Achilles Tendon Rupture

Article Author:
William Gossman
Article Editor:
Steve Bhimji
Updated:
9/19/2018 7:23:35 PM
PubMed Link:
Achilles Tendon Rupture

Introduction

Achilles tendon rupture is a common injury in athletes. It often presents with sudden onset of pain associated with a snapping sound in the lower leg. Patients often describe this sensation as having been kicked or shot in the lower leg. The injury is often disabling, and ambulation is difficult. Even standing up can be associated with unsteadiness. Achilles tendon injuries typically tend to occur in individuals who are only active intermittently. When the injury occurs, it is immediately disabling.[1][2][3]

Etiology

Causes of Achilles tendon rupture include sudden forced plantar flexion of the foot, direct trauma, and long-standing paratendonitis. Sports that are often associated with Achilles tendon rupture include diving, tennis, basketball, and track. Risk factors for a rupture of the Achilles tendon include poor conditioning before exercise, prolonged use of corticosteroids, over exertion, and the use of quinolone antibiotics. The Achilles tendon rupture usually tends to occur about two to four cm above the calcaneal insertion of the tendon. In individuals who are right-handed, the left Achilles tendon is most likely to rupture and vice versa.[4][5][6]

The exact cause of Achilles tendon injury appears to be multifactorial. The injury is most common in cyclists, runners, volleyball players, and gymnasts. When the ankle is subject to extreme pronation, it places enormous stress on the tendon, leading to injury. In cyclists, the combination of low saddle height and extreme dorsiflexion during pedaling may also be a factor in an overuse injury.

Systemic Factors

Systemic diseases that may be associated with Achilles tendon injuries include the following:

  • Chronic renal failure
  • Collagen deficiency
  • Diabetes Mellitus
  • Gout
  • Infections
  • Lupus
  • Parathyroid disorders
  • Rheumatoid arthritis
  • Thyroid disorders 

Foot problems that increase the risk of Achilles tendon injuries include the following:

  • Cavus foot
  • Insufficient gastrocsoleus flexibility and strength
  • limited ability to perform ankle dorsiflexion
  • Tibia vara
  • Varus alignment with functional hyperpronation

It has been observed that Achilles tendon rupture is often more common in people with blood group O. Further anyone with a family history is also at a high risk of developing Achilles tendon rupture at some point in their life.

Epidemiology

The incidence rates of Achilles tendinosis varies from 6-18% in athletes. Football players are the least likely to develop this problem compared to gymnasts and tennis players. It is believed that about a million athletes suffer from Achilles tendon injuries each year.  The true incidence of Achilles tendinosis is unknown, although reported incidence rates are 7% to 18% in runners, 9% in dancers, 5% in gymnasts, 2% in tennis players, and less than 1% in American football players. It is estimated that Achilles disorders affect approximately 1 million athletes per year.[7]

The incidence of Achilles tendon injuries is on the increase in the USA because of more participation of people into sporting activities. Outside the USA, the exact incidence of Achilles tendon injuries are not known, but studies from Denmark and Scotland reveal 6-37 cases per 100,000 persons.

Achilles tendon injuries appear to be more common in males, and this is probably related to greater participation in sports activities. Most injuries are seen in between the third and fifth decade of life. Many of these individuals are only active intermittently and rarely warm up.

Pathophysiology

Achilles tendonitis is often not associated with primary prostaglandin-mediated inflammation. It appears there is a neurogenic inflammation with the presence of calcitonin gene-related peptide and substance P present. Histopathological studies reveal thickening and fibrin adhesions of the tendon with the occasional disarray of the fibers.

Neurovascularization is frequently seen in the degenerating tendon, which is also associated with pain. Tendon rupture is usually the terminal event during the degeneration process. After rupture, type 111 collagen appears to be the major collagen manufactured, suggesting that the repair process is incomplete. Animal studies show that if there is more than 8% stretching of their original length, tendon rupture is most likely.

History and Physical

Patients may complain of pain in the region of the Achilles tendon. On physical exam, patients with Achilles tendon rupture are unable to stand on their toes or have very weak plantar flexion of the ankle. Palpation may reveal a tendon discontinuity or signs of bruising around the posterior ankle. The Thompson test can be performed by squeezing the calf and watching for weakness or loss of plantar flexion in comparison to the contralateral side. The Thompson test is best done with the patient lying prone on the exam table with the feet off the edge of the table.

Evaluation

Diagnosis of can is confirmed with ultrasound or MRI. If there is trauma to the lower leg, plain x-rays should be obtained to rule out a fracture.[8]

Treatment / Management

The initial management of Achilles tendon rupture is rest, elevation, control of pain, and casting. There is still debate about benefits of surgery. Healing rates with serial casting are no different compared to surgical anastomosis of the tendon, but return to work may be slightly prolonged in patients treated medically. All patients require physical and orthotic therapy to help strengthen the muscles and improve range of motion of the ankle.[9][3][10]

Rehabilitation is critical to regaining maximal ankle function. There continues to be debate whether to undertake medical or surgical treatment for Achilles tendon rupture.

There are several techniques for Achilles tendon repair, but all involve reapproximation of the torn ends. Sometimes the repair is reinforced by the plantaris tendon or the gastrocsoleus aponeurosis.

Non-surgical treatment is indicated for patients who are inactive, old and those with systemic disorders or poor skin integrity. Others who should undergo non-surgical management include diabetics, those with wound healing difficulties, neuropathies or systemic comorbidities that increase the risk of anesthesia, wound infection or neurovascular injury.

Overall, the healing rates between casting and surgical repair are similar. The debate about an early return to activity after surgery is now being questioned. If a cast is used, it should remain for at least 6-12 weeks. Benefits of a non-surgical approach include no hospital admission costs, no wound complications and no risk of anesthesia. The biggest disadvantage is a risk of re-rupture which is as high as 40%.

Prognosis

For most patients with Achilles tendon rupture, the prognosis is excellent. But in some non-athletes, there may be some residual deficits like a reduced range of motion.The majority of athletes are able to resume their previous sporting activity without any limitations. However, it is important to be aware that non-surgical treatment has a re-rupture rate of nearly 40% compared to only 0.5% for those treated surgically.

Complications

Excessive immobilization can result in contracture and permanent weakness

Post-surgical complications include infection, adhesions, sural nerve injury and skin slough.

Postoperative and Rehabilitation Care

No matter which method is used to treat the tendon rupture, participating in an exercise program is vital. One may swim, cycle, jog or walk to increase muscle strength and range of motion.

Deterrence and Patient Education

Stretching a few minutes prior to intense activity is highly recommended.

Pearls and Other Issues

To prevent rupture of the Achilles tendon, adequate warming and stretching before physical activity is recommended.

Enhancing Healthcare Team Outcomes

Even though there are several treatments for Achilles tendon rupture, there is no consensus on which one to undertake. There is a wide variation in management of Achilles tendon injury between orthopedic surgeons and sports physicians. Further, there is no uniformity in postoperative rehabilitation. Experts recommend that a multidisciplinary approach may help achieve better outcomes. [8] [11]  (Level V) The team should include a trauma surgeon, orthopedic surgeon, rehabilitation specialist, and a sports physician. It is important that the pharmacist ensure that the patient is not on any medications that can affect the healing process. The nurse should educate the patient on the importance of stretching prior to any exercise and participating in a regular exercise program after repair.

Outcomes

Conservative treatment is usually preferred for non-athletes, but the risk of re-rupture is high. While surgery offers a lower risk of re-rupture, it is also associated with post-surgical complications that may delay recovery. Overall, the outcomes for Achilles tendon rupture are good to excellent after treatment.[12][13][14] (Level V)