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{{short description|Medical condition were the tendon at the back of the ankle breaks}} {{short description|Medical condition where the tendon at the back of the ankle breaks}}
{{Infobox medical condition (new) {{Infobox medical condition (new)
| name = Achilles tendon rupture | name = Achilles tendon rupture
| synonyms = Achilles tendon tear,<ref name=Mer2017/> Achilles rupture<ref name=BMJ2018/> | synonyms = Achilles tendon tear,<ref name=Mer2017/> Achilles rupture<ref name=BMJ2018/>
| image = achilles-tendon.jpg | image = Achilles Tendon Tear.png
| caption = The achilles tendon | caption = The achilles tendon
| pronounce = | pronounce =
| field = ], ] | field = ], ]
| symptoms = Pain in the heel<ref name=Hub2018/> | symptoms = Pain in the heel<ref name=Hub2018/>
| complications = | complications =
| onset = Sudden<ref name=Hub2018/> | onset = Sudden<ref name=Hub2018/>
| duration = | duration =
| types = | types =
| causes = Forced ] of the foot, direct ], long-standing ]<ref name=Gos2018/> | causes = Forced ] of the foot, direct ], long-standing ]<ref name=Gos2018/>
| risks = ], significant change in exercise, ], ], ]s<ref name=Mer2017/><ref name=Fer2016/> | risks = ], significant change in exercise, ], ], ]s<ref name=Mer2017/><ref name=Fer2016/>
| diagnosis = Based on symptoms and ], supported by ]<ref name=Fer2016/> | diagnosis = Based on symptoms and ], supported by ]<ref name=Fer2016/>
| differential = ], ], ] of the ]<ref name=Fer2016/> | differential = ], ], ] of the ]<ref name=Fer2016/>
| prevention = | prevention =
| treatment = ] or surgery<ref name=El2018/><ref name=Fer2016/> | treatment = ] or surgery<ref name=El2018/><ref name=Fer2016/>
| medication = | medication =
| prognosis = | prognosis =
| frequency = 1 per 10,000 people per year<ref name=Fer2016/> | frequency = 1 per 10,000 people per year<ref name=Fer2016/>
| deaths = | deaths =
}} }}
<!-- Definition and symptoms --> <!-- Definition and symptoms -->
'''Achilles tendon rupture''' is when the ], at the back of the ], breaks.<ref name=Fer2016/> Symptoms include the sudden onset of sharp pain in the ].<ref name=Hub2018>{{cite journal | vauthors = Hubbard MJ, Hildebrand BA, Battafarano MM, Battafarano DF | title = Common Soft Tissue Musculoskeletal Pain Disorders | journal = Primary Care | volume = 45 | issue = 2 | pages = 289–303 | date = June 2018 | pmid = 29759125 | doi = 10.1016/j.pop.2018.02.006 | s2cid = 46886582 }}</ref> A snapping sound may be heard as the tendon breaks and walking becomes difficult.<ref name=Gos2018>{{cite journal | vauthors = Shamrock AG, Varacallo M | title = Achilles Tendon, Rupture | journal = StatPearls | date = January 2018 | pmid = 28613594 }}</ref> '''Achilles tendon rupture''' is when the ], at the back of the ], breaks.<ref name=Fer2016/> Symptoms include the sudden onset of sharp pain in the ].<ref name=Hub2018>{{cite journal | vauthors = Hubbard MJ, Hildebrand BA, Battafarano MM, Battafarano DF | title = Common Soft Tissue Musculoskeletal Pain Disorders | journal = Primary Care | volume = 45 | issue = 2 | pages = 289–303 | date = June 2018 | pmid = 29759125 | doi = 10.1016/j.pop.2018.02.006 | s2cid = 46886582 }}</ref> A snapping sound may be heard as the tendon breaks and walking becomes difficult.<ref name=Gos2018>{{cite journal | vauthors = Shamrock AG, Varacallo M | title = Achilles Tendon, Rupture | journal = StatPearls | date = January 2018 | pmid = 28613594 }}</ref>


<!-- Cause and diagnosis --> <!-- Cause and diagnosis -->
Line 30: Line 30:


<!-- Prevention and treatment --> <!-- Prevention and treatment -->
Prevention may include stretching before activity.<ref name=Gos2018/> Treatment may be by surgery repair or ] with the toes somewhat ].<ref name=El2018>{{cite journal | vauthors = El-Akkawi AI, Joanroy R, Barfod KW, Kallemose T, Kristensen SS, Viberg B | title = Effect of Early Versus Late Weightbearing in Conservatively Treated Acute Achilles Tendon Rupture: A Meta-Analysis | journal = The Journal of Foot and Ankle Surgery | volume = 57 | issue = 2 | pages = 346–352 | date = March 2018 | pmid = 28974345 | doi = 10.1053/j.jfas.2017.06.006 | s2cid = 3506883 }}</ref><ref name=BMJ2018>{{cite journal | vauthors = Ochen Y, Beks RB, van Heijl M, Hietbrink F, Leenen LP, van der Velde D, Heng M, van der Meijden O, Groenwold RH, Houwert RM | display-authors = 6 | title = Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis | journal = BMJ | volume = 364 | pages = k5120 | date = January 2019 | pmid = 30617123 | pmc = 6322065 | doi = 10.1136/bmj.k5120 }}</ref> Relatively rapid return to weight bearing (within 4 weeks) appears okay.<ref name=El2018/><ref>{{cite journal | vauthors = van der Eng DM, Schepers T, Goslings JC, Schep NW | title = Rerupture rate after early weightbearing in operative versus conservative treatment of Achilles tendon ruptures: a meta-analysis | journal = The Journal of Foot and Ankle Surgery | volume = 52 | issue = 5 | pages = 622–8 | date = 2012 | pmid = 23659914 | doi = 10.1053/j.jfas.2013.03.027 }}</ref> While surgery traditionally results in a small decrease in the risk of re-rupture, the risk of other complications is greater.<ref name=BMJ2018/> Additionally rapid rehabilitation may remove this difference in ruptures.<ref name=BMJ2018/> If appropriate treatment does not occur within 4 weeks of the injury outcomes are not as good.<ref>{{cite journal | vauthors = Maffulli N, Ajis A | title = Management of chronic ruptures of the Achilles tendon | journal = The Journal of Bone and Joint Surgery. American Volume | volume = 90 | issue = 6 | pages = 1348–60 | date = June 2008 | pmid = 18519331 | doi = 10.2106/JBJS.G.01241 }}</ref> Prevention may include stretching before activity and gradual progression of exercise intensity.<ref name=Gos2018/> Treatment may consist of surgical repair or conservative management.<ref name=El2018>{{cite journal | vauthors = El-Akkawi AI, Joanroy R, Barfod KW, Kallemose T, Kristensen SS, Viberg B | title = Effect of Early Versus Late Weightbearing in Conservatively Treated Acute Achilles Tendon Rupture: A Meta-Analysis | journal = The Journal of Foot and Ankle Surgery | volume = 57 | issue = 2 | pages = 346–352 | date = March 2018 | pmid = 28974345 | doi = 10.1053/j.jfas.2017.06.006 | s2cid = 3506883 }}</ref><ref name=BMJ2018>{{cite journal | vauthors = Ochen Y, Beks RB, van Heijl M, Hietbrink F, Leenen LP, van der Velde D, Heng M, van der Meijden O, Groenwold RH, Houwert RM | display-authors = 6 | title = Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis | journal = BMJ | volume = 364 | pages = k5120 | date = January 2019 | pmid = 30617123 | pmc = 6322065 | doi = 10.1136/bmj.k5120 }}</ref> Quick return to weight bearing (within 4 weeks) appears acceptable and is often recommended.<ref name=El2018/><ref>{{cite journal | vauthors = van der Eng DM, Schepers T, Goslings JC, Schep NW | title = Rerupture rate after early weightbearing in operative versus conservative treatment of Achilles tendon ruptures: a meta-analysis | journal = The Journal of Foot and Ankle Surgery | volume = 52 | issue = 5 | pages = 622–628 | date = 2012 | pmid = 23659914 | doi = 10.1053/j.jfas.2013.03.027 }}</ref> While surgery traditionally results in a small decrease in the risk of re-rupture, the risk of other complications is greater.<ref name=BMJ2018/> Non-surgical treatment is an alternative as there is supporting evidence that rerupture rates and satisfactory outcomes are comparable to surgery.<ref name=BMJ2018/> If appropriate treatment does not occur within 4 weeks of the injury outcomes are not as good.<ref>{{cite journal | vauthors = Maffulli N, Ajis A | title = Management of chronic ruptures of the Achilles tendon | journal = The Journal of Bone and Joint Surgery. American Volume | volume = 90 | issue = 6 | pages = 1348–1360 | date = June 2008 | pmid = 18519331 | doi = 10.2106/JBJS.G.01241 }}</ref>


<!-- Epidemiology and history --> <!-- Epidemiology and history -->
Achilles tendon rupture occurs in about 1 per 10,000 people per year.<ref name=Fer2016>{{cite book |last1=Ferri |first1=Fred F. | name-list-style = vanc |title=Ferri's Clinical Advisor 2016 E-Book: 5 Books in 1 |date=2015 |publisher=Elsevier Health Sciences |isbn=9780323378222 |page=19 |url=https://books.google.com/books?id=bbLSCQAAQBAJ&pg=PA19 |language=en}}</ref> Males are more commonly affected than females.<ref name=Mer2017/> People in their 30s to 50s are most commonly affected.<ref name=Fer2016/> Achilles tendon rupture occurs in about 1 per 10,000 people per year.<ref name=Fer2016>{{cite book | vauthors = Ferri FF |title=Ferri's Clinical Advisor 2016 E-Book: 5 Books in 1 |date=2015 |publisher=Elsevier Health Sciences |isbn=9780323378222 |page=19 |url=https://books.google.com/books?id=bbLSCQAAQBAJ&pg=PA19 |language=en}}</ref> Males are more commonly affected than females.<ref name=Mer2017/> People in their 30s to 50s are most commonly affected.<ref name=Fer2016/>


==Signs and symptoms== ==Signs and symptoms==
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==Causes== ==Causes==
The Achilles tendon is most often injured by sudden downward or upward movement of the foot. Or by forced upward flexion of the foot outside its normal range of motion.<ref>Shamrock AG, Varacallo M (January 2018). "Achilles Tendon, Rupture". ''StatPearls''. ] 28613594</ref> The Achilles tendon is most often injured by sudden downward or upward movement of the foot, or by forced upward flexion of the foot outside its normal range of motion.<ref>Shamrock AG, Varacallo M (January 2018). "Achilles Tendon, Rupture". ''StatPearls''. ] 28613594</ref> Other ways the Achilles tendon can be torn involve sudden direct trauma or damage to the tendon, or sudden use of the Achilles after prolonged periods of inactivity, such as bed rest or leg injury. Some other common tears can happen from intense sports overuse. Twisting or jerking motions can also contribute to injury.<ref name="Gos2018" /> Some antibiotics, such as ], may increase the risk of tendon injury or rupture. These antibiotics are known as ].<ref name=":0">{{cite journal | vauthors = Bidell MR, Lodise TP | title = Fluoroquinolone-Associated Tendinopathy: Does Levofloxacin Pose the Greatest Risk? | journal = Pharmacotherapy | volume = 36 | issue = 6 | pages = 679–693 | date = June 2016 | pmid = 27138564 | doi = 10.1002/phar.1761 | s2cid = 206359106 }}</ref> As of 2016 the mechanism through which fluoroquinolones cause this was unclear.<ref name=":0" />


Many people may develop an Achilles rupture or tear, such as recreational athletes, older people, or those with a previous Achilles tendon injury. Tendon injections, quinolone use, and extreme changes in exercise intensity can contribute.<ref name="Gos2018" /> Most cases of Achilles tendon rupture are traumatic ]. The average age of patients is 29–40 years with a male-to-female ratio of nearly 20:1. Yet, recent studies have shown that Achilles tendon ruptures are rising in all ages up to 60 years of age. It has been theorized that this is due to the popularity of remaining active with older age.<ref name="DamsReininga2017">{{cite journal | vauthors = Dams OC, Reininga IH, Gielen JL, van den Akker-Scheek I, Zwerver J | title = Imaging modalities in the diagnosis and monitoring of Achilles tendon ruptures: A systematic review | journal = Injury | volume = 48 | issue = 11 | pages = 2383–2399 | date = November 2017 | pmid = 28943056 | doi = 10.1016/j.injury.2017.09.013 | s2cid = 25815282 | url = https://pure.rug.nl/ws/files/50117154/Imaging_modalities_in_the_diagnosis_and_monitoring_of_Achilles_tendon.pdf }}</ref> Additionally, even the occasional weekend exercise activity for "weekend warriors" may put one at risk. The risk continues to be higher in people who are older than 60, and also taking ]s, or have ]. Risk also increases with dose amount and for longer periods of time.<ref name="DamsReininga2017" />
Other ways the Achilles tendon can be torn involve sudden direct trauma or damage to the tendon. Sudden use of the Achilles after prolonged periods of inactivity, such as bed rest or leg injury. Some other common tears can happen from intense sports overuse. Twisting or jerking motions can also contribute to injury. <ref name="Gos2018" />

Some antibiotics, such as ], may increase the risk of tendon rupture. These antibiotics are known as ].<ref name=":0" />

People who commonly fall victim to Achilles rupture or tear include recreational athletes, people of old age, individuals with previous Achilles tendon tears or ruptures, previous tendon injections or ] use, extreme changes in training intensity or activity level, and participation in a new activity.{{citation needed|date=August 2015}}

Most cases of Achilles tendon rupture are traumatic ]. The average age of patients is 29–40 years with a male-to-female ratio of nearly 20:1. However, recent studies have shown that Achilles tendon ruptures are rising in all age demographics up to the sixth decade of life as remaining active has become popularized around the world.<ref>{{cite journal | vauthors = Meulenkamp B, Stacey D, Fergusson D, Hutton B, Mlis RS, Graham ID | title = Protocol for treatment of Achilles tendon ruptures; a systematic review with network meta-analysis | journal = Systematic Reviews | volume = 7 | issue = 1 | pages = 247 | date = December 2018 | pmid = 30580763 | pmc = 6304227 | doi = 10.1186/s13643-018-0912-5 }}</ref> Direct steroid injections into the tendon have also been linked to rupture.

The use of ]s can cause several forms of tendinitis and tendon rupture, including rupture of the Achilles tendon. The risk is higher in people who are older than 60, who are also taking ]s, or have ]; it also increases with dose and taking them for longer periods of time. As of 2016 the mechanism through which quinolones cause this, was unclear.<ref name=":0">{{cite journal | vauthors = Bidell MR, Lodise TP | title = Fluoroquinolone-Associated Tendinopathy: Does Levofloxacin Pose the Greatest Risk? | journal = Pharmacotherapy | volume = 36 | issue = 6 | pages = 679–93 | date = June 2016 | pmid = 27138564 | doi = 10.1002/phar.1761 | s2cid = 206359106 }}</ref>


==Anatomy== ==Anatomy==
] ]
The Achilles tendon is the strongest and thickest ] in the body, connecting the ], ] and ] to the ]. It is approximately 15 centimeters (5.9&nbsp;inches) long and begins near the middle portion of the calf. Contraction of the ] ] flexes the foot, enabling such activities as walking, jumping, and running. The Achilles tendon receives its blood supply from its ] with the ] and its innervation from the sural nerve and to a lesser degree from the tibial nerve.{{citation needed|date=August 2015}} The Achilles tendon is the strongest and thickest ] in the body.<ref name=":1">{{cite journal | vauthors = Doral MN, Alam M, Bozkurt M, Turhan E, Atay OA, Dönmez G, Maffulli N | title = Functional anatomy of the Achilles tendon | journal = Knee Surgery, Sports Traumatology, Arthroscopy | volume = 18 | issue = 5 | pages = 638–643 | date = May 2010 | pmid = 20182867 | doi = 10.1007/s00167-010-1083-7 | s2cid = 24159374 }}</ref> It connects the calf muscles to the heel bone of the foot. The calf muscles are the ], ] and the heel bone is called the ]. It is approximately 15 centimeters (5.9 inches) long and begins near the middle part of the calf. Contraction of the calf muscles flexes the foot down. This is important in activities such as walking, jumping, and running. The Achilles tendon receives its blood supply from its ] Its nerve supply is from the ] and to a lesser degree from the ].<ref name=":1" />


==Diagnosis== ==Diagnosis==
] ]
Diagnosis may be based on symptoms and the history of the event; typically people say it feels like being kicked or shot behind the ]. Upon examination, a gap may be felt just above the heel unless swelling has filled the gap and the ] (aka Thompson test) will be positive; squeezing the calf muscles of the affected side while the person lies on their stomach, face down, with his feet hanging loose results in no movement (no passive plantarflexion) of the foot, while movement is expected with an intact Achilles tendon and should be observable upon manipulation of the uninvolved calf. Walking will usually be severely impaired, as the person will be unable to step off the ground using the injured leg. The person will also be unable to stand up on the toes of that leg, and pointing the foot downward (]) will be impaired. Pain may be severe, and swelling is common.{{citation needed|date=August 2015}} Diagnosis is based on symptoms and history of the event. People describe it like being kicked or shot behind the ]. During physical examination, a gap may be felt above the heel unless swelling is present. A common physical exam test the doctor or provider may perform is the ] (aka Thompson test). To perform the test, have the person lay on their stomach, face down, and with their feet hanging from the exam table. The test is positive if squeezing the calf muscles of the affected side results in no movement (no passive plantarflexion) of the foot. The test is negative with an intact Achilles tendon and squeezing the calf muscle results in the foot flexing down. Walking is usually impaired, as the person will be unable to step off the ground using the injured leg. The person will also be unable to stand up on the toes of that leg, and pointing the foot downward (]) is impaired. Pain may be severe, and swelling around the ankle is common.<ref>{{cite journal | vauthors = Cuttica DJ, Hyer CF, Berlet GC | title = Intraoperative value of the thompson test | journal = The Journal of Foot and Ankle Surgery | volume = 54 | issue = 1 | pages = 99–101 | date = January 2015 | pmid = 25441265 | doi = 10.1053/j.jfas.2014.09.014 }}</ref>


Although a tear may be diagnosed by history and physical exam alone, an ] scan is sometimes required to clarify or confirm the diagnosis. Once diagnosis is made, ultrasound imaging is an effective way to monitor the healing progress of the tendon over time. An ultrasound is recommended over ] and MRI is generally not needed.<ref name="DamsReininga2017" /><ref name=":2" /> Both MRI and ultrasound are effective tools and have their strengths and limitations. However, when it comes to an Achilles tendon tear, an ultrasound is usually recommended first because of convenience, quick availability, and cost.<ref name=":9" />
Sometimes an ] scan may be required to clarify or confirm the diagnosis and is recommended over ].<ref name="DamsReininga2017">{{cite journal | vauthors = Dams OC, Reininga IH, Gielen JL, van den Akker-Scheek I, Zwerver J | title = Imaging modalities in the diagnosis and monitoring of Achilles tendon ruptures: A systematic review | journal = Injury | volume = 48 | issue = 11 | pages = 2383–2399 | date = November 2017 | pmid = 28943056 | doi = 10.1016/j.injury.2017.09.013 }}</ref> MRI is generally not needed.<ref>{{cite web|title=American Podiatric Medical Association {{!}} Choosing Wisely|url=http://www.choosingwisely.org/societies/american-podiatric-medical-association/|website=www.choosingwisely.org|access-date=31 August 2017}}</ref>
===Imaging=== ===Imaging===
] ]
Musculoskeletal ultrasonography can be used to determine the tendon thickness, character, and presence of a tear. It works by sending extremely high frequencies of sound through the body. Some of these sounds are reflected back off the spaces between interstitial fluid and soft tissue or bone. These reflected images can be analyzed and computed into an image. These images are captured in real time and can be very helpful in detecting movement of the tendon and visualising possible injuries or tears. This device makes it very easy to spot structural damages to soft tissues, and consistent method of detecting this type of injury. This imaging modality is inexpensive, involves no ionizing radiation and, in the hands of skilled ultrasonographers, may be very reliable. ] can be used to determine the tendon thickness, character, and presence of a tear. It works by sending harmless high frequencies of sound waves through the body. Some of these sound waves reflect back off the spaces between fluid and soft tissue or bone. These reflected images are analyzed and created into an image. These images capture in real time and are helpful in detecting movement of the tendon and visualizing injuries or tears. This device makes it possible to identify injuries and observe healing over time. Ultrasound is inexpensive and involves no harmful radiation. It is operator-dependent and so requires a level of skill and practice for it to be used effectively.<ref name=":9">{{cite journal | vauthors = Aminlari A, Stone J, McKee R, Subramony R, Nadolski A, Tolia V, Hayden SR | title = Diagnosing Achilles Tendon Rupture with Ultrasound in Patients Treated Surgically: A Systematic Review and Meta-Analysis | journal = The Journal of Emergency Medicine | volume = 61 | issue = 5 | pages = 558–567 | date = November 2021 | pmid = 34801318 | doi = 10.1016/j.jemermed.2021.09.008 | s2cid = 244381264 }}</ref>


MRI can be used to discern incomplete ruptures from degeneration of the Achilles tendon, and MRI can also distinguish between paratenonitis, tendinosis, and bursitis. This technique uses a strong uniform magnetic field to align millions of protons running through the body. These protons are then bombarded with radio waves that knock some of them out of alignment. When these protons return they emit their own unique radio waves that can be analysed by a computer in 3D to create sharp cross sectional image of the area of interest. MRI can provide unparalleled contrast in soft tissue for an extremely high quality photograph making it easy for technicians to spot tears and other injuries.{{citation needed|date=August 2015}} ] can be used to distinguish incomplete ruptures from degeneration of the Achilles tendon. MRI can also distinguish between ], ], and ]. This technique uses a strong uniform magnetic field to align millions of protons running through the body. These protons are then bombarded with radio waves that knock some of them out of alignment. When these protons return they emit their own unique radio waves that is analyzed by a computer in 3D to create a sharp cross sectional image of the area. MRI provides excellent soft tissue imaging making it easier for technicians to spot tears or other injuries.<ref>{{cite journal | vauthors = Grover VP, Tognarelli JM, Crossey MM, Cox IJ, Taylor-Robinson SD, McPhail MJ | title = Magnetic Resonance Imaging: Principles and Techniques: Lessons for Clinicians | journal = Journal of Clinical and Experimental Hepatology | volume = 5 | issue = 3 | pages = 246–255 | date = September 2015 | pmid = 26628842 | pmc = 4632105 | doi = 10.1016/j.jceh.2015.08.001 }}</ref>


] can also be used to indirectly identify Achilles tears. Radiography uses ] to analyse the point of injury. This is not very effective at identifying injuries to soft tissue. X-rays are created when high energy electrons hit a metal source. X-ray images are acquired by utilising the different attenuation characteristics of dense (e.g. calcium in bone) and less dense (e.g. muscle) tissues when these rays pass through tissue and are captured on film. X-rays are generally exposed to optimise visualisation of dense objects such as bone while soft tissue remains relatively undifferentiated in the background. Radiography has little role in assessment of Achilles' tendon injury and is more useful for ruling out other injuries such as calcaneal fractures.<ref>{{EMedicine|article|309393|Achilles Tendon Injuries|differential}}</ref> ] can also be used to indirectly identify Achilles tendon tears. Radiography uses ] to analyze the point of injury. This is not very effective at identifying soft tissue injuries. X-rays are created when high energy electrons hit a metal source. X-ray images are acquired by utilizing the different densities of the bone or tissue. When these rays pass through tissue they are captured on film. X-rays are generally best for dense objects such as bone while soft tissue is shown poorly. Radiography is not the best for assessing an Achilles tendon injury. It is more useful for ruling out other injuries such as heal bone fractures.<ref name=":2">{{EMedicine|article|309393|Achilles Tendon Injuries|differential}}</ref>

=== Differential diagnosis ===
Some conditions to consider when diagnosing an Achilles tendon tear are ], ], and ] of the ].


==Treatment== ==Treatment==
]Treatment options include surgery and non-surgical rehabilitation.<ref name="Hub2018" /> Surgery has shown a lower risk of re-rupture. However, it has a higher rate of short-term problems.<ref name="Hub2018" /> Surgery complications include leg clots, nerve damage, infection, and clots in the lungs. The most common problem after non-surgical treatment is leg clots. The main problem after surgery is infection.<ref name=":3">{{cite web |date=August 20, 2014 |title=Achilles tendon rupture |url=http://www.mayoclinic.org/diseases-conditions/achilles-tendon-rupture/basics/definition/con-20020370 |publisher=Mayo Clinic}}</ref> Certain rehabilitation techniques have shown similar re-rupture rates to surgery.<ref name="Hub2018" /> In centers without early range of motion rehabilitation available, surgery is preferred to decrease re-rupture rates.<ref name=":4">Nazerali RS, Hakimi M, Giza E, Sahar DE. Single-stage reconstruction of achilles tendon rupture with flexor hallucis longus tendon transfer and simultaneous free radial fasciocutaneous forearm flap. Ann Plast Surg. 2013 Apr;70(4):416-8. doi: 10.1097/SAP.0b013e3182853d6c. PMID 23486135.</ref>
]
Treatment options include surgical and non-surgical approaches.<ref name=BMJ2018/> Surgery has traditionally been shown to have a lower risk of re-rupture, however, it has a higher rate of short term complications compared to non-surgical approaches.<ref name=BMJ2018/> Complications include deep vein thrombosis, sural nerve injury, would infection, and pulmonary embolism. The main complication following a non-surgical approach was deep vein thrombosis, while the main complication following a surgical approach was infection.<ref>{{Cite journal|last1=Ochen|first1=Yassine|last2=Beks|first2=Reinier B.|last3=van Heijl|first3=Mark|last4=Hietbrink|first4=Falco|last5=Leenen|first5=Luke P. H.|last6=van der Velde|first6=Detlef|last7=Heng|first7=Marilyn|last8=van der Meijden|first8=Olivier|last9=Groenwold|first9=Rolf H. H.|last10=Houwert|first10=R. Marijn|date=2019-01-07|title=Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis|journal=BMJ (Clinical Research Ed.)|volume=364|pages=k5120|doi=10.1136/bmj.k5120|issn=1756-1833|pmc=6322065|pmid=30617123}}</ref> Additionally certain rehabilitation techniques (early weight-bearing in an orthosis and early range of movement exercises) appear to have shown similar rates of re-rupture compared to surgery.<ref name=BMJ2018/>

In centers that do not have early range of motion rehabilitation available, surgical repair is preferred to decrease re-rupture rates.<ref>{{cite journal | vauthors = Soroceanu A, Sidhwa F, Aarabi S, Kaufman A, Glazebrook M | title = Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials | journal = The Journal of Bone and Joint Surgery. American Volume | volume = 94 | issue = 23 | pages = 2136–43 | date = December 2012 | pmid = 23224384 | pmc = 3509775 | doi = 10.2106/JBJS.K.00917 }}</ref>


===Surgery=== ===Surgery===
There are at least four different types of surgeries; open surgery, percutaneous surgery, ultrasound-guided surgery, and WALANT surgery.<ref>{{Cite web |title=My Achilles tendon rupture {{!}} Fisiodue Fisioterapia Palma de Mallorca |url=https://www.fisiodue.com/achilles-tendon-rupture/ |access-date=2022-05-09 |website=Fisiodue |language=es}}</ref>
There are two different types of surgeries; open surgery and percutaneous surgery.


During an open surgery, an incision is made in the back of the leg and the Achilles tendon is stitched together. In a complete or serious rupture the tendon of ] or another vestigial muscle is harvested and wrapped around the Achilles tendon, increasing the strength of the repaired tendon.<ref>{{cite web |publisher=Mayo Clinic |title=Achilles tendon rupture |date=August 20, 2014 |url=http://www.mayoclinic.org/diseases-conditions/achilles-tendon-rupture/basics/definition/con-20020370}}</ref> If the tissue quality is poor, e.g. the injury has been neglected, the surgeon might use a reinforcement mesh (], Artelon or other degradable material). If there is both significant Achilles tendon domain loss and overlying soft tissue deficit, simultaneous ] tendon transfer with free tissue transfer (skin flap) has been described as a one-stage repair.<ref>Nazerali RS, Hakimi M, Giza E, Sahar DE. Single-stage reconstruction of achilles tendon rupture with flexor hallucis longus tendon transfer and simultaneous free radial fasciocutaneous forearm flap. Ann Plast Surg. 2013 Apr;70(4):416-8. doi: 10.1097/SAP.0b013e3182853d6c. PMID 23486135.</ref> During an ], an incision is made in the back of the leg and the Achilles tendon is stitched together. In complete ruptures, the tendon of another muscle is used and wrapped around the Achilles tendon. Commonly, the tendon of the ] is used and this wrapping increases the strength of the repaired tendon.<ref name=":3" /> If the quality of tissues is poor, such as from a neglected injury, a reinforcement mesh is an option. These meshes can be of ], Artelon or other degradable material. In the case of both poor tissue and significant loss of the Achilles tendon, the flexor hallucis longus tendon can be used. The ] tendon of the big toe is transferred with free tissue (skin flap) in a process described as a one-stage repair.<ref name=":4" />


In ] surgery, the surgeon makes several small incisions, rather than one large incision, and sews the tendon back together through the incision(s). Surgery may be delayed for about a week after the rupture to let the ] go down.<ref>{{cite web |publisher=WebMD |date=January 3, 2013 |title=Surgery for an Achilles Tendon Rupture |url=http://www.webmd.com/a-to-z-guides/surgery-for-an-achilles-tendon-rupture}}</ref> For sedentary patients and those who have vasculopathy or risks for poor healing, percutaneous surgical repair may be a better treatment choice than open surgical repair.<ref>{{cite web |first1=Waqqar |last1=Khan-Farooqi |first2=Robert B. |last2=Anderson | name-list-style = vanc |url=http://www.rheumatologynetwork.com/biomechanics-report/achilles-tendon-evaluation-and-repair |title=Achilles tendon evaluation and repair |date=April 28, 2010 |publisher=Rheumatology Network}}</ref> Surgical care is evolving, with minimally invasive and percutaneous surgical techniques being developed to negate the risk of wound complications and infections found with open surgery. These techniques are more challenging than traditional open surgery, with a learning curve for surgeons, and are not yet widely used. <ref>{{Cite journal|last1=Meulenkamp|first1=Brad|last2=Stacey|first2=Dawn|last3=Fergusson|first3=Dean|last4=Hutton|first4=Brian|last5=MLIS|first5=Risa Shorr|last6=Graham|first6=Ian D.|date=2018-12-23|title=Protocol for treatment of Achilles tendon ruptures; a systematic review with network meta-analysis|journal=Systematic Reviews|volume=7|issue=1|pages=247|doi=10.1186/s13643-018-0912-5|issn=2046-4053|pmc=6304227|pmid=30580763}}</ref> In ] surgery, several small incisions are made, rather than one large incision. The tendon is sewn back together through the incision(s). Surgery is often delayed for about a week after the rupture to let the ] go down.<ref name=":5">{{cite journal |vauthors=Zellers JA, Christensen M, Kjær IL, Rathleff MS, Silbernagel KG |date=November 2019 |title=Defining Components of Early Functional Rehabilitation for Acute Achilles Tendon Rupture: A Systematic Review |journal=Orthopaedic Journal of Sports Medicine |volume=7 |issue=11 |pages=2325967119884071 |doi=10.1177/2325967119884071 |pmc=6878623 |pmid=31803789}}</ref> For sedentary patients and those who have vascular diseases or risks for poor healing, percutaneous surgical repair may be the better surgical option.<ref name=":6" /> Surgical care is evolving, with minimally invasive and percutaneous surgical techniques. These developments hope to lessen the risk of wound complications and infections found with open surgery. These techniques are more challenging than traditional open surgery, with a learning curve for surgeons, and are not yet widely used.<ref name=":7" />


===Rehabilitation=== ===Rehabilitation===
Non-surgical treatment used to be long and a tedious process. It involved a series of casts, and took longer to complete than surgical treatment. Recently, both surgical and non-surgical rehabilitation protocols have become quicker and more successful.<ref name=":8">{{Cite journal |last1=Huang |first1=Jiazhang |last2=Wang |first2=Chen |last3=Ma |first3=Xin |last4=Wang |first4=Xu |last5=Zhang |first5=Chao |last6=Chen |first6=Li |date=April 2015 |title=Rehabilitation Regimen After Surgical Treatment of Acute Achilles Tendon Ruptures: A Systematic Review With Meta-analysis |url=http://journals.sagepub.com/doi/10.1177/0363546514531014 |journal=The American Journal of Sports Medicine |language=en |volume=43 |issue=4 |pages=1008–1016 |doi=10.1177/0363546514531014 |pmid=24793572 |s2cid=206528867 |issn=0363-5465}}</ref> Before, patients who underwent surgery would wear a cast for approximately 4 to 8 weeks. After surgery, they were only allowed to gently move the ankle once out of the cast. Recent studies have shown that is not the best method. Patients that are allowed to gently move and stretch the ankle immediately after surgery, have faster and more successful recoveries.<ref name=":8" /> They will wear removable boots to ensure their safety with these exercises. For surgical and non-surgical patients, they will still generally limit non-weightbearing (NWB) activity to two weeks.<ref name=":5" /> This is done using modern removable boots, either fixed or hinged, rather than casts. Physiotherapy is often begun as early as two weeks regardless of surgical or non-surgical treatment.<ref name=":8" /> This includes weightbearing and range of motion exercises. This is followed by progressive strengthening and general conditioning of the muscle and tendon.<ref name=":5" />
{{more citations needed section|date=January 2012}}
Non-surgical treatment used to involve very long periods in a series of casts, and took longer to complete than surgical treatment. But both surgical and non-surgical rehabilitation protocols have recently become quicker, shorter, more aggressive, and more successful. It used to be that patients who underwent surgery would wear a cast for approximately 4 to 8 weeks after surgery and were only allowed to gently move the ankle once out of the cast. Recent studies have shown that patients have quicker and more successful recoveries when they are allowed to move and lightly stretch their ankle immediately after surgery. To keep their ankle safe these patients use a removable boot while walking and doing daily activities. Modern studies including non-surgical patients generally limit non-weight-bearing (NWB) to two weeks, and use modern removable boots, either fixed or hinged, rather than casts. Physiotherapy is often begun as early as two weeks following the start of either kind of treatment.{{citation needed|date=August 2015}} This includes weightbearing and range of motion intervention strategies as well as strengthening and general conditioning.<ref>{{cite journal | vauthors = Zellers JA, Christensen M, Kjær IL, Rathleff MS, Silbernagel KG | title = Defining Components of Early Functional Rehabilitation for Acute Achilles Tendon Rupture: A Systematic Review | journal = Orthopaedic Journal of Sports Medicine | volume = 7 | issue = 11 | pages = 2325967119884071 | date = November 2019 | pmid = 31803789 | pmc = 6878623 | doi = 10.1177/2325967119884071 }}</ref>


There are three things that need to be kept in mind while rehabilitating a ruptured Achilles: range of motion, functional strength, and sometimes orthotic support. Range of motion is important because it takes into mind the tightness of the repaired tendon. When beginning rehab a patient should perform stretches lightly and increase the intensity as time and pain permits. Putting linear stress on the tendon is important because it stimulates connective tissue repair, which can be achieved while performing the “runners stretch,” (putting your toes a couple inches up the wall while your heel is on the ground). Doing stretches to gain functional strength are also important because it improves healing in the tendon, which will in turn lead to a quicker return to activities. These stretches should be more intense and should involve some sort of weight bearing, which helps reorient and strengthen the collagen fibers in the injured ankle. A popular stretch used for this phase of rehabilitation is the toe raise on an elevated surface. The patient is to push up onto the toes and lower his or her self as far down as possible and repeat several times. The other part of the rehab process is orthotic support. This doesn't have anything to do with stretching or strengthening the tendon, rather it is in place to keep the patient comfortable. These are custom made inserts that fit into the patients shoe and help with proper pronation of the foot, which is otherwise a problem that can lead to problems with the Achilles.{{citation needed|date=August 2015}} There are three things to consider with Achilles rupture rehabilitation. These are range of motion, functional strength, and sometimes orthotic support.<ref name=":8" /> Range of motion is important because it takes into mind the tightness of the repaired tendon. When beginning rehabilitation, a person should perform light stretches. Over time, the goal should be to increase the intensity of that stretch. Stretching the tendon is important because it stimulates connective tissue repair.<ref name=":8" /> This can be done while performing the "runner's stretch". The runner's stretch involves putting the toes a few inches up a wall while the heel is on the ground. Doing stretches to gain functional strength is also important because it improves healing in the tendon. This will in turn lead to a quicker return to activities. These stretches should continue to increase in intensity over time. Over time the goal is to include some weight bearing, to reorient and strengthen the collagen fibers in the injured ankle.<ref name=":8" /> A popular stretch used for this phase of rehabilitation is the toe raise on an elevated surface. The patient is to push up onto the toes and lower themselves as far down as possible and repeat several times. The other part of the rehab process is orthotic support. This doesn't have anything to do with stretching or strengthening the tendon, rather it is in place to keep the patient comfortable.<ref>{{Cite journal |last1=Scott |first1=Lisa A. |last2=Munteanu |first2=Shannon E. |last3=Menz |first3=Hylton B. |date=January 2015 |title=Effectiveness of Orthotic Devices in the Treatment of Achilles Tendinopathy: A Systematic Review |url=http://link.springer.com/10.1007/s40279-014-0237-z |journal=Sports Medicine |language=en |volume=45 |issue=1 |pages=95–110 |doi=10.1007/s40279-014-0237-z |pmid=25108348 |s2cid=25491960 |issn=0112-1642}}</ref> These are custom-made inserts that fit into the patient's shoe. They help with proper pronation of the foot, which is when the ankle leans toward the middle of the body.


To briefly summarize the steps of rehabilitating a ruptured Achilles tendon, you should begin with range of motion type stretching. This will allow the ankle to get used to moving again and get ready for weight bearing activities. Then there is functional strength, this is where weight bearing should begin in order to start strengthening the tendon and getting it ready to perform daily activities and eventually in athletic situations.<ref>{{cite web |last1=Cluett |first1=Jonathan | name-list-style = vanc |date=April 29, 2007 |title=Achilles Tendon Rupture: What is an Achilles Tendon Rupture |url=http://orthopedics.about.com/cs/ankleproblems/a/achilles.htm}} In summary, the steps of rehabilitating a ruptured Achilles tendon begin with range of motion type stretching. Studies have shown that the earlier movement is started, the better.<ref name=":8" /> This will allow the ankle to get used to moving again and get ready for weight-bearing activities. This is followed by functional strength. This is where weight-bearing should begin to strengthen the tendon. The intensity should gradually increase over time. The end goal is to get the person to resume their normal and athletic activities.<ref name=":6">{{cite web |vauthors=Cluett J |date=April 29, 2007 |title=Achilles Tendon Rupture: What is an Achilles Tendon Rupture |url=http://orthopedics.about.com/cs/ankleproblems/a/achilles.htm |access-date=August 2, 2015 |archive-date=September 5, 2015 |archive-url=https://web.archive.org/web/20150905232951/http://orthopedics.about.com/cs/ankleproblems/a/achilles.htm |url-status=dead }}</ref><ref name=":7">{{cite web | vauthors = Christensen KD |date=July 20, 2003 |title=Rehab of the Achilles Tendon |url=http://www.ccptr.org/articles/rehab-of-the-achilles-tendon/ |access-date=May 6, 2010 |archive-url=https://web.archive.org/web/20091129143948/http://www.ccptr.org/articles/rehab-of-the-achilles-tendon/ |archive-date=November 29, 2009 |url-status=dead }}</ref>
</ref><ref>{{cite web | vauthors = Christensen KD |date=July 20, 2003 |title=Rehab of the Achilles Tendon |url=http://www.ccptr.org/articles/rehab-of-the-achilles-tendon/ |access-date=May 6, 2010 |archive-url=https://web.archive.org/web/20091129143948/http://www.ccptr.org/articles/rehab-of-the-achilles-tendon/ |archive-date=November 29, 2009 |url-status=dead }}</ref>


==Epidemiology== ==Epidemiology==
Of all the large tendon ruptures, 1 in 5 will be an Achilles tendon rupture. An Achilles tendon rupture is estimated to occur in a little over 1 per 10,000 people per year. Males are also over 2 times more likely to suffer from an Achilles tendon rupture as opposed to women. There are 2 age groups more likely to suffer from an Achilles tendon rupture. A younger age group between 25-40 and an older age group over 60. Sports and high-impact activity is the most common cause of rupture in younger people. Whereas sudden rupture from chronic tendon damage is more common in older people.<ref>Park SH, Lee HS, Young KW, Seo SG. Treatment of Acute Achilles Tendon Rupture. Clin Orthop Surg. 2020;12(1):1-8. doi:10.4055/cios.2020.12.1.1</ref> Of all the large tendon ruptures, 1 in 5 will be an Achilles tendon rupture. An Achilles tendon rupture is estimated to occur in a little over 1 per 10,000 people per year. Males are also over 2 times more likely to develop an Achilles tendon rupture as opposed to women. Achilles tendon rupture tends to occur most frequently between the ages of 25-40 and over 60 years of age. ] and high-impact activity is the most common cause of rupture in younger people, whereas sudden rupture from chronic tendon damage is more common in older people.<ref>Park SH, Lee HS, Young KW, Seo SG. Treatment of Acute Achilles Tendon Rupture. Clin Orthop Surg. 2020;12(1):1-8. doi:10.4055/cios.2020.12.1.1</ref> The rate of return to sports in the months or years following the rupture (whether operated on or not, partial or total) is 70 to 80%.<ref>{{Cite journal |last1=Tarantino |first1=Domiziano |last2=Palermi |first2=Stefano |last3=Sirico |first3=Felice |last4=Corrado |first4=Bruno |date=2020-12-17 |title=Achilles Tendon Rupture: Mechanisms of Injury, Principles of Rehabilitation and Return to Play |journal=Journal of Functional Morphology and Kinesiology |volume=5 |issue=4 |pages=95 |doi=10.3390/jfmk5040095 |issn=2411-5142 |pmc=7804867 |pmid=33467310 |doi-access=free }}</ref>


== References == == References ==
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Latest revision as of 23:31, 30 June 2024

Medical condition where the tendon at the back of the ankle breaks Medical condition
Achilles tendon rupture
Other namesAchilles tendon tear, Achilles rupture
The achilles tendon
SpecialtyOrthopedics, emergency medicine
SymptomsPain in the heel
Usual onsetSudden
CausesForced plantar flexion of the foot, direct trauma, long-standing tendonitis
Risk factorsFluoroquinolones, significant change in exercise, rheumatoid arthritis, gout, corticosteroids
Diagnostic methodBased on symptoms and examination, supported by medical imaging
Differential diagnosisAchilles tendinitis, ankle sprain, avulsion fracture of the calcaneus
TreatmentCasting or surgery
Frequency1 per 10,000 people per year

Achilles tendon rupture is when the Achilles tendon, at the back of the ankle, breaks. Symptoms include the sudden onset of sharp pain in the heel. A snapping sound may be heard as the tendon breaks and walking becomes difficult.

Rupture typically occurs as a result of a sudden bending up of the foot when the calf muscle is engaged, direct trauma, or long-standing tendonitis. Other risk factors include the use of fluoroquinolones, a significant change in exercise, rheumatoid arthritis, gout, or corticosteroid use. Diagnosis is typically based on symptoms and examination and supported by medical imaging.

Prevention may include stretching before activity and gradual progression of exercise intensity. Treatment may consist of surgical repair or conservative management. Quick return to weight bearing (within 4 weeks) appears acceptable and is often recommended. While surgery traditionally results in a small decrease in the risk of re-rupture, the risk of other complications is greater. Non-surgical treatment is an alternative as there is supporting evidence that rerupture rates and satisfactory outcomes are comparable to surgery. If appropriate treatment does not occur within 4 weeks of the injury outcomes are not as good.

Achilles tendon rupture occurs in about 1 per 10,000 people per year. Males are more commonly affected than females. People in their 30s to 50s are most commonly affected.

Signs and symptoms

The main symptom of an Achilles tendon rupture is the sudden onset of sharp pain in the heel. Additionally, a snap or "pop" may be heard as the tendon breaks. Some people describe the pain as a hit or kick behind the lower leg. There is difficulty walking immediately. It may be difficult to push off or stand on the toes of the injured leg. Swelling may be present around the heel.

Causes

The Achilles tendon is most often injured by sudden downward or upward movement of the foot, or by forced upward flexion of the foot outside its normal range of motion. Other ways the Achilles tendon can be torn involve sudden direct trauma or damage to the tendon, or sudden use of the Achilles after prolonged periods of inactivity, such as bed rest or leg injury. Some other common tears can happen from intense sports overuse. Twisting or jerking motions can also contribute to injury. Some antibiotics, such as levofloxacin, may increase the risk of tendon injury or rupture. These antibiotics are known as fluoroquinolones. As of 2016 the mechanism through which fluoroquinolones cause this was unclear.

Many people may develop an Achilles rupture or tear, such as recreational athletes, older people, or those with a previous Achilles tendon injury. Tendon injections, quinolone use, and extreme changes in exercise intensity can contribute. Most cases of Achilles tendon rupture are traumatic sports injuries. The average age of patients is 29–40 years with a male-to-female ratio of nearly 20:1. Yet, recent studies have shown that Achilles tendon ruptures are rising in all ages up to 60 years of age. It has been theorized that this is due to the popularity of remaining active with older age. Additionally, even the occasional weekend exercise activity for "weekend warriors" may put one at risk. The risk continues to be higher in people who are older than 60, and also taking corticosteroids, or have kidney disease. Risk also increases with dose amount and for longer periods of time.

Anatomy

Achilles anatomy

The Achilles tendon is the strongest and thickest tendon in the body. It connects the calf muscles to the heel bone of the foot. The calf muscles are the gastrocnemius, soleus and the heel bone is called the calcaneus. It is approximately 15 centimeters (5.9 inches) long and begins near the middle part of the calf. Contraction of the calf muscles flexes the foot down. This is important in activities such as walking, jumping, and running. The Achilles tendon receives its blood supply from its muscular and tendon junction. Its nerve supply is from the sural nerve and to a lesser degree from the tibial nerve.

Diagnosis

Calf squeeze test in a person with a right Achilles tendon rupture

Diagnosis is based on symptoms and history of the event. People describe it like being kicked or shot behind the ankle. During physical examination, a gap may be felt above the heel unless swelling is present. A common physical exam test the doctor or provider may perform is the Simmonds' test (aka Thompson test). To perform the test, have the person lay on their stomach, face down, and with their feet hanging from the exam table. The test is positive if squeezing the calf muscles of the affected side results in no movement (no passive plantarflexion) of the foot. The test is negative with an intact Achilles tendon and squeezing the calf muscle results in the foot flexing down. Walking is usually impaired, as the person will be unable to step off the ground using the injured leg. The person will also be unable to stand up on the toes of that leg, and pointing the foot downward (plantarflexion) is impaired. Pain may be severe, and swelling around the ankle is common.

Although a tear may be diagnosed by history and physical exam alone, an ultrasound scan is sometimes required to clarify or confirm the diagnosis. Once diagnosis is made, ultrasound imaging is an effective way to monitor the healing progress of the tendon over time. An ultrasound is recommended over MRI and MRI is generally not needed. Both MRI and ultrasound are effective tools and have their strengths and limitations. However, when it comes to an Achilles tendon tear, an ultrasound is usually recommended first because of convenience, quick availability, and cost.

Imaging

Achilles tendon rupture seen on ultrasound. Note discontinuity over several centimeters (red line). No fracture or avulsion (radiograph).

Ultrasonography can be used to determine the tendon thickness, character, and presence of a tear. It works by sending harmless high frequencies of sound waves through the body. Some of these sound waves reflect back off the spaces between fluid and soft tissue or bone. These reflected images are analyzed and created into an image. These images capture in real time and are helpful in detecting movement of the tendon and visualizing injuries or tears. This device makes it possible to identify injuries and observe healing over time. Ultrasound is inexpensive and involves no harmful radiation. It is operator-dependent and so requires a level of skill and practice for it to be used effectively.

MRI can be used to distinguish incomplete ruptures from degeneration of the Achilles tendon. MRI can also distinguish between paratenonitis, tendinosis, and bursitis. This technique uses a strong uniform magnetic field to align millions of protons running through the body. These protons are then bombarded with radio waves that knock some of them out of alignment. When these protons return they emit their own unique radio waves that is analyzed by a computer in 3D to create a sharp cross sectional image of the area. MRI provides excellent soft tissue imaging making it easier for technicians to spot tears or other injuries.

Radiography can also be used to indirectly identify Achilles tendon tears. Radiography uses X-rays to analyze the point of injury. This is not very effective at identifying soft tissue injuries. X-rays are created when high energy electrons hit a metal source. X-ray images are acquired by utilizing the different densities of the bone or tissue. When these rays pass through tissue they are captured on film. X-rays are generally best for dense objects such as bone while soft tissue is shown poorly. Radiography is not the best for assessing an Achilles tendon injury. It is more useful for ruling out other injuries such as heal bone fractures.

Differential diagnosis

Some conditions to consider when diagnosing an Achilles tendon tear are Achilles tendinitis, ankle sprain, and avulsion fracture of the calcaneus.

Treatment

Surgical repair of a ruptured Achilles tendon.

Treatment options include surgery and non-surgical rehabilitation. Surgery has shown a lower risk of re-rupture. However, it has a higher rate of short-term problems. Surgery complications include leg clots, nerve damage, infection, and clots in the lungs. The most common problem after non-surgical treatment is leg clots. The main problem after surgery is infection. Certain rehabilitation techniques have shown similar re-rupture rates to surgery. In centers without early range of motion rehabilitation available, surgery is preferred to decrease re-rupture rates.

Surgery

There are at least four different types of surgeries; open surgery, percutaneous surgery, ultrasound-guided surgery, and WALANT surgery.

During an open surgery, an incision is made in the back of the leg and the Achilles tendon is stitched together. In complete ruptures, the tendon of another muscle is used and wrapped around the Achilles tendon. Commonly, the tendon of the plantaris is used and this wrapping increases the strength of the repaired tendon. If the quality of tissues is poor, such as from a neglected injury, a reinforcement mesh is an option. These meshes can be of collagen, Artelon or other degradable material. In the case of both poor tissue and significant loss of the Achilles tendon, the flexor hallucis longus tendon can be used. The flexor hallucis longus tendon of the big toe is transferred with free tissue (skin flap) in a process described as a one-stage repair.

In percutaneous surgery, several small incisions are made, rather than one large incision. The tendon is sewn back together through the incision(s). Surgery is often delayed for about a week after the rupture to let the swelling go down. For sedentary patients and those who have vascular diseases or risks for poor healing, percutaneous surgical repair may be the better surgical option. Surgical care is evolving, with minimally invasive and percutaneous surgical techniques. These developments hope to lessen the risk of wound complications and infections found with open surgery. These techniques are more challenging than traditional open surgery, with a learning curve for surgeons, and are not yet widely used.

Rehabilitation

Non-surgical treatment used to be long and a tedious process. It involved a series of casts, and took longer to complete than surgical treatment. Recently, both surgical and non-surgical rehabilitation protocols have become quicker and more successful. Before, patients who underwent surgery would wear a cast for approximately 4 to 8 weeks. After surgery, they were only allowed to gently move the ankle once out of the cast. Recent studies have shown that is not the best method. Patients that are allowed to gently move and stretch the ankle immediately after surgery, have faster and more successful recoveries. They will wear removable boots to ensure their safety with these exercises. For surgical and non-surgical patients, they will still generally limit non-weightbearing (NWB) activity to two weeks. This is done using modern removable boots, either fixed or hinged, rather than casts. Physiotherapy is often begun as early as two weeks regardless of surgical or non-surgical treatment. This includes weightbearing and range of motion exercises. This is followed by progressive strengthening and general conditioning of the muscle and tendon.

There are three things to consider with Achilles rupture rehabilitation. These are range of motion, functional strength, and sometimes orthotic support. Range of motion is important because it takes into mind the tightness of the repaired tendon. When beginning rehabilitation, a person should perform light stretches. Over time, the goal should be to increase the intensity of that stretch. Stretching the tendon is important because it stimulates connective tissue repair. This can be done while performing the "runner's stretch". The runner's stretch involves putting the toes a few inches up a wall while the heel is on the ground. Doing stretches to gain functional strength is also important because it improves healing in the tendon. This will in turn lead to a quicker return to activities. These stretches should continue to increase in intensity over time. Over time the goal is to include some weight bearing, to reorient and strengthen the collagen fibers in the injured ankle. A popular stretch used for this phase of rehabilitation is the toe raise on an elevated surface. The patient is to push up onto the toes and lower themselves as far down as possible and repeat several times. The other part of the rehab process is orthotic support. This doesn't have anything to do with stretching or strengthening the tendon, rather it is in place to keep the patient comfortable. These are custom-made inserts that fit into the patient's shoe. They help with proper pronation of the foot, which is when the ankle leans toward the middle of the body.

In summary, the steps of rehabilitating a ruptured Achilles tendon begin with range of motion type stretching. Studies have shown that the earlier movement is started, the better. This will allow the ankle to get used to moving again and get ready for weight-bearing activities. This is followed by functional strength. This is where weight-bearing should begin to strengthen the tendon. The intensity should gradually increase over time. The end goal is to get the person to resume their normal and athletic activities.

Epidemiology

Of all the large tendon ruptures, 1 in 5 will be an Achilles tendon rupture. An Achilles tendon rupture is estimated to occur in a little over 1 per 10,000 people per year. Males are also over 2 times more likely to develop an Achilles tendon rupture as opposed to women. Achilles tendon rupture tends to occur most frequently between the ages of 25-40 and over 60 years of age. Sports and high-impact activity is the most common cause of rupture in younger people, whereas sudden rupture from chronic tendon damage is more common in older people. The rate of return to sports in the months or years following the rupture (whether operated on or not, partial or total) is 70 to 80%.

References

  1. ^ "Achilles Tendon Tears". MSD Manual Professional Edition. August 2017. Retrieved 26 June 2018.
  2. ^ Ochen Y, Beks RB, van Heijl M, Hietbrink F, Leenen LP, van der Velde D, et al. (January 2019). "Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis". BMJ. 364: k5120. doi:10.1136/bmj.k5120. PMC 6322065. PMID 30617123.
  3. ^ Hubbard MJ, Hildebrand BA, Battafarano MM, Battafarano DF (June 2018). "Common Soft Tissue Musculoskeletal Pain Disorders". Primary Care. 45 (2): 289–303. doi:10.1016/j.pop.2018.02.006. PMID 29759125. S2CID 46886582.
  4. ^ Shamrock AG, Varacallo M (January 2018). "Achilles Tendon, Rupture". StatPearls. PMID 28613594.
  5. ^ Ferri FF (2015). Ferri's Clinical Advisor 2016 E-Book: 5 Books in 1. Elsevier Health Sciences. p. 19. ISBN 9780323378222.
  6. ^ El-Akkawi AI, Joanroy R, Barfod KW, Kallemose T, Kristensen SS, Viberg B (March 2018). "Effect of Early Versus Late Weightbearing in Conservatively Treated Acute Achilles Tendon Rupture: A Meta-Analysis". The Journal of Foot and Ankle Surgery. 57 (2): 346–352. doi:10.1053/j.jfas.2017.06.006. PMID 28974345. S2CID 3506883.
  7. van der Eng DM, Schepers T, Goslings JC, Schep NW (2012). "Rerupture rate after early weightbearing in operative versus conservative treatment of Achilles tendon ruptures: a meta-analysis". The Journal of Foot and Ankle Surgery. 52 (5): 622–628. doi:10.1053/j.jfas.2013.03.027. PMID 23659914.
  8. Maffulli N, Ajis A (June 2008). "Management of chronic ruptures of the Achilles tendon". The Journal of Bone and Joint Surgery. American Volume. 90 (6): 1348–1360. doi:10.2106/JBJS.G.01241. PMID 18519331.
  9. Shamrock AG, Varacallo M (January 2018). "Achilles Tendon, Rupture". StatPearls. PMID 28613594
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External links

ClassificationD
External resources
Soft tissue disorders
Capsular
joint
Synoviopathy
Bursopathy
Noncapsular
joint
Symptoms
Enthesopathy/
Enthesitis/
Tendinopathy
upper limb
lower limb
other/general:
Nonjoint
Fasciopathy
Fibromatosis/contracture
Dislocations/subluxations, sprains and strains
Joints and
ligaments
Head and neck
Shoulder and upper arm
Elbow and forearm
Hip and thigh
Knee and leg
Ankle and foot
Muscles and
tendons
Shoulder and upper arm
Hip and thigh
Knee and leg
Categories: