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Achilles Tendon Rupture

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Other Names

  • Achilles rupture
  • Achilles tendon ruptures (ATR)
  • Achilles Tendon Tear

Background

History

Epidemiology

  • It is the most commonly injured tendon in the human body (need citation)
    • Accounts for 20% of all large tendon ruptures[1]
  • Incidence
    • Has increased in recent decades, likely due to increased participation in sporting events (need citation)
    • Incidence ranges from 11 - 37 per 100,000 population[2]
  • Mean age is 39.8 years, bimodal with peaks at 25-40 years and also over 60[3]
  • The correct diagnosis may be missed in up to 25% of patients at initial presentation[4]

Pathophysiology

  • General
    • Occur mainly during sporting events
    • Commonly in untrained, middle-aged recreational athletes
    • Up to 1/3 of patients do not practice or exercise intensly
    • Vast majority are total ruptures, partial ATR is very rare

Pathohistology

  • Degenerative changes are common histopathological findings after ATR
    • High vascularity
    • Collagen disorganization
    • Hypercellularity relatively close to the ruptured site
    • Likely predispose/ increase risk of rupture
  • Collagen
    • There is often a reduction in the type I collagen fibers that make up 95% of the Achilles
    • Replaced with larger type III collagen fibers, which are less resistant to tensile forces
  • After rupture, tendons heal forming scar tissue
    • Most will never regain the same collagen structure, composition, and organization of healthy tissue[5]
    • Can cause a decrease in mechanical properties, increase risk for re-rupture[6]

Etiology

  • General
    • Classically produced by a single, high-low impact with sudden or violent dorsiflexion of ankle
    • Acceleration-deceleration mechanism is reported in 90% of ATR[5]
    • This is most common during sports and recreation
  • Age 25-40
    • High energy mechanism from sports
  • Age over 60
    • Low energy mechanism likely due to degenerative changes and/or chronic tendinopathy

Pathoanatomy

  • Achilles Tendon
    • Formed by common insertion of Gastrocnemius, Soleus and Plantaris muscles
    • Primary plantarflexor of the ankle
    • Thickest, strongest and largest tendon in the body
  • Acute Tendon Rupture
    • Typically occurs in the midportion, 2-6 cm proximal from the insertion on the calcaneus
    • This is partially due to the poor vascularity in this part of the tendon[7]

Risk Factors

Ankle XR showing edema and disruption of the normal contour of the achilles tendon on lateral radiographs[8]
  • Demographic
    • Increased age
    • Male gender (2-12 fold increase)[9]
  • Sports
    • Football
    • Tennis
    • Badminton
    • Jumping
    • Running athletes
  • Biomechanical/ Orthopedic
    • Gastrocnemius-soleus dysfunction
    • Sub-optimally conditioned musculotendinous unit,
    • Changes in training pattern
    • Poor technique
    • Previous injuries
    • Inappropriate footwear
    • Poor tendon vascularity
  • Systemic
  • Medications

Differential Diagnosis


Clinical Features

Illustration of the Thompson test. Normal exam in the top image and an abnormal exam in the bottom[10]
  • History
    • Sudden severe pain at the time of injury
    • Sensation of being "kicked" in the leg, or a popping or giving way sensation
    • Pain and swelling posterior calf into calcaneus
    • Inability to plantarflex
  • Physical Exam: Physical Exam Foot And Ankle
    • Diffuse edema, bruising are often present
    • A palpable gap may be palpated
  • Special Tests
    • Thompson Test: Patient prone, squeeze calf look for absence of plantar flexion
    • Matles Test: Patient is prone, knees flexed to 90°, observe resting position of feet
    • Hyper Dorsiflexion Sign: Passively dorsiflex both feet maximally
    • Copelands Test: Use a blood pressure cuff to evaluate tendon
    • Obriens Needle Test: Use a needle placed in the tendon to evaluate
    • [[Achilles Palpation Test]: Palpate for the defect

Evaluation

Sonogram of an Achilles tendon tear in long axis. Note the discontinuation of fibers with hypoechoic fluid in the center

AAOS Clinical Practice Guidelines

  • The diagnosis is primary clinical, based on history and physical exam
    • Imaging can be used as an adjunct to help confirm the suspected diagnosis
  • Diagnosis of acute rupture is established by two or more of the following:[11]
    • Positive Thompson test
    • Decreased plantar flexion strength
    • Presence of a palpable defect
    • Increased passive ankle dorsiflexion with gentle manipulation

Radiographs

  • Standard Radiographs Ankle
    • Typically used to exclude other diseases
  • Findings
    • Often appear normal
    • Heterogeneity of the Achilles tendon silhouette can be seen
  • May demonstrate signs of pre-existing degeneration or tendinosis including
    • Calcific lesion
    • Haglund prominence
    • Calcaneus avulsion fracture

Ultrasound

  • Considered diagnostic gold standard
  • Useful to identify
    • Location of a tear
    • Gap between the torn ends of the tendon
    • Partial vs complete rupture

MRI

  • Not routinely indicated if diagnosis is clear
    • Not dynamic, can't identify partial vs complete rupture very well

Classification

  • Loosely classified into
    • Acute
    • Chronic/ degenerative

Management

Prognosis

  • Surgical vs Nonsurgical
    • Management is still debated
    • Optimal treatment choice for acute ATR is not settled
    • Khan et al showed higher re-rupture rates in conservative group (12.6% vs 3.5%)[12], however this difference was attenuated by reducing the period of immobilization and using early functional rehabilitation
  • Deficits
    • Athletes have a 10-30% reduction in functional strength, endurance (need citation)
    • Deficits can persist up to at least 2 years[13]
    • Better calf recovery at 1 year: (a) female gender, (b) absence of resting pain at 3 months, physical function and calf endurance at 6 months [14]
  • Factors that appear to influence recovery, final outcome
    • Patient related: BMI, nutritional status, athletic status, comorbidities
    • Injury related: delayed presentation, etiology, gap size of lesion
  • Size of tendon gap on ultrasound
    • Mubark: Does not appear to correlate with functional status, ATRS score at 12 months of nonoperative management[15]
    • Yassin et al: increasing gap ( >10 mm) associated with poorer patient reported outcomes after rehab[16]
  • Achilles Tendon Rupture Score (ATRS)
    • Patient reported questionnaire for quantifying symptoms following an Achilles tendon rupture
    • Validated in a Danish cohort[17]
  • Return to play rates
    • Vary between 61% and 96% depending on the study and sport[18]
    • Zellers et al: SR concluded RTP was 80%[19], similar to another study by Johns et al at 76%[20]
    • In one study, 30.6% of pro athletes were unable to RTP and those who did played in fewer games, less play time, lower performance than preinjury status [21]
      • Note that in the athletes who did RTP, these deficits were noted at 1 year postoperatively, but at 2 years they were similar to healthy controls
    • Siu et al found professional basketball players reached peak post-injury performance level at the second season after surgery[22]

Nonoperative

  • Indications
    • Acute injuries with surgeon or patient preference
    • Poor surgical candidates (non-ambulatory, frail)
  • Immobilization with Short Leg Cast
    • Plantar flexion position for the first 4 weeks
    • Neutral position for the next 2-4 weeks

Operative

  • Indications
    • Acute injuries with patient or surgeon preference
  • Technique
    • Open
    • Mini-open
    • Percutaneous repair
    • Reconstruction with VY advancement
    • FHL transfer

Rehab and Return to Play

Rehabilitation

  • Functional Rehab/ Accelerated Rehab
    • Early weight bearing, functional rehabilitation appears to be superior to traditional immobilization
    • Mark-Christensen et al: meta-analysis suggests functional rehab trended superior to immobilization for outcomes (re-rupture rate, RTP, RT work, patient satisfaction, etc)[23]
    • Aufwerber et al: accelerated post-operative protocol resulted in better general health and vitality at 6 months, no difference in heel-rise function[24]
    • Many other studies have showed similar benefits in accelerated post-operative rehab[25][26]
  • Early weightbearing
    • Appears to have similar or better outcomes when compared to traditional plaster casting in non-operative patients
    • Associated with better early functional outcomes at lower cost[27]
    • Re-rupture rates are not higher in early weightbearing compared to NWB and casting[28]
    • Improves ankle ROM, no increased risk of tendon elongation or affecting long term functional outcomes[29]
    • Early weightbearing may lead to increased tendon elongation at 2 weeks, but no difference at 1 year[24]
    • Rate of tendon repair seemed to be significantly improved compared to continuous immobilization (improved collagen fibers, collagen synthesis, number and size of fibrils, tendon strength, vascularity, breaking strength, reduced adhesions[30]
  • Maffulli postoperative protocol[31]
    • Day 0: Weight bear on metataral heads with elbow crutches as tolerated
    • 2 Weeks: plaster removed, placed in wedged walking boot
      • 1 wedge was removed every other week
      • Emphasis on proprioception, active planterflexion, inversion, eversion against manual resistance from PT
    • 6 weeks: out of immobilization, active mobilization with PT
    • 12 weeks: undertake more vigorous PT
    • 6, 9 and 12 months: followed until they can perform 5 toe raises unaided, able to return to work or sport

Return to Play

  • General
    • There are no clear, evidence based guidelines to help guide athletes to RTP
    • Most patients return to sports about 6 months after surgery
    • One protocol recommends non-contact sports at 16 weeks, contact sports at 20 weeks, but not evidence based[32]
  • Proposed criteria by Van Sterkenburg et al[33]
    • Ability to perform repetitive single heel raises and toe walking
    • ≤ 25% calf strength deficit compared to the normal contralateral side (should be met approximately 12 weeks after injury)
  • Achilles Tendon Rupture Score (ATRS)
    • Has been used as an objective measurement to help guide RTP
    • Hansen et al: ATRS at 3 months predicts ability to RTP at 1 year[34]

Complications

  • Loss of function
  • Failure to return to sports at the same level of performance pre-injury
    • Systematic review found 80% of athletes return to play[19]
  • Re-rupture Postoperatively
    • Rettig et al: overall postoperative rerupture rate is 4.5%[35]
    • Tends to occur within the first 12 weeks after treatment
  • Calf muscle weakness
  • Infection
    • Infection and wound complication rate is high at 12.5%[36]
  • Sural Nerve Injury

See Also


References

  1. Gillies H, Chalmers J. The management of fresh ruptures of the tendo achillis. J Bone Joint Surg Am. 1970;52(2):337–343.
  2. Jarvinen TA, Kannus P, Maffulli N, Khan KM. Achilles tendon disorders: etiology and epidemiology. Foot Ankle Clin. 2005;10(2):255–266.
  3. Moller A, Astron M, Westlin N. Increasing incidence of Achilles tendon rupture. Acta Orthop Scand. 1996;67(5):479–481.
  4. Maulli, N. Clinical tests in sports medicine: More on Achilles tendon. Br. J. Sports Med. 1996, 30, 250.
  5. 5.0 5.1 Aicale, R.; Tarantino, D.; Maulli, N. Basic Science of Tendons. In Bio-Orthopaedics: A New Approach; Gobbi, A., Espregueira-Mendes, J., Lane, J.G., Karahan, M., Eds.; Springer: Berlin, Germany, 2017; pp. 249–273.
  6. Lin, T.W.T.W.; Cardenas, L.; Soslowsky, L.J.L.J. Biomechanics of tendon injury and repair. J. Biomech. 2004, 37, 865–877
  7. Aström, M.; Westlin, N. Blood flow in chronic Achilles tendinopathy. Clin. Orthop. Relat. Res. 1994, 308, 166–172.
  8. Bowen, L., et al. "Investigating the Validity of Soft Tissue Signs on Lateral Ankle X-Ray to Aid Diagnosis of Achilles Tendon Rupture in the Emergency Department." Int J Foot Ankle 3 (2019): 033.
  9. Movin T, Ryberg A, McBride DJ, Maffulli N. Acute rupture of the Achilles tendon. Foot Ankle Clin. 2005;10(2):331–356.
  10. Thompson TC, Doherty JH. Spontaneous rupture of tendon of Achilles: a new clinical diagnostic test. J Trauma. 1962; 2: 126-129.
  11. Chiodo CP, Glazebrook M, Bluman EM, et al. Diagnosis and treatment of acute Achilles tendon rupture. J Am Acad Orthop Surg. 2010;18(8):503–510.
  12. Khan RJ, Fick D, Keogh A, Crawford J, Brammar T, Parker M. Treatment of acute achilles tendon ruptures: a meta-analysis of randomized, controlled trials. J Bone Joint Surg Am. 2005;87(10):2202–2210.
  13. Olsson, N.; Nilsson-Helander, K.; Karlsson, J.; Eriksson, B.I.; Thomée, R.; Faxén, E.; Silbernagel, K.G. Major functional deficits persist 2 years after acute Achilles tendon rupture. Knee Surg. Sports Traumatol. Arthrosc. 2011, 19, 1385–1393
  14. Bostick, G.P.; Jomha, N.M.; Suchak, A.A.; Beaupre, L.A. Factors Associated With Calf Muscle Endurance Recovery 1 Year After Achilles Tendon Rupture Repair. J. Orthop. Sports Phys. Ther. 2010, 40, 345–351.
  15. Mubark, I.; Abouelela, A.; Arya, S.; Buchanan, D.; Elgalli, M.; Parker, J.; Ashwood, N.; Karagkevrekis, C. Achilles Tendon Rupture: Can the Tendon Gap on Ultrasound Scan Predict the Outcome of Functional Rehabilitation Program? Cureus 2020, 12, e10298.
  16. Yassin, M.; Myatt, R.; Thomas, W.; Gupta, V.; Hoque, T.; Mahadevan, D. Does size of tendon gap aspect patient-reported outcome following Achilles tendon rupture treated with functional rehabilitation? Bone Jt. J. 2020, 102, 1535–1541.
  17. Ann Ganestam, Kristoffer Barfod, Jakob Klit, Anders Troelsen. Validity and Reliability of the Achilles Tendon Total Rupture Score; The Journal of Foot and Ankle Surgery, Available online 18 August 2013
  18. Tarantino, Domiziano, et al. "Achilles Tendon Rupture: Mechanisms of Injury, Principles of Rehabilitation and Return to Play." Journal of Functional Morphology and Kinesiology 5.4 (2020): 95.
  19. 19.0 19.1 Zellers, J.A.; Carmont, M.R.; Silbernagel, K.G. Return to play post-Achilles tendon rupture: A systematic review and meta-analysis of rate and measures of return to play. Br. J. Sports Med. 2016, 50, 1325–1332.
  20. Johns,W.;Walley, K.C.; Seedat, R.; Thordarson, D.B.; Jackson, B.; Gonzalez, T. Career Outlook and Performance of Professional Athletes after Achilles Tendon Rupture: A Systematic Review. Foot Ankle Int. 2020.
  21. Trofa, D.P.; Miller, J.C.; Jang, E.S.;Woode, D.R.; Greisberg, J.K.; Vosseller, J.T. Professional Athletes’ Return to Play and Performance After Operative Repair of an Achilles Tendon Rupture. Am. J. Sports Med. 2017, 45, 2864–2871.
  22. Siu, R.; Ling, S.K.-K.; Fung, N.; Pak, N.; Yung, P.S. Prognosis of elite basketball players after an Achilles tendon rupture. Asia Pac. J. Sports Med. Arthrosc. Rehabil. Technol. 2020, 21, 5–10.
  23. Mark-Christensen, T.; Troelsen, A.; Kallemose, T.; Barfod, K.W. Functional rehabilitation of patients with acute Achilles tendon rupture: A meta-analysis of current evidence. Knee Surg. Sports Traumatol. Arthrosc. 2016, 24, 1852–1859.
  24. 24.0 24.1 Aufwerber, S.; Heijne, A.; Edman, G.; Silbernagel, K.G.; Ackermann, P.W. Does Early Functional Mobilization Affect Long-Term Outcomes After an Achilles Tendon Rupture? A Randomized Clinical Trial. Orthop. J. Sports Med. 2020, 8.
  25. Kim, U.; Choi, Y.S.; Jang, G.C.; Choi, Y.R. Early rehabilitation after open repair for patients with a rupture of the Achilles tendon. Injury 2017, 48, 1710–1713.
  26. Braunstein, M.; Baumbach, S.F.; Boecker, W.; Carmont, M.R.; Polzer, H. Development of an accelerated functional rehabilitation protocol following minimal invasive Achilles tendon repair. Knee Surg. Sports Traumatol. Arthrosc. 2018, 26, 846–853.
  27. Costa, M.; Achten, J.; Wagland, S.; Marian, I.R.; Maredza, M.; Schussel, M.M.; Liew, A.S.; Parsons, N.R.; Dutton, S.J.; Kearney, R.S.; et al. Plaster cast versus functional bracing for Achilles tendon rupture: The UKSTAR RCT. Health Technol. Assess. 2020, 24, 1–86.
  28. Harrington, T.L.; Breedlove, G.J.; Sharpe, J.J. Systematic Review of Nonoperative Functional Protocols for Acute Achilles Ruptures Utilizing a Formal Rehabilitation Protocol Showing Lowest Rerupture Rates. Foot Ankle Spec. 2020
  29. Valkering, K.P.; Aufwerber, S.; Ranuccio, F.; Lunini, E.; Edman, G.; Ackermann, P.W. Functional weight-bearing mobilization after Achilles tendon rupture enhances early healing response: A single-blinded randomized controlled trial. Knee Surg. Sports Traumatol. Arthrosc. 2017, 25, 1807–1816
  30. Mortensen, N.H.M.; Skov, O.; Jensen, P.E. Early Motion of the Ankle after Operative Treatment of a Rupture of the Achilles Tendon. A Prospective, Randomized Clinical and Radiographic Study. J. Bone Jt. Surg. 1999, 81, 983–990.
  31. Maffulli, G.; Del Buono, A.; Richards, P.; Oliva, F.; Maulli, N. Conservative, minimally invasive and open surgical repair for management of acute ruptures of the Achilles tendon: A clinical and functional retrospective study. Muscle Ligaments Tendons J. 2017, 7, 46–52.
  32. Ardern, C.L.; Glasgow, P.; Schneiders, A.; Witvrouw, E.; Clarsen, B.; Cools, A.; Gojanovic, B.; Grion, S.; Khan, K.M.; Moksnes, H.; et al. 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. Br. J. Sports Med. 2016, 50, 853–864
  33. van Sterkenburg MN, Kerkhoffs GM, van Dijk CN. Good outcome after stripping the plantaris tendon in patients with chronic mid-portion Achilles tendinopathy. Knee Surg Sports Traumatol Arthrosc. 2011;19(8):1362–1366
  34. Hansen, M.S.; Christensen, M.; Budolfsen, T.; Østergaard, T.F.; Kallemose, T.; Troelsen, A.; Barfod, K.W. Achilles tendon Total Rupture Score at 3 months can predict patients’ ability to return to sport 1 year after injury. Knee Surg. Sports Traumatol. Arthrosc. 2016, 24, 1365–1371.
  35. Rettig AC, Liotta FJ, Klootwyk TE, Porter DA, Mieling P. Potential risk of rerupture in primary achilles tendon repair in athletes younger than 30 years of age. Am J Sports Med. 2005;33(1):119–123.
  36. 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;94(23):2136–2143
Created by:
John Kiel on 7 July 2019 07:25:20
Last edited:
6 April 2022 16:24:42
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