pinpoint pain” (pain at the place of impact) at the time the fracture occurs and perhaps for a few hours later, but often the pain goes away after several hours.

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Deviation (misshapen or abnormal appearance) of the toe.

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Bruising and swelling the next day.

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It is not true that “if you can walk on it, it is not broken”.  Evaluation by the podiatric surgeon is always recommended.

Stress fractures are tiny, hairline breaks that are usually caused by repetitive stress.   Stress fractures often afflict athletes who, for example, too rapidly increase their running mileage.  Or they may be caused by an abnormal foot structure, deformities, or osteoporosis.  Improper footwear may also lead to stress fractures.  Stress fractures should not be ignored, because they will come back unless properly treated.  Symptoms of stress fractures include:

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Pain with or after normal activity

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Pain that goes away when resting and then returns when standing or during activity

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“Pinpoint pain” (pain at the site of the fracture) when touched

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Swelling, but no bruising

Sprains and fractures have similar symptoms, although sometimes with a sprain, the whole area hurts rather than just one point.  Your podiatric surgeon will be able to diagnose which you have and provide appropriate treatment.  Certain sprains or dislocations can be severely disabling.  Without proper treatment they can lead to crippling arthritis.

Consequences of Improper Treatment

Some people say that “the doctor cannot do anything for a broken bone in the foot”.  This is usually not true.  In fact, if a fractured toe or metatarsal bone is not treated correctly, serious complications may develop.  For example:

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A deformity in the bony architecture which may limit the ability to move the foot or cause difficulty in fitting shoes

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Arthritis, which may be caused by a fracture in a joint (the juncture where two bones meet), or may be a result of angular deformities that develop when a displaced fracture is severe or has not been properly corrected

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Chronic pain and long-term dysfunction

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Non-union, or failure to heal, can lead to subsequent surgery or chronic pain.

Treatment of Toe Fractures

Fractures of the toe bones are almost always traumatic fractures.  Treatment for traumatic fractures depends on the break itself and may include these options:

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Rest— Sometimes rest is all that is needed to treat a traumatic fracture of the toe.

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SplintingThe toe may be fitted with a splint to keep it in a fixed position.

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Rigid or stiff-soled shoeWearing a stiff-soled shoe protects the toe and helps keep it properly positioned.

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“Buddy taping” Wrap the fractured toe to another toe is sometimes appropriate, but in other cases it may be harmful.

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SurgeryIf the break is badly displaced or if the joint is affected, surgery may be necessary.  Surgery often involves the use of fixation devices, such as screws, plates, and pins.

Treatment of Metatarsal Fractures

Breaks in the metatarsal bones may be either stress or traumatic fractures.  Certain kinds of fractures of the metatarsal bones present unique challenges.  For example, sometimes a fracture of the first metatarsal bone (behind the big toe) can lead to arthritis.  Since the big toe is used so frequently and bears more weight than other toes, arthritis in that area can make it painful to walk, bend, or even stand.

Another type of break, called a Jones’ fracture, occurs at the base of the fifth metatarsal bone (behind the little toe).  It is often misdiagnosed as an ankle sprain, and misdiagnosis can have serious consequences since sprains and fractures require different treatments.  Your podiatric surgeon is an expert in correctly identifying these conditions as well as other problems of the foot.

Treatment of metatarsal fractures depends on the type and extent of the fracture, and may include:

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Rest Sometimes rest is the only treatment needed to promote healing of a stress or traumatic fracture of a metatarsal bone.

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Avoid the offending activityBecause stress fractures result from repetitive stress, it is important to avoid the activity that led to the fracture.  Crutches or a wheelchair are sometimes required to offload weight from the foot to give it time to heal.

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Immobilization, casting, or rigid shoe— A stiff-soled shoe or other form of immobilization may be used to protect the fractured bone while it is healing.

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Surgery Some traumatic fractures of the metatarsal bones require surgery, especially if the break is badly displaced.

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Follow-up care Your podiatric foot and ankle surgeon will provide instructions for care following surgical or non-surgical treatment.  Physical therapy, exercises, and rehabilitation may be included in a schedule for return to normal activities.

 

2. Fifth Metatarsal Fracture (top)

Fractures (breaks) are common in the fifth metatarsal which is the long bone on the outside of the foot that connects to the little toe.  Two types of fractures that often occur in the fifth metatarsal are:

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Avulsion fracture In an avulsion fracture, a small piece of bone is pulled off the main portion of the bone by a tendon or ligament.  This type of fracture is the result of an inversion injury, in which the ankle rolls inward.  Avulsion fractures are often overlooked when they occur with an ankle sprain.

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Jones’ fracture Jones’ fractures occur in a small area of the fifth metatarsal that receives less blood and is therefore more prone to injury. A Jones’ fracture can be either a stress fracture (a tiny hairline break that occurs over time) or an acute (sudden) break.  Jones’ fractures are caused by overuse, repetitive stress, or trauma.  They are less common and more difficult to treat than avulsion fractures.

Other types of fractures can occur in the fifth metatarsal.  Examples include mid-shaft fractures, which usually result from trauma or twisting, and fractures of the metatarsal head and neck.

Signs and Symptoms

Avulsion and Jones’ fractures have the same signs and symptoms.  These include:

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Pain, swelling, and tenderness on the outside of the foot

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Difficulty walking

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Bruising may occur

Diagnosis

Anyone who has symptoms of a fifth metatarsal fracture should see a foot and ankle surgeon as soon as possible for proper diagnosis and treatment.  To arrive at a diagnosis, the surgeon will ask how the injury occurred or when the pain started.  The foot will be examined, with the doctor gently pressing on different areas of the foot to determine where there is pain.

The surgeon will also order x-rays.  Because a Jones’ fracture sometimes does not show up on initial x-rays, additional imaging studies may be needed.

Treatment

When it is not possible to see a foot and ankle surgeon immediately, the “R-I-C-E” method of care should be performed. This involves:

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Rest It is crucial to stay off the injured foot, since walking can cause further damage.

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Ice To reduce swelling and pain, apply a bag of ice over a thin towel to the affected area for 20 minutes of each waking hour.  Do not put the ice directly against the skin.

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CompressionWrap the foot in an elastic bandage or wear a compression stocking to prevent further swelling.

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Elevation Keep the foot elevated to reduce the swelling.  It should be even with or slightly above the hip level.

Options for treatment of an avulsion fracture may include:

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ImmobilizationDepending on the severity of the injury, the foot is kept immobile with a cast, cast boot, or stiff-soled shoe.  Crutches may also be needed to avoid placing weight on the injured foot.

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SurgeryIf the injury involves a displaced bone, multiple breaks, or has failed to adequately heal, surgery may be needed.

Options for treatment of a Jones’ fracture may include:

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ImmobilizationAs with avulsion fractures, initial treatment may involve immobilization, but typically for a longer period of time because these fractures take longer to heal.

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Bone stimulationA pain-free external device is used to speed the healing of some fractures.  Bone stimulation may be used as part of the treatment or following an inadequate response to immobilization.

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Surgery Surgery may be needed, since Jones’ fractures often do not heal through immobilization and bone stimulation.  If surgery is required for treatment of a fifth metatarsal fracture, the foot and ankle surgeon will determine the type of procedure that is best suited to the individual patient.

 

3. Lisfranc Injuries (top)

The Lisfranc joint is the point at which the metatarsal bones (long bones that lead up to the toes) and the tarsal bones (bones in the arch) connect.  The Lisfranc ligament is a tough band of tissue that joins two of these bones.  It is important for maintaining proper alignment and strength of this joint.

How do Lisfranc Injuries Occur?

Injuries to the Lisfranc joint most commonly occur in automobile accident victims, military personnel, runners, horseback riders, football players, and participants of other contact sports.  Lisfranc injuries occur as a result of direct or indirect forces to the foot.

A direct force often involves something heavy falling on the foot.  Indirect force commonly involves twisting the foot.  This can happen, for example, when the foot catches on a stirrup while falling from a horse.

Types of Lisfranc Injuries

There are three types of Lisfranc injuries, which sometimes occur together:

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Sprains The Lisfranc ligament, as well as other ligaments on the bottom of the midfoot, are stronger than the ligaments on the top of the midfoot.  Therefore, when they are weakened through a sprain (a stretching of the ligament), patients experience instability of the joint in the middle of the foot.

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FracturesA break in a bone in the Lisfranc joint can be either an avulsion fracture (a small piece of bone is pulled off) or a break through the bone or bones of the midfoot.

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Dislocations The bones of the Lisfranc joint may be forced from their normal positions.

Signs and Symptoms

The signs and symptoms of a Lisfranc injury may include:

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Swelling of the foot

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Pain throughout the midfoot when standing or when pressure is applied

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Inability to bear weight (in severe injuries)

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Bruising or blistering on the arch which is an important sign of a Lisfranc injury.  Bruising may also occur on the top of the foot

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Abnormal widening of the foot

Diagnosis

Lisfranc injuries are sometimes mistaken for ankle sprains, making the diagnostic process very important.  To arrive at a diagnosis, the foot and ankle surgeon will ask how the injury occurred.  The surgeon will examine the foot and determine the severity of the injury.

X-rays and other imaging studies, such as a CT or MRI, may be necessary to fully evaluate the extent of the injury.  The surgeon may also perform an additional examination while the patient is under anesthesia to further evaluate a fracture or weakening of the joint and surrounding bones.

Treatment

Anyone who has symptoms of a Lisfranc injury should see a foot and ankle surgeon right away.  If unable to do so immediately, it is important to stay off the injured foot, keep it elevated (at or slightly above hip level), and apply a bag of ice wrapped in a thin towel to the area every 20 minutes of each waking hour.  These steps will help keep the swelling and pain under control.

Treatment by the foot and ankle surgeon may include one or more of the following, depending on the type and severity of the Lisfranc injury:

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Immobilization Sometimes the foot is placed in a cast to keep it immobile, and crutches are used to avoid putting weight on the injured foot.

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Oral medications Non-steroidal anti-inflammatory medications (NSAID), such as ibuprofen, help reduce the pain and inflammation.

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Ice and elevation Swelling is reduced by icing the affected area and keeping the foot elevated, as described above.

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Physical therapyAfter the swelling and pain have subsided, physical therapy may be prescribed.

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SurgeryMost types of Lisfranc injuries require surgery.

The foot and ankle surgeon will determine the type of procedure that is best suited to the individual patient.  Some injuries of this type may require emergency surgery.

Complications of Lisfranc Injuries

Complications can and often do arise following Lisfranc injuries.  A possible early complication following the injury is compartment syndrome, in which pressure builds up within the tissues of the foot, requiring immediate surgery to prevent tissue damage.  A build-up of pressure could damage the nerves, blood vessels, and muscles in the foot.

Arthritis and problems with foot alignment may develop.  In most cases, arthritis develops several months or longer following a Lisfranc injury, requiring additional treatment.

 

4. Calcaneal Fractures (top)

The calcaneus, also called the heel bone, is a large bone that forms the foundation of the rear part of the foot.  The calcaneus connects with the talus and cuboid bones.  The connection between the talus and calcaneus forms the subtalar joint.  This joint is important for normal foot function.

The calcaneus is often compared to a hard-boiled egg, because it has a thin, hard shell on the outside and softer, spongy bone on the inside.  When the outer shell is broken, the bone tends to collapse and become fragmented.  For this reason, calcaneal fractures are severe injuries.  Furthermore, if the fracture involves the joints, there is the potential for long-term consequences such as arthritis and chronic pain.

How do Calcaneal Fractures Occur?

Most calcaneal fractures are the result of a traumatic event, most commonly falling from a height, such as a ladder, or being in an automobile accident where the heel is crushed against the floorboard.  Calcaneal fractures can also occur with other types of injuries, such as an ankle sprain.  A smaller number of calcaneal fractures are stress fractures, caused by overuse or repetitive stress on the heel bone.

Types of Calcaneal Fractures

Fractures of the calcaneus may or may not involve the subtalar and surrounding joints.  Fractures involving the joints (intra-articular fractures) are the most severe calcaneal fractures, and include damage to the cartilage (the connective tissue between two bones).   The outlook for recovery depends on how severely the calcaneus was crushed at the time of injury. 

Fractures that do not involve the joint (extra-articular fractures) include:

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Those caused by trauma, such as avulsion fractures (in which a piece of bone is pulled off of the calcaneus by the Achilles tendon or a ligament) or crush injuries resulting in multiple fracture fragments.

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Stress fractures caused by overuse or mild injury.  The severity and treatment of extra-articular fractures depend on their location and size.

Signs and Symptoms

Calcaneal fractures produce different signs and symptoms, depending on whether they are traumatic or stress fractures.  The signs and symptoms of traumatic fractures may include:

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Sudden pain in the heel and inability to bear weight on that foot

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Swelling in the heel area

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Bruising of the heel and ankle

The signs and symptoms of stress fractures may include:

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Generalized pain in the heel area that usually develops slowly (over several days to weeks)

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Swelling in the heel area

Diagnosis

To diagnose and evaluate a calcaneal fracture, the foot and ankle surgeon will ask questions about how the injury occurred, examine the affected foot and ankle, and order x-rays.  In addition, advanced imaging tests are commonly required.

Treatment

Treatment of calcaneal fractures is dictated by the type of fracture and extent of the injury.  The foot and ankle surgeon will discuss with the patient the best treatment whether surgical or non-surgical for the fracture.

For some fractures, non-surgical treatments may be used.  These include:

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Rest, ice, compression, and elevation (R-I-C-E)Rest (staying off the injured foot) is needed to allow the fracture to heal.  Ice reduces swelling and pain; apply a bag of ice covered with a thin towel to the affected area.  Compression (wrapping the foot in an elastic bandage or wearing a compression stocking) and Elevation (keeping the foot even with or slightly above the heart level) also reduce the swelling.

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Immobilization Sometimes the foot is placed in a cast or cast boot to keep the fractured bone from moving.  Crutches may be needed to avoid weightbearing

For traumatic fractures, treatment often involves surgery to reconstruct the joint, or in severe cases, to fuse the joint.  The surgeon will choose the best surgical approach for the patient.

Rehabilitation

Whether the treatment for a calcaneal fracture has been surgical or non-surgical, physical therapy often plays a key role in regaining strength and restoring function.

Complications of Calcaneal Fractures

Calcaneal fractures can be serious injuries that may produce lifelong problems.  Arthritis, stiffness, and pain in the joint frequently develop.  Sometimes the fractured bone fails to heal in the proper position.  Other possible long-term consequences of calcaneal fractures are decreased ankle motion and walking with a limp due to collapse of the heel bone and loss of length in the leg.  Patients often require additional surgery and/or long term or permanent use of a brace or an orthotic device (arch support) to help manage these complications.

 

5. Ankle Fractures (top)

A fracture is a partial or complete break in a bone.  In the ankle, fractures can range from the less serious avulsion injuries (small pieces of bone that have been pulled off) to severe shattering-type breaks of the tibia, fibula, or both.

Ankle fractures are common injuries that are most often caused by the ankle rolling inward or outward.  Many people mistake an ankle fracture for an ankle sprain, but they are quite different and therefore require an accurate and early diagnosis. They sometimes occur simultaneously.

Signs and Symptoms

An ankle fracture is accompanied by one or all of these signs and symptoms:

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Pain at the site of the fracture, which in some cases can extend from the foot to the knee

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Significant swelling, which may occur along the length of the leg or may be more localized

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Blisters may occur over the fracture site.  These should be promptly treated by your surgeon.

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Bruising, which develops soon after the injury

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Inability to walk, however, it is possible to walk with less severe breaks, so never rely on walking as a test of whether a bone has been fractured

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Change in the appearance of the ankle so that it differs from the other ankle

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Bone protruding through the skin a sign that immediate care is needed!  Fractures that pierce the skin require immediate attention because they can lead to severe infection and prolonged recovery.

What to Do

Following an ankle injury it is important to have the ankle evaluated by a foot and ankle surgeon for proper diagnosis and treatment.  If you are unable to do so right away, go to the emergency room and then follow up with a foot and ankle surgeon as soon as possible for a more thorough assessment.

Until you are able to be examined by a doctor, the “R-I-C-E” principle should be followed.  This involves:

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Rest— It is crucial to stay off the injured foot, since walking can cause further damage.

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IceTo reduce swelling and pain, apply a bag of ice over a thin towel to the affected area for 20 minutes of each waking hour.  Do not put ice directly against the skin.

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CompressionWrap the ankle in an elastic bandage or wear a compression stocking to prevent further swelling.

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Elevation Keep the foot elevated to reduce the swelling.  It should be even with or slightly above the hip level.

Diagnosis

The foot and ankle surgeon will examine the affected limb, touching specific areas to evaluate the injury.  In addition, the surgeon may order x-rays and other imaging studies, as necessary.

Treatment

Treatment of ankle fractures depends upon the type and severity of the injury.  Options include:

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Immobilization Certain fractures are treated by protecting and restricting the ankle and foot in a cast or splint.  This allows the bone to heal.

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Prescription medicationsTo help relieve the pain, the surgeon may prescribe pain medications or anti-inflammatory drugs.

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Surgery For some injuries, surgery is needed to repair the fracture and other related injuries, if present.  The foot and ankle surgeon will select the procedure that is appropriate for your injury.

Follow-up Care

It is important to follow your surgeon’s instructions after treatment.  Failure to do so can lead to infection, deformity, arthritis, and chronic pain.

 

6. Achilles Rupture (top)

A tendon is a band of tissue that connects a muscle to a bone.  The Achilles tendon runs down the back of the lower leg and connects the calf muscle to the heel bone.  Also called the “heel cord”, the Achilles tendon facilitates walking by helping to raise the heel off the ground.

What is an Achilles Tendon Rupture?

An Achilles tendon rupture is a complete or partial tear that occurs when the tendon is stretched beyond its capacity.  Forceful jumping or pivoting, or sudden accelerations of running, can overstretch the tendon and cause a tear.  An injury to the tendon can also result from falling or tripping.

Achilles tendon ruptures are most often seen in “weekend warriors” who are typically, middle-aged people participating in sports in their spare time.  Less commonly, illness or medications, such as steroids or certain antibiotics, may weaken the tendon and contribute to ruptures.

Signs and Symptoms

A person with a ruptured Achilles tendon may experience one or more of the following:

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Sudden pain (which feels like a kick or a stab) in the back of the ankle or calf often subsiding into a dull ache

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A popping or snapping sensation

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Swelling on the back of the leg between the heel and the calf

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Difficulty walking (especially upstairs or uphill) and difficulty rising up on the toes

These symptoms require prompt medical attention to prevent further damage.  Until the patient is able to see a doctor, the “R-I-C-E” method should be used.  This involves:

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Rest— Stay off the injured foot and ankle, since walking can cause pain or further damage.

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IceApply a bag of ice covered with a thin towel to reduce swelling and pain. Do not put ice directly against the skin.

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CompressionWrap the foot and ankle in an elastic bandage to prevent further swelling.

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ElevationKeep the leg elevated to reduce the swelling.  It should be even with or slightly above heart level.

Diagnosis

In diagnosing an Achilles tendon rupture, the foot and ankle surgeon will ask questions about how and when the injury occurred and whether the patient has previously injured the tendon or experienced similar symptoms.  The surgeon will examine the foot and ankle, feeling for a defect in the tendon that suggests a tear.  Range of motion and muscle strength will be evaluated and compared to the uninjured foot and ankle.  If the Achilles tendon is ruptured, the patient will have less strength in pushing down (as on a gas pedal) and will have difficulty rising on the toes.

The diagnosis of an Achilles tendon rupture is typically straightforward and can be made through this type of examination.  In some cases, however, the surgeon may order an MRI or other advanced imaging tests.

Treatment

Treatment options for an Achilles tendon rupture include surgical and non-surgical approaches.  The decision of whether to proceed with surgery or non-surgical treatment is based on the severity of the rupture and the patient’s health status and activity level.

Conservative Treatment

Non-surgical treatment, which is generally associated with a higher rate of re-rupture, is selected for minor ruptures, less active patients, and those with medical conditions that prevent them from undergoing surgery.  Non-surgical treatment involves use of a cast, walking boot, or brace to restrict motion and allow the torn tendon to heal.

Surgical Treatment

Surgery offers important potential benefits.  Besides decreasing the likelihood of re-rupturing the Achilles tendon, surgery often increases the patient’s push-off strength and improves muscle function and movement of the ankle.

Various surgical techniques are available to repair the rupture.  The surgeon will select the procedure best suited to the patient.  Following surgery, the foot and ankle are initially immobilized in a cast or walking boot.  The surgeon will determine when the patient can begin weightbearing.  Complications such as incision healing difficulties, re-rupture of the tendon, or nerve pain can arise after surgery.

Physical Therapy

Whether an Achilles tendon rupture is treated surgically or conservatively, physical therapy is an important component of the healing process.  Physical therapy involves exercises that strengthen the muscles and improve the range of motion of the foot and ankle.

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Rochester Center For Foot & Ankle Surgery
248-651-0162
Crittenton Medical Building
1135 West University Drive, Suite 305
Rochester, Michigan 48307

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