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Achilles tendon rupture
Specialty	Emergency medicine

The Achilles Tendon is the most commonly injured tendon. Rupture can occur while performing actions requiring explosive acceleration, such as pushing off or jumping. The male to female ratio for Achilles tendon rupture varies between 7:1 and 4:1 across various studies.

Anatomy

The Achilles tendon is the strongest and thickest tendon in the body, connecting the gastrocnemius and soleus to the calcaneus. It is approximately 15 centimeters (5.9 inches) long and begins near the middle portion of the calf. Contraction of the gastrosoleus plantarflexes the foot, enabling such activities as walking and jumping. The Achilles tendon receives its blood supply from its musculotendinous junction with the triceps surae and its innervation from the sural nerve and to a lesser degree from the tibial nerve.

Causes

The Achilles tendon is most commonly injured by sudden plantarflexion or dorsiflexion of the ankle, or by forced dorsiflexion of the ankle outside its normal range of motion.

Other mechanisms by which the Achilles can be torn involve sudden direct trauma to the tendon, or sudden activation of the Achilles after atrophy from prolonged periods of inactivity. Some other common tears can occur from overuse while participating in intense sports. Twisting or jerking motions can also contribute to injury.

Risk factors

People that 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 quinolone use, extreme changes in training intensity or activity level, and participation in a new activity.

Most cases of Achilles tendon rupture are traumatic sports injuries. The average age of patients is 30–40 years with a male-to-female ratio of nearly 20:1. Fluoroquinolone antibiotics, such as ciprofloxacin, and glucocorticoids have been linked with an increased risk of Achilles tendon rupture. Direct steroid injections into the tendon have also been linked to rupture.

Quinolone has been associated with Achilles tendinitis and Achilles tendon ruptures for quite some time now. Quinolones are antibacterial agents that act at the level of DNA by inhibiting DNA Gyrase. DNA Gyrase is an enzyme used to unwind double stranded DNA which is essential to DNA Replication. Quinolone is specialized in the fact that it can attack bacterial DNA and prevent them from replicating by this process, and are frequently prescribed to elderly. Approximately 2% to 6% of all elderly people over the age of 60 that have had Achilles ruptures can be attributed to the use of quinolones.

Diagnosis

Diagnosis is made by clinical history; typically people say it feels like being kicked or shot behind the ankle. Upon examination a gap may be felt just above the heel unless swelling has filled the gap and the Simmonds' test (aka Thompson test) will be positive; squeezing the calf muscles of the affected side while the patient lies prone, 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 patient will be unable to step off the ground using the injured leg. The patient will also be unable to stand up on the toes of that leg, and pointing the foot downward (plantarflexion) will be impaired. Pain may be severe and swelling is common.

An O'Brien test can also be performed which entails placing a sterile needle through the skin and into the tendon. If the needle hub moves in the opposite direction of the tendon and the same direction as the toes when the foot is moved up and down then the tendon is at least partially intact.

Sometimes an ultrasound scan may be required to clarify or confirm the diagnosis. MRI can also be used to confirm the diagnosis.

Clinical Diagnosis

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 your 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.

Magnetic resonance imaging (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 east for technicians to spot tears and other injuries.

Radiography can also be used to indirectly identify achilles tears. Radiography uses X-rays to analyse the point of injury. This is not very effective at identifying injuries to soft tissue. These rays are created when high energy electrons hit a metal source, and in this case calcium in bones acts as the metal source, and these rays can be captured on fluorescent film. X-rays accurately identify dense objects such as bone while soft tissue remains very opaque and undifferentiated in the background. Radiography is more for ruling out the possibilities of other injuries such as calcaneous fractions, tendon swelling, and calcification...

Treatment

Treatment options for an Achilles tendon rupture include surgical and non-surgical approaches. Among the medical profession opinions are divided what is to be preferred.

Non-surgical management traditionally was selected for minor ruptures, less active patients, and those with medical conditions that prevent them from undergoing surgery. It traditionally consisted of restriction in a plaster cast for six to eight weeks with the foot pointed downwards (to oppose the ends of the ruptured tendon). But recent studies have produced superior results with much more rapid rehabilitation in fixed or hinged boots.

Some surgeons feel an early surgical repair of the tendon is beneficial. The surgical option was long thought to offer a significantly smaller risk of re-rupture compared to traditional non-operative management (5% vs 15%). Of course, surgery imposes higher relative risks of perioperative mortality and morbidity e.g. infection including MRSA, bleeding, deep vein thrombosis, lingering anesthesia effects, etc.

However, four recent studies have scientifically tested the benefits of surgery, using randomized streaming of patients into surgical and non-surgical protocols, and applying virtually identical (and aggressive) rehabilitation protocols to both types of patients. All four such studies completed to date have found no benefit from the surgery, separated from the other confounding variables. They have all produced statistically indistinguishable results in re-rupture rates, strength, and range of motion, while most have reaffirmed the greater complication rate from surgery.

Judging by the consistent results of these modern randomized trials, it now appears that the long-believed benefits of surgery, reinforced by virtually all studies done before 2007, were primarily artifacts of a selection bias, directing younger, healthier, and fitter patients to surgery, and the rest to non-surgical immobilization. Nonetheless, many "experts" continue to promote Achilles repair surgery, often citing older studies and statistics.

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 plantaris or another vestigial muscle is harvested and wrapped around the Achilles tendon, increasing the strength of the repaired tendon. If the tissue quality is poor, e.g. the injury has been neglected, the surgeon might use a reinforcement mesh (collagen, Artelon or other degradable material).

In percutaneous 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 swelling go down. 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.

Rehabilitation

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.

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 a that can lead to problems with the Achilles.

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.

Professional Athletes

Many professional athletes deal with achilles tendon ruptures, the majority of them coming from the NFL. Rupturing an Achilles tendon is a very serious injury that takes months to rehabilitate and it has even been known to end careers. Athletes who have ruptured their Achilles include those from the NFL, NBA, NHL, professional soccer, college athletes, etc.

This is a list of a few well known professional athletes who have undergone an Achilles rupture: Todd Pinkston, WR for the Philadelphia Eagles, Dan Marino, QB for the Miami Dolphins, Reggie Kelly, TE for the Cincinnati Bengals, Marlin Jackson, CB for the Philadelphia Eagles, Vinny Testaverde, QB for the New York Jets, Jerome James from the Chicago Bulls, Mehmet Okur from the Utah Jazz, Justin Williams from the Carolina Hurricanes, Kalin Lucas a point guard from Michigan State, Misty May-Treanor from the U.S. Olympic beach volleyball team, and professional wrestler Edge. Most recently, David Beckham, an internationally known footballer and icon ruptured his achilles tendon, also ending his ability to play in the 2010 FIFA World Cup for England.

References

1. Paul D. van der Linden, PharmD; Miriam C. J. M. Sturkenboom, PhD; Ron M. C. Herings, PhD; Hubert M. G. Leufkens, PhD; Sam Rowlands, MD; Bruno H. Ch. Stricker, PhD. "Increased Risk of Achilles Tendon Rupture With Quinolone Antibacterial Use, Especially in Elderly Patients Taking Oral Corticosteroids". Arch Intern Med. 2003;163:1801-1807.
2. Brian A Jacobs, MD, FACSM. Achilles Tendon Rupture: Differential Diagnoses & Workup. http://emedicine.medscape.com/article/85024-diagnosis. June 24, 2009,
3. Richter J, Josten C, Dàvid A, Clasbrummel B, Muhr G (1994). "". Zentralbl Chir (in German). 119 (8): 538–44. PMID 7975942.{{cite journal}}: CS1 maint: multiple names: authors list (link)
4. Bruce C. Twaddle, FRACS†,* and Peter Poon, FRACS, Am J Sports Med December 2007 vol. 35 no. 12 2033-2038, “Early Motion for Achilles Tendon Ruptures: Is Surgery Important?: A Randomized, Prospective Study”, ajs.sagepub.com/content/35/12/2033.abstract
5. Netherlands: Metz R, et al, Foot Ankle Spec. 2009 Oct;2(5):219-26. Epub 2009 Sep 4. “Recovery of calf muscle strength following acute achilles tendon rupture treatment: a comparison between minimally invasive surgery and conservative treatment.” — (In this study, there actually was one result in which the two treatment groups differed statistically significantly: In isokinetic strength at 90 degrees per second after 6 months, the NON-surgical patients were significantly stronger!)
6. Gothenburg, Sweden, May 2009: http://www.physorg.com/news161516132.html (”Surgery may not be necessary for Achilles tendon rupture”)
7. Willits K, Amendola A, Bryant D, Mohtadi NG, Giffin JR, Fowler P, Kean CO, Kirkley A. Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures: A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation. — J Bone Joint Surg Am. 2010 Oct 29. PubMed PMID: 21037028.
8. Mayo Clinic. "". {{cite journal}}: Cite journal requires |journal= (help)
9. WebMd
10. Khan-Farooqi W, Anderson RB. Achilles tendon evaluation and repair. J Musculoskel Med. 2010;27:188-193.
11. Cluett, J. (2007, April 29). Achilles Tendon Rupture: What is an Achilles Tendon Rupture. Retrieved May 6, 2010, from http://orthopedics.about.com/cs/ankleproblems/a/achilles_3.htm
12. Christensen, K.D. (2008). Rehab of the Achilles Tendon. Retrieved May 6, 2010, from http://www.ccptr.org/articles/rehab-of-the-achilles-tendon/.htm

External links

• "Achilles tendon rupture". Mayo Clinic. September 26, 2007. Retrieved 2008-03-24.
• Blog - experiences with Achilles tendon rupture, treatment etc
• Image sequence demonstrating Achilles tendinosis and Achilles tendon rupture

• Injuries
• Sports medicine