Achilles Tendon Rupture
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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

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
Achilles tendon rupture on USS
Achilles tendon rupture on USS. The area of disrupted tissue is indicated by the red line. Image by Hellerhoff is licensed with CC BY-SA 3.0

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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Dr Tom Leach

Dr Tom Leach MBChB DCH EMCert(ACEM) currently works as a GP Registrar and an Emergency Department CMO in Australia. He is also a Clinical Associate Lecturer at the Australian National University. After graduating from his medical degree at the University of Manchester in 2011, Tom completed his Foundation Training at Bolton Royal Hospital, before moving to Australia in 2013. He started almostadoctor whilst a third year medical student in 2009. Read full bio

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