Welcome back to Mangled Mondays, where every Monday we talk about another facet of maiming, mangling, mauling, and mistreating your main characters — and all of their friends.
Today we’ll be talking about Severing the Achilles Tendon. For the rest of the Mangled Mondays series, [click here].
What Is It?
The Achilles tendon is named in honor of the mythical warrior Achilles, who was said to be dipped in the River Styx by the sea nymph Thetis, making him invulnerable to wounds. The one place in which he wasn’t invulnerable was the spot directly above his heel, where Thetis had held him for the magical dunking.
While the rest of us – and likely your characters – have no such benefit of magical armor, the weakness in the spot above the heel persists.
If you take your hand and feel the back of your leg just above the heel bone (the calcaneus if you’re feeling formal), you’ll feel a thick, ropey tendon that runs from your heel up into your calf and disappears under a mass of muscle.
This is the Achilles tendon. It’s extremely important in how your move your feet, which also means that severing it is a great way to disable your character. In fact, this and the hamstring were vulnerable attack points in ages of history when knives and swords were extremely popular weapons of war. This is because both injuries, while not necessarily lethal, put the enemy on the ground, where they could be dealt with in whatever manner the attacker chose.
In modern fighting, this might be a rarer injury, since combat with firearms is much more common. But there are plenty of ways in which it could happen, which we’ll go into below.
Severing the Achilles tendon is both painful and debilitating. Because the tendon is so deeply involved in the feet, the ability to walk is instantly removed, though ambulation with crutches is entirely possible.
These wounds also bleed significantly, and, if nearby blood vessels are damaged, can cause shock if not treated.
Finally, on a visceral level, these wounds are psychologically disruptive to see for two reasons. The first is that the foot will often simply flop and is at the mercy of gravity; the ability to control it is severely compromised, which can appear unnatural. The second is that the bone is very often exposed, along with tendons and muscles; this is a discomfiting sight.
The solution to both hemorrhage and appearance, then, is for a helpful character to dress and bandage the wound as soon as possible.
If the severed tendon is because of a tear due to rotation, neither of these psychological factors comes into play.
- If open, the laceration will be apparent and will allow a view deep into the foot.
- Bleeding, if the result of a laceration.
- If the result of a twisting injury, there will be a “bunching” of tendon beneath the skin.
- Inability to flex the foot. It may simply dangle loose at the end of the leg.
How Does It Happen?
A severed Achilles tendon, also known as a ruptured Achilles tendon, has two main causes.
The first is laceration. This can come from…
…an enemy sword, a bear trap, or a misplaced piece of broken glass that punctures the heel and enters the Achilles. A gunshot wound that passes through this part of the leg could also cause the tear, but so could a dog bite or careless use of a weed whacker.
The second is a twisting, or torsional, injury. This is a possible complication of your character turning their foot the wrong way. These injuries can occur in various sports, including football, basketball, mountaineering, rock climbing, etc. The foot could also become caught between two objects and be manipulated incorrectly in an attempt to free it; this could cause either an open wound (laceration) or a torsional wound as discussed above.
Less frequently, application of a lot of weight onto the ball of the foot with the heel raised can cause this injury, such as a parkour traceur’s or ballet dancer’s landing a leap or fall on one foot.
The first concern with an Achilles rupture that’s bleeding is to stop the bleeding. The foot has a large number of blood vessels, and the Achilles is fairly close to a pulse point in the side of the foot, so bleeding can be significant, though it’s unlikely that this will require a tourniquet. A good strong pressure dressing should control the bleeding in all but the worst of injuries.
The next step is to stabilize the ankle. A makeshift splint can be used for this, although a pillow can do nicely; the pillow is wrapped around the heel and foot and taped into a position that supports the ankle.
Side effects of blood loss and care for characters in shock are covered elsewhere in this book; the basics are to keep the character warm, establish IVs if possible, and to get them to a hospital.
Surgery / Hospitalization
The surgery to repair the Achilles tendon is often an emergent surgery, but it may not take place the same day as the injury, depending on the availability of surgical teams and operating rooms. (In fact, in older characters whose tendons have ruptured rather than lacerated, it may not take place at all; they may simply use a cast with the foot flexed and crutches for 6–8 weeks.)
Corrective surgery is of two types: either the ends of the tendon are sutured back into place using “purse-string” sutures, or a muscle from the calf is inverted and sewn into place in lieu of the existing tendon.
The surgery should be fairly short, about two hours, and can be done under general anesthesia or under a nerve block and epidural.
After surgery the leg will be splinted and cast to prevent movement; this will come off in about 6 weeks.
In the Austere Environment
Without good medical care, the character will be crippled by this injury, particularly if the tendon is lacerated.
Inability to use the foot is a significant problem. It increases stress on the opposite leg, and the character will require crutches or a wheelchair in order to get around. In environments that aren’t mobility friendly, this can be an especially difficult challenge.
If the wound is open, the standard risks of infection are also around, and the character will be running the dangers of having an open wound. (This kind of injury can be sewn up without suturing the underlying muscle damage, but only after being well cleaned.)
The Rocky Road to Recovery
Use of the knee on the same side — the ipsilateral knee – will remain intact. Neurocognitive function and the use of all other limbs will be unaffected by a ruptured Achilles.
Characters will be unable to walk for several weeks after the injury. This lack of walking will make the characters’ leg feel tight and may be painful. Crutches may be employed if the other leg is weight-bearing.
While characters may return to their normal levels of activity, understand that there can be lasting damage that could affect the character when running, climbing stairs, riding a bicycle, etc. While they will walk, they may not walk with the same gait as before and might limp.
However, a perfect recovery is also not an unreasonable outcome.
Features of Recovery: Hospital Stay
The surgery will likely be done on the 1st or 2nd day of admission, and the character will likely be sent home on the 3rd or 4th day. After surgery their leg will be elevated on a pillow. They’ll be given painkillers (probably a short course of a midlevel opiate like oxycodone), antiinflammatories (acetaminophen), and sent home with the same.
Features of Recovery: PT/OT
Physical therapy will be on an outpatient basis unless the character has problems with both legs, making use of a wheelchair impossible.
Once the cast comes off (about 6 weeks after the injury) and is replaced with a softer Aircast, the character will be encouraged to stretch and to begin strengthening the tendon. Weight bearing can begin at +/– 8 weeks, which can progress to walking at about 10 weeks.
The New Normal
As discussed above, characters may have a limp or trouble with certain types of weight-bearing activity.
Generally speaking, characters are back to their full capabilities within 4–6 months, but they’ll likely have a surgical scar on the back of the heel, at the tendon.
As with most injuries, reinjury tends to be more damaging and take longer to recover from than the original injury.
Total Recovery Time (Typical)
The back of the leg, when open, will reveal the ends of muscles and tendons.
When closed, characters may see a “lump” in the back of the leg below the calf muscle.
If the Achilles ruptures rather than being lacerated, the character will feel as though someone kicked them in the back of the ankle, and they will both feel and hear a dull pop or thud.
The Thompson test is a test for a ruptured Achilles, where a provider will squeeze both calf muscles while the character lies on their stomach. The foot of the healthy leg will wiggle a bit; the foot of the injured leg will not.
- Severing the Achilles tendon is a great way for one character to disable another, preventing walking (and therefore escape or some forms of combat).
- The surgery to repair the tendon is quick (2 hours), but recovery is slow (4–6 months to full rehabilitation).
- Characters will use crutches as their primary mobility aid unless the injury is bilateral or the other leg is compromised, in which case a wheelchair will be used.
xoxo, Aunt Scripty
This post is an excerpt from Blood on the Page Volume One: A Writer’s Compendium of Injuries. The book details thirty-one injuries with which to maim, mangle, and maul your characters, as well as nine indispensable articles of Wound Wisdom covering everything from burn stages to suture selection.