Achilles Tendon Rupture
- 1 Other Names
- 2 Background
- 3 Pathophysiology
- 4 Risk Factors
- 5 Differential Diagnosis
- 6 Clinical Features
- 7 Evaluation
- 8 Classification
- 9 Management
- 10 Rehab and Return to Play
- 11 Complications
- 12 See Also
- 13 References
- Achilles rupture
- Achilles tendon ruptures (ATR)
- Achilles Tendon Tear
- It is the most commonly injured tendon in the human body (need citation)
- Accounts for 20% of all large tendon ruptures
- Has increased in recent decades, likely due to increased participation in sporting events (need citation)
- Incidence ranges from 11 - 37 per 100,000 population
- Mean age is 39.8 years, bimodal with peaks at 25-40 years and also over 60
- The correct diagnosis may be missed in up to 25% of patients at initial presentation
- 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
- 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
- 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
- Classically produced by a single, high-low impact with sudden or violent dorsiflexion of ankle
- Acceleration-deceleration mechanism is reported in 90% of ATR
- 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
- Achilles Tendon
- 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
- Increased age
- Male gender (2-12 fold increase)
- 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
- Infectious diseases (needs to be updated)
- Neurologic conditions (needs to be updated)
- Renal Insuficiency
- Diabetes Mellitus
- Inflammatory and autoimmune conditions (needs to be updated)
- Genetically determined collagen abnormalities (needs to be updated)
- Fractures & Dislocations
- Muscle and Tendon Injuries
- Ligament Injuries
- Nerve Injuries
- 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
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:
- Positive Thompson test
- Decreased plantar flexion strength
- Presence of a palpable defect
- Increased passive ankle dorsiflexion with gentle manipulation
- Standard Radiographs Ankle
- Typically used to exclude other diseases
- 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
- Considered diagnostic gold standard
- Useful to identify
- Location of a tear
- Gap between the torn ends of the tendon
- Partial vs complete rupture
- Not routinely indicated if diagnosis is clear
- Not dynamic, can't identify partial vs complete rupture very well
- Loosely classified into
- Chronic/ degenerative
- 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%), however this difference was attenuated by reducing the period of immobilization and using early functional rehabilitation
- 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
- Achilles Tendon Rupture Score (ATRS)
- Patient reported questionnaire for quantifying symptoms following an Achilles tendon rupture
- Validated in a Danish cohort
- Return to play rates
- Vary between 61% and 96% depending on the study and sport
- Zellers et al: SR concluded RTP was 80%, similar to another study by Johns et al at 76%
- 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 
- 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
- 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
- Acute injuries with patient or surgeon preference
- Percutaneous repair
- Reconstruction with VY advancement
- FHL transfer
Rehab and Return to Play
- 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)
- Aufwerber et al: accelerated post-operative protocol resulted in better general health and vitality at 6 months, no difference in heel-rise function
- Many other studies have showed similar benefits in accelerated post-operative rehab
- 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
- Re-rupture rates are not higher in early weightbearing compared to NWB and casting
- Improves ankle ROM, no increased risk of tendon elongation or affecting long term functional outcomes
- Early weightbearing may lead to increased tendon elongation at 2 weeks, but no difference at 1 year
- 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
- Maffulli postoperative protocol
- 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
- 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
- Proposed criteria by Van Sterkenburg et al
- 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
- 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
- Re-rupture Postoperatively
- Rettig et al: overall postoperative rerupture rate is 4.5%
- Tends to occur within the first 12 weeks after treatment
- Calf muscle weakness
- Infection and wound complication rate is high at 12.5%
- Sural Nerve Injury
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