Introduction

  • The Achilles tendon is the largest tendon in the body. Tendinopathy and rupture can affect both athletes and those with sedentary lifestyles
  • Acute injury (i.e. rupture) to the Achilles tendon usually occurs from sudden acceleration or deceleration. This is different to Achilles tendinopathy – which is often a chronic overuse condition
  • Achilles tendon rupture occurs in athletes in 80% of cases. It is more common in those who have had previous Achilles tendon problems
  • Achilles tendon rupture can be partial or complete
  • Complete tears are usually managed surgically, but in older sedentary patients may be managed conservatively. Surgical management reduces the risk of re-rupture, but has a higher acute complication rate

Aetiology

  • Usually in athletes
    • Most commonly in sports that involve a quick acceleration – e.g. sprinting, tennis, basketball, football
  • Typically aged 30-50
  • M > F
  • May also occurs as a result of a fall with forces dorsiflexion
  • More common in chronic Achilles tendinopathy
  • Drugs
    • Corticocosteroids
    • Fluoroquinolones – e.g. ciprofloxacin
    • Avoid use of both of these medications together!
  • Pre-existing conditions
    • Rheumatoid arthritis or other inflammatory rheumatological disorders

Pathology

  • The Achilles tendon connects the gastrocnemius and soles muscles to the posterior of the calcaneus
  • It begins at the mid calf
  • It has slightly unusual anatomy – there is not true synovial sheath and instead it is surrounded by a sheath called the¬†paratenon.This is a highly vascular structure and it allows for a sliding action of the tendon inside the paratenon
  • The blood supply is least around the mid tendon – defined as the region 2-6cm proximal to the insertion. This is the area most likely to rupture

Presentation

  • Sudden onset Achilles tendon pain. Initially sharp pain, often settles within hours to days to more of a dull ache
  • A loud “snap” or “bang” is sometimes heard when the tendon ruptures!
  • Some patients report feeling as though they were hit on the back of the tendon
  • Usually occurs with a pushing-off motion – in contact to ankle sprain, which is often due to impact on landing
  • Inability to stand on tip toe on affected side

Examination

  • Often localised swelling
  • Altered gait
  • Inability to stand on tip toes
  • Reduced plantar flexion
  • Simmond’s Triad.¬†Ask the patient to lay prone on the couch, with their feet dangling off the end of the bed. Compare both sides. Check:
    • Altered “angle of dangle” –¬†in Achilles tendon rupture the affect foot will naturally “dangle” in a more dorsiflexed position than the unaffected side
    • Calf squeeze (aka¬†Thomson‚Äôs calf squeeze test) –¬†in a normal, intact Achilles¬†tendon, a calf squeeze should cause plantar flexion of the ankle. In¬†Achilles tendon rupture, there will be minimal or no plantar flexion
    • Palpable notch or gap in the Achilles tendon at this site of the rupture

Investigation

  • Often a clinical diagnosis
  • USS (usually first line) or MRI can help to differentiate a partial from a complete tear, or to narrow down differentials

Management

  • Non-weight bearing –¬†immediately
  • Urgent referral to orthopaedics – surgery is usually required
    • Surgical repairs reduces the risk of subsequent recurrent rupture, but also carries risks – such as wound infection
    • Following surgery, rehabilitation plan is often similar to conservative management outlined below
    • 80% of athletes return to sport
    • Athletes may not be able to resume full activity for up to 1 year
    • There is often some loss of function – even small amount of functional loss can have a significant impact for athletes
  • Conservative management is an option for older more sedentary patients – but decision should be made by orthopaedic specialist
    • Plaster cast for 2 weeks
    • Can be changed to immobilising boot from 2 weeks
    • Weight bear as pain allows from 4-6 weeks
    • Physiotherapy involvement from the start
  • Partial tears are usually managed conservatively, with an immobilisation boot from the start, and earlier weight bearing

Complications

  • Achilles tendon scarring and contracture – especially if there is not early mobilising and range of movement exercises – best direct by physiotherapist
  • Re-rupture
    • 3-5% after surgical treatment
    • 8-12% with conservative management
  • DVT

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