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Achilles tendon rupture/tear

Etiology: 1) trauma (see pathology) 2) risk factors a) poor conditioning b) advanced age c) fluoroquinolone antibiotics d) corticosteroids e) overexertion Epidemiology: - occur in all age groups & all levels of athletes - commly occur in men age 30-50 years who have had no previous injury or problem reported in the affected leg - the injured are typically 'weekend warriors' who are active intermittently - most Achilles tendon tears occur in the left leg; this may be related to handedness; right-handed individuals 'push off' more frequently with the left foot Pathology: - most tears occur ~2-6 cm above the calcaneal insertion of the tendon - most common mechanisms of injury include a) sudden forced plantar flexion of the foot b) unexpected dorsiflexion of the foot c) violent dorsiflexion of a plantar flexed foot - other mechanisms include a) direct trauma b) attrition of the tendon as a result of longstanding peritenonitis with or without tendinosis Clinical manifestations: - heel pain - often, the patient will feel as if they have been kicked in the ankle during walking or sport - may be a snap, followed by posterior ankle pain - patients often feel a mild to moderate pain at first with limited pain after a small period of time. - patients will continue to feel unstable - swelling and weakness in the back of the leg - inability to walk normally - impaired plantar flexion of the affected foot - weak dorsiflxion - inability to rise on the toes on the injured leg, if the tendon completely ruptured - Thompson test may be diagnostic Laboratory: - routine laboratory testing generally unnecessary Radiology: 1) plain radiographs a) more useful for ruling out other injuries than ruling in Achilles tendon ruptures b) may show soft-tissue swelling, increased ankle dorsiflexion on stress views, vascular or heterotopic calcifications, accessory ossicles, calcaneal fractures, Haglund deformity, or bony metaplasia 2) ultrasound can be used to determine the tendon thickness, character, & presence of a tear 3) magnetic resonance imaging (MRI) a) can discern incomplete ruptures from degeneration of the Achilles tendon b) can distinguish between paratenonitis, tendinosis, & bursitis c) not routinely indicated - history & physical examination sufficient in nearly all cases [5] - ultrasound sufficient for decisions of surgery vs medical management [5] Differential diagnosis: 1) ankle fracture 2) ankle sprain 3) calcaneofibular ligament injury 4) talofibular ligament injury 5) other disorders to consider a) Achilles tendinosis b) calcaneus bone injuries c) fascial tears d) gastrocnemius tear(medial head of the gastrocnemius) e) soleus tear f) inflammatory arthropathy g) inflammatory processes h) syndesmosis i) tennis leg (tear of the plantaris tendon) j) vascular injuries Management: 1) referral to podiatry/surgery 2) surgical repair for active patient a) 6-8 weeks with leg in a walking boot, cast, brace or splint b) to promote healing & to avoid stretching the surgical repair, the foot may initially be positioned in plantar flexion in the boot or brace, & then moved gradually to a neutral position c) decreased risk of rupture (2.3% vs 3.9%) [6] d) increased risk for complications (4.9% vs 1.6%) [6] 2) nonsurgical treatment a) a cast or walking boot allows the ends of the torn tendon to reattach themselves on their own b) a removable walking boot might be preferable to plaster casts [7] c) likelihood of re-rupture is higher with a nonsurgical approach, & recovery can take longer d) if re-rupture occurs, surgical repair may be more difficult 3) rehabilitation involving physical therapy to strengthen leg muscles & Achilles tendon 4) prognosis: - most people return to their former level of activity within 4-6 months - rerupture is more common with nonoperative management [8] - nerve injury is more common with surgery [8]

Related

Achilles/calcaneal/heel tendon (chorda magna, tendo calcaneus)

General

tendon rupture

References

  1. Achilles tendon rupture Mayo Clinic.com http://www.mayoclinic.com/health/achilles-tendon-rupture/DS00160
  2. Jacobs BA et al Achilles Tendon Rupture eMedicine http://emedicine.medscape.com/article/85024-overview
  3. Medical Knowledge Self Assessment Program (MKSAP) 14, 17, 18. American College of Physicians, Philadelphia 2006, 2015, 2018
  4. Soroceanu A, Sidhwa F, Aarabi S, Kaufman A, Glazebrook M. Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials. J Bone Joint Surg Am. 2012 Dec 5;94(23):2136-43. Review. PMID: 23224384 Free PMC Article
  5. American Podiatric Medical Association Five Things Physicians and Patients Should Question Choosing Wisely. August 1, 2017 http://www.choosingwisely.org/societies/american-podiatric-medical-association/
  6. Ochen Y, Beks RB, van Heijl M et al Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis. BMJ 2019;364:k5120 PMID: 30617123 Free full text https://www.bmj.com/content/364/bmj.k5120 - Maffulli N, Peretti GM Surgery or conservative management for Achilles tendon rupture? BMJ 2019;364:k5344 MID: 30617220 https://www.bmj.com/content/364/bmj.k5344 - Ochen Y, Heng M, Groenwold RHH, Houwert RM. Surgeons should know when not to operate The BMJ Opinion. Jan 7, 2019 Not indexed in PubMed https://blogs.bmj.com/bmj/2019/01/07/surgeons-should-know-when-not-to-operate/
  7. Costa ML et al. Plaster cast versus functional brace for non-surgical treatment of Achilles tendon rupture (UKSTAR): A multicentre randomised controlled trial and economic evaluation. Lancet 2020 Feb 8; 395:441. PMID: 32035553 Free PMC Article https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32942-3/fulltext - Maffulli N. Peretti GM. Treatment decisions for acute Achilles tendon ruptures. Lancet 2020 Feb 8; 395:397. PMID: 32035536 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)33133-2/fulltext
  8. Myhrvold SB et al. Nonoperative or surgical treatment of acute Achilles' tendon rupture. N Engl J Med 2022 Apr 14; 386:1409 PMID: 35417636 https://www.nejm.org/doi/10.1056/NEJMoa2108447