Ruptured achilles heel. Achilles Tendon Rupture: Causes, Symptoms, and Treatment Options

09.09.202311.06.2023 by alexxlab

What are the main causes of Achilles tendon rupture. How is Achilles tendon rupture diagnosed. What are the treatment options for Achilles tendon rupture. Who is most at risk for Achilles tendon injuries. How can Achilles tendon ruptures be prevented.

Содержание

Understanding Achilles Tendon Rupture: A Common Lower Extremity Injury

Achilles tendon rupture is the most frequent tendon rupture in the lower extremity, typically affecting adults between their third and fifth decades of life. This injury can cause significant pain and disability, often presenting with a sudden onset of pain accompanied by a “snapping” sensation or audible “pop” at the injury site. Some patients describe feeling as if they’ve been kicked in the lower leg.

Interestingly, Achilles tendon ruptures are more common in “weekend warrior” athletes – individuals who are only intermittently active. Unfortunately, this injury is misdiagnosed as an ankle sprain in approximately 20% to 25% of cases, highlighting the importance of accurate diagnosis and prompt treatment.

Causes and Risk Factors for Achilles Tendon Rupture

Several factors can contribute to Achilles tendon rupture:

Sudden forced plantar flexion of the foot
Direct trauma to the tendon
Long-standing tendinopathy or intratendinous degenerative conditions
Sports activities such as diving, tennis, basketball, and track
Poor conditioning before exercise
Prolonged use of corticosteroids
Overexertion
Use of quinolone antibiotics

The Achilles tendon typically ruptures about two to four centimeters above its calcaneal insertion. Interestingly, in right-handed individuals, the left Achilles tendon is most likely to rupture, and vice versa.

Systemic Factors Increasing Risk

Several systemic conditions can increase the risk of Achilles tendon injuries:

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

Foot Problems Associated with Increased Risk

Certain foot conditions can also contribute to a higher risk of Achilles tendon injuries:

Cavus foot
Insufficient gastroc-soleus flexibility and strength
Limited ability to perform ankle dorsiflexion
Tibia vara
Varus alignment with functional hyperpronation

Interestingly, individuals with blood group O and those with a family history of tendon rupture are at a higher risk of developing Achilles tendon rupture at some point in their lives.

Epidemiology of Achilles Tendon Ruptures

The incidence of Achilles tendon ruptures varies in the literature, with recent studies reporting a rate of 18 patients per 100,000 population annually. In athletic individuals, the incidence rate of Achilles tendon injuries ranges from 6% to 18%. Football players are the least likely to develop this problem compared to gymnasts and tennis players. It’s estimated that about a million athletes experience Achilles tendon injuries each year.

The true incidence of Achilles tendinosis is unknown, but reported rates include:

7% to 18% in runners
9% in dancers
5% in gymnasts
2% in tennis players
Less than 1% in American football players

The incidence of Achilles tendon injuries is increasing in the USA, likely due to more people participating in sporting activities. While the exact incidence of Achilles tendon injuries outside the USA is unknown, it’s believed to be a significant issue in athletic populations worldwide.

Diagnosing Achilles Tendon Rupture

Proper diagnosis of Achilles tendon rupture is crucial for effective treatment. How is Achilles tendon rupture typically diagnosed? The diagnosis often involves a combination of clinical examination and imaging studies.

Clinical Examination

The Thompson test is a key component of the clinical examination for suspected Achilles tendon rupture. How is the Thompson test performed? The examiner squeezes the calf muscle of the affected leg while the patient lies prone. In a normal, intact Achilles tendon, this action should cause plantar flexion of the foot. A positive Thompson test, indicating a potential Achilles tendon rupture, occurs when there’s no plantar flexion upon squeezing the calf.

Imaging Studies

While clinical examination is often sufficient for diagnosis, imaging studies can provide additional information and confirm the diagnosis. These may include:

Ultrasound: A quick, non-invasive method to visualize the tendon and assess its integrity
MRI: Provides detailed images of the tendon and surrounding tissues, useful for surgical planning
X-ray: While not directly showing the tendon, it can rule out other injuries like fractures

Treatment Options for Achilles Tendon Rupture

The treatment of Achilles tendon rupture can be broadly categorized into operative and non-operative management. What factors are considered when deciding between these treatment options?

Factors Influencing Treatment Choice

Patient age and activity level
Overall health status
Time since injury
Degree of tendon retraction
Patient preference

Non-operative Management

Non-operative treatment typically involves immobilization of the ankle in a cast or boot, followed by a gradual rehabilitation program. This approach may be suitable for:

Older or less active patients
Patients with significant comorbidities that increase surgical risks
Partial tendon tears

Operative Management

Surgical repair of the ruptured Achilles tendon is often recommended for:

Young, active patients
Athletes
Complete tendon ruptures with significant retraction

Surgical techniques may include open repair, minimally invasive repair, or percutaneous repair, depending on the specific case and surgeon preference.

Rehabilitation and Recovery After Achilles Tendon Rupture

Regardless of the treatment approach, rehabilitation plays a crucial role in recovery from Achilles tendon rupture. What does the typical rehabilitation process involve?

Phases of Rehabilitation

Protection Phase: Immobilization to allow initial healing
Early Mobilization: Gentle range of motion exercises
Strengthening: Progressive exercises to rebuild calf muscle strength
Functional Training: Sport-specific exercises to prepare for return to activity

The duration and specifics of each phase can vary depending on the individual case and treatment approach. Full recovery and return to pre-injury activity levels can take several months to a year.

Preventing Achilles Tendon Ruptures

Given the significant impact of Achilles tendon ruptures, prevention is a key consideration. How can individuals reduce their risk of experiencing this injury?

Preventive Strategies

Proper warm-up before exercise
Gradual increase in exercise intensity and duration
Regular stretching and strengthening exercises for the calf muscles
Wearing appropriate footwear
Avoiding sudden increases in training load
Addressing any underlying foot problems or biomechanical issues

For individuals with known risk factors, such as previous Achilles tendon injuries or certain medical conditions, extra caution and preventive measures may be necessary.

Long-term Outcomes and Complications

Understanding the potential long-term outcomes and complications of Achilles tendon rupture is crucial for patients and healthcare providers. What can patients expect in terms of recovery and potential issues?

Recovery Expectations

Most patients can expect to return to their pre-injury level of activity, but this process can take time:

3-6 months: Return to normal daily activities
6-12 months: Return to sports and high-impact activities

However, some patients may experience persistent weakness or reduced function in the affected leg.

Potential Complications

While most Achilles tendon ruptures heal well with appropriate treatment, complications can occur:

Re-rupture: Risk is higher with non-operative treatment
Infection: More common with surgical treatment
Nerve injury: Can occur during surgery
Chronic pain or stiffness
Deep vein thrombosis: Risk increases with immobilization

Regular follow-up and adherence to rehabilitation protocols can help minimize these risks and optimize outcomes.

Advances in Achilles Tendon Rupture Treatment

As medical science progresses, new approaches to treating Achilles tendon ruptures are emerging. What are some of the recent advances in this field?

Innovative Treatment Approaches

Minimally invasive surgical techniques: Reducing surgical trauma and potentially speeding recovery
Biological augmentation: Use of platelet-rich plasma or stem cells to enhance healing
Advanced imaging: Improved diagnostic accuracy and surgical planning
Accelerated rehabilitation protocols: Earlier weight-bearing and range of motion exercises

These advances aim to improve outcomes, reduce complications, and speed up recovery times for patients with Achilles tendon ruptures.

Future Directions

Research in Achilles tendon rupture treatment continues to evolve. Areas of ongoing investigation include:

Tissue engineering approaches for tendon repair
Personalized treatment protocols based on individual patient factors
Advanced biomechanical analysis to optimize rehabilitation
Novel pharmacological interventions to enhance tendon healing

As our understanding of tendon biology and biomechanics improves, we can expect further refinements in the prevention, diagnosis, and treatment of Achilles tendon ruptures.

The Role of the Interprofessional Team in Managing Achilles Tendon Ruptures

Effective management of Achilles tendon ruptures often requires a coordinated effort from various healthcare professionals. How does an interprofessional team approach enhance outcomes for patients with this injury?

Key Team Members

Orthopedic Surgeons: Diagnose the injury and perform surgical repairs when necessary
Physical Therapists: Guide rehabilitation and help patients regain strength and function
Sports Medicine Physicians: Provide non-operative management and oversee return to sports
Radiologists: Interpret imaging studies to confirm diagnosis and assess healing
Primary Care Physicians: Manage overall health and any contributing medical conditions
Nurses: Provide patient education and assist with post-operative care

Benefits of Interprofessional Collaboration

A well-coordinated interprofessional team can provide several advantages:

Comprehensive assessment of the patient’s condition and needs
Tailored treatment plans that consider all aspects of the patient’s health and lifestyle
Improved communication between healthcare providers and patients
More efficient use of healthcare resources
Better monitoring of progress and early identification of potential complications

By working together, these professionals can ensure that patients receive optimal care throughout their recovery journey, from initial diagnosis through rehabilitation and return to activity.

Patient Education and Self-Management in Achilles Tendon Rupture Recovery

While professional medical care is crucial in treating Achilles tendon ruptures, patient involvement and self-management play a significant role in recovery. What can patients do to optimize their healing process and long-term outcomes?

Key Aspects of Patient Education

Understanding the injury and treatment process
Proper use of assistive devices (crutches, walking boots)
Wound care and infection prevention (for surgical patients)
Recognition of potential complications
Importance of adherence to rehabilitation protocols

Self-Management Strategies

Patients can actively participate in their recovery by:

Following prescribed activity restrictions and gradual return to weight-bearing
Performing home exercises as instructed by physical therapists
Maintaining a healthy diet to support tissue healing
Managing pain and swelling with appropriate measures (e.g., elevation, ice)
Gradually reintroducing activities under professional guidance
Monitoring for signs of complications and seeking prompt medical attention if concerns arise

By actively engaging in their recovery process, patients can contribute significantly to their healing and potentially achieve better long-term outcomes.

Long-term Considerations

Even after the initial recovery period, patients should remain mindful of their Achilles tendon health. This may include:

Continuing with maintenance exercises to preserve strength and flexibility
Being cautious when returning to high-impact activities
Paying attention to proper footwear and biomechanics
Recognizing early signs of potential re-injury or overuse

With proper education and self-management, patients can play an active role in their recovery from Achilles tendon rupture and minimize the risk of future injuries.

Achilles Tendon Rupture – StatPearls

Continuing Education Activity

Achilles tendon rupture is the most common tendon rupture in the lower extremity. The injury most commonly occurs in adults in their third to fifth decade of life. Acute ruptures often present with sudden onset of pain associated with a “snapping” or audible “pop” heard at the site of injury. Patients may describe a sensation similar to being kicked in the lower leg. Achilles tendon rupture causes significant pain and disability. This activity reviews the etiology, presentation, evaluation, and management of Achilles tendon rupture and examines the role of the interprofessional team in managing it.

Objectives:

Describe risk factors associated with Achilles tendon rupture.
Explain how the Thompson test is performed and what a positive test suggests.
Describe the factors to consider when deciding whether to treat an Achilles tendon rupture with operative versus nonoperative management.
Describe how an optimally functioning interprofessional team would coordinate care to enhance outcomes for patients with Achilles tendon rupture.

Access free multiple choice questions on this topic.

Introduction

Achilles tendon rupture is the most common tendon rupture in the lower extremity. The injury most commonly occurs in adults in their third to fifth decade of life.[1] Acute ruptures often present with sudden onset of pain associated with a “snapping” or audible “pop” heard at the injury site. Patients can describe the sensation of being kicked in the lower leg. The injury causes significant pain and disability.

Achilles tendon injuries typically occur in individuals who are only active intermittently (i.e., the “weekend warrior” athletes). The injury is reportedly misdiagnosed as an ankle sprain in 20% to 25% of patients. Moreover, patients in their third to the fifth decade of life are most commonly affected, as 10% report a history of prodromal symptoms, and known risk factors include prior intratendinous degeneration (ie, tendinosis), fluoroquinolone use, steroid injections, and inflammatory arthritides. [2][3][4][5]

Etiology

Causes of Achilles tendon rupture include sudden forced plantar flexion of the foot, direct trauma, and long-standing tendinopathy or intratendinous degenerative conditions. Sports 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, overexertion, 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 right-handed individuals, the left Achilles tendon is most likely to rupture and vice versa.[6][7][8]

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 gastroc-soleus flexibility and strength
limited ability to perform ankle dorsiflexion
Tibia vara
Varus alignment with functional hyperpronation

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

Epidemiology

The incidence of Achilles tendon ruptures vary in the literature, with recent studies reporting a rate of 18 patients per 100,000 patient population annually. Regarding athletic individuals, the incidence rate of Achilles tendon injuries ranges from 6% to 18%, and football players are the least likely to develop this problem compared to gymnasts and tennis players. About a million athletes are believed to have 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. Achilles disorders affect approximately 1 million athletes per year.[9]

The incidence of Achilles tendon injuries is increasing in the USA because of more participation of people in sporting activities. The exact incidence of Achilles tendon injuries is unknown outside the USA, but studies from Denmark and Scotland reveal 6 to 37 cases per 100,000 persons.

Achilles tendon injuries appear more commonly in males, probably related to greater participation in sports activities. Most injuries are seen 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 an incomplete repair process. Animal studies show that tendon rupture is most likely if there is more than 8% stretching of their original length.

The proximal segment of the tendon receives its blood from the muscle bellies connected to the tendon. Blood supply to the distal segment of the tendon is via the tendon-bone interface.

History and Physical

Patients often present with acute, sharp pain in the Achilles tendon region. On physical exam, patients with Achilles tendon rupture cannot 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 examiner performs the Thompson test to assess for Achilles tendon continuity in the setting of suspected rupture. The examiner places the patient in the prone position with the ipsilateral knee flexed to about 90 degrees. The foot/ankle is in the resting position. Upon squeezing the calf, the examiner notes the presence and degree of plantarflexion at the foot/ankle. This should be compared to the contralateral side. A positive (abnormal) test is strongly associated with Achilles rupture.

Evaluation

In the setting of trauma to the lower leg, radiographs are obtained to rule out the presence of a fracture. The diagnosis can be confirmed with ultrasound imaging or MRI based on clinical suspicion following the physical examination. [10]

Treatment / Management

Operative Versus Nonoperative Management

The initial management of Achilles tendon rupture is rest, elevation, pain control, and functional bracing. There is still debate surrounding the potential benefits versus risks of surgical intervention. Studies have demonstrated good functional results and patient satisfaction with both operative and nonoperative modalities.

Healing rates with serial casting/functional bracing are no different compared to the 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 the range of motion of the ankle.[11][4][12]

Rehabilitation is critical to regaining maximal ankle function. While the debate remains regarding the optimal treatment modality, the consensus includes the following:

Patients with significant medical comorbidities or relatively sedentary lifestyles are often recommended for nonoperative management.
The patient/surgeon discussion should include a detailed discussion concerning the current literature reporting satisfactory outcomes with both treatment plans and the following topics:
- Possibility of quicker return to work with operative intervention
- Equivalent plantar flexion strength at long-term followup
- Possibility of an increased risk of re-rupture and re-injury with nonoperative management (compared to operative management)
- Lower complication rates for nonoperative treatment compared to operative management

Several techniques for Achilles tendon repair exist, but all involve the reapproximation of torn ends. Sometimes the repair is reinforced by the plantaris tendon or the gastroc-soleus aponeurosis.

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 to 12 weeks. Benefits of a nonsurgical approach include no hospital admission costs, no wound complications, and no risk of anesthesia. The most significant disadvantage is the risk of re-rupture, which is as high as 40%.

Differential Diagnosis

Achilles bursitis
Ankle fracture
Ankle impingement syndrome
Ankle osteoarthritis
Ankle sprain
Calf injuries
Calcaneofibular ligament injury
Calcaneus fractures
Deep venous thrombosis (DVT)
Exertional compartment syndrome
Fascial tears
Gastrocnemius or soleus muscle strain or rupture
Haglund deformity
Plantaris tendon tear
Psoriatic arthritis
Reiter syndrome
Retrocalcaneal bursitis
Ruptured Baker cyst
Syndesmosis
Talofibular ligament injury

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. Most athletes can resume their previous sporting activity without any limitations. However, non-surgical treatment has a re-rupture rate of nearly 40% compared to only 0.5% for those treated surgically.

Complications

Re-rupture

Wound Healing Complications

Overall, a 5-10% risk following surgery
Risk factors for postoperative wound complications include the following:
- Smoking (most common and most significant risk factor)
- Female sex
- Steroid use
- Open technique (vs percutaneous procedures)

Sural Nerve Injury

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.

Rehabilitation

Rehabilitation will vary based on surgical versus non-surgical approach and referring physician’s protocol, highlighting the importance of the therapist working closely with referring physician to optimize care. This is particularly important for brace use and weight-bearing status as these areas are those in which therapy management tends to vary the most with this condition. Depending on operative vs. non-operative, immobilization may range from approximately 3 to 4 weeks in operative and 3 to 9 weeks conservative with orthotic use following both approaches depending on referring orthopedic protocol. Varying degrees of plantarflexion to neutral positioning are utilized during this time, with specifics on the optimal positioning still widely debated.[14][15][16] Emphasizing the need to avoid hyper dorsiflexion during this time has been noted as an important component in avoiding elongation of the Achilles tendon and long-term functional deficits.[14]

If conservative methods are used, therapy begins during the immobilization phase of cast wear for weight-bearing mobilization training and exercise to promote the maintenance of strength in the remainder of the affected limb. More recent studies have shown the benefits of initiating functional casts coupled with early weight bearing in conservative treatment, including a faster return to activity and improved ankle dorsiflexion (traditionally operative treatment corresponded with earlier weight-bearing and exercise initiation), but this continues to vary and will be determined by the referring physician.[14][15][16]

For surgical patients, rehabilitation exercises typically begin 2 to 4 weeks postop.[17] Post-immobilization therapy consists of exercise progression, including ankle range of motion exercises, resistive and progressive strengthening exercises, isometric exercises, cardiovascular exercises, and balance exercises as appropriate.[18]

Exercise focus is typically low impact for the first six months, with high-impact exercises incorporated after six months, emphasizing a return to sport as appropriate. Data has shown a need for a heavy focus on calf strengthening within the first year of injury as a reduction in strength gain potential has been demonstrated beyond the one-year post-injury date. [14]

Deterrence and Patient Education

While active patients and recreational athletes often return to baseline activity levels and work following both nonoperative and operative management of these injuries. High-level professional athletes most often report inferior results and return to play regardless of the chosen management plan.

A 2017 study from the American Journal of Sports Medicine reported professional athletes’ follow-up performance (NBA, NFL, MLB, and NHL) at 1- and 2-year follow-ups after surgery performed between 1989 and 2013:

>30% failure to return to play
Athletes returning noted (at 1-year follow-up) the following:
- Fewer games played, overall
- Less playing time, overall
- Suboptimal performance level, overall
Athletes able to return to play by 2-year follow-up show no statistically significant difference in performance level[19]

Thus, athletes demonstrating the ability to return to play by 1-year should expect to achieve continuous improvement to baseline performance by the ensuing season.

Pearls and Other Issues

To prevent Achilles tendon rupture, 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 to undertake. There is a wide variation in the management of Achilles tendon injury between orthopedic surgeons and sports physicians. Further, there is no uniformity in postoperative rehabilitation. Experts recommend that an interprofessional approach may help achieve better outcomes.[10][20] [Level 5]

The team should include a trauma surgeon, an orthopedic surgeon, a rehabilitation specialist, and a sports physician. The pharmacist must ensure the patient is not on any medications that can affect healing. The nurse should educate the patient on the importance of stretching before 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.[21][22][23] [Level 5]

Review Questions

Access free multiple choice questions on this topic.
Comment on this article.

Figure

achilles tendon rupture. Image courtesy S Bhimji MD

Figure

Achilles tendon rupture. Image courtesy S Bhimji MD

Figure

Achilles Tendon Rupture
T2 MRI demonstrating a full-thickness Achilles rupture with gapping at the classing “watershed” area. Contributed by Mark A. Dreyer, DPM, FACFAS

References

1.: Järvinen TA, Kannus P, Maffulli N, Khan KM. Achilles tendon disorders: etiology and epidemiology. Foot Ankle Clin. 2005 Jun;10(2):255-66. [PubMed: 15922917]
2.: Carmont MR. Achilles tendon rupture: the evaluation and outcome of percutaneous and minimally invasive repair. Br J Sports Med. 2018 Oct;52(19):1281-1282. [PubMed: 29936431]
3.: Noback PC, Freibott CE, Tantigate D, Jang E, Greisberg JK, Wong T, Vosseller JT. Prevalence of Asymptomatic Achilles Tendinosis. Foot Ankle Int. 2018 Oct;39(10):1205-1209. [PubMed: 29855207]
4.: Haapasalo H, Peltoniemi U, Laine HJ, Kannus P, Mattila VM. Treatment of acute Achilles tendon rupture with a standardised protocol. Arch Orthop Trauma Surg. 2018 Aug;138(8):1089-1096. [PubMed: 29725765]
5.: Yasui Y, Tonogai I, Rosenbaum AJ, Shimozono Y, Kawano H, Kennedy JG. The Risk of Achilles Tendon Rupture in the Patients with Achilles Tendinopathy: Healthcare Database Analysis in the United States. Biomed Res Int. 2017;2017:7021862. [PMC free article: PMC5429922] [PubMed: 28540301]
6.: Alušík Š, Paluch Z. [Drug induced tendon injury]. Vnitr Lek. 2018 Winter;63(12):967-971. [PubMed: 29334747]
7.: Ahmad J, Jones K. The Effect of Obesity on Surgical Treatment of Achilles Tendon Ruptures. J Am Acad Orthop Surg. 2017 Nov;25(11):773-779. [PubMed: 28957986]
8.: Maffulli N, Via AG, Oliva F. Chronic Achilles Tendon Rupture. Open Orthop J. 2017;11:660-669. [PMC free article: PMC5633724] [PubMed: 29081863]
9.: Egger AC, Berkowitz MJ. Achilles tendon injuries. Curr Rev Musculoskelet Med. 2017 Mar;10(1):72-80. [PMC free article: PMC5344857] [PubMed: 28194638]
10.: Dams OC, van den Akker-Scheek I, Diercks RL, Wendt KW, Zwerver J, Reininga IHF. Surveying the management of Achilles tendon ruptures in the Netherlands: lack of consensus and need for treatment guidelines. Knee Surg Sports Traumatol Arthrosc. 2019 Sep;27(9):2754-2764. [PMC free article: PMC6706364] [PubMed: 29971520]
11.: Kanchanatawan W, Densiri-Aksorn W, Maneesrisajja T, Suppauksorn S, Arirachakaran A, Rungchamrussopa P, Boonma P. Hybrid Achilles Tendon Repair. Arthrosc Tech. 2018 Jun;7(6):e639-e644. [PMC free article: PMC6019910] [PubMed: 30013904]
12.: Westin O, Svensson M, Nilsson Helander K, Samuelsson K, Grävare Silbernagel K, Olsson N, Karlsson J, Hansson Olofsson E. Cost-effectiveness analysis of surgical versus non-surgical management of acute Achilles tendon ruptures. Knee Surg Sports Traumatol Arthrosc. 2018 Oct;26(10):3074-3082. [PMC free article: PMC6154020] [PubMed: 29696317]
13.: Lantto I, Heikkinen J, Flinkkila T, Ohtonen P, Siira P, Laine V, Leppilahti J. A Prospective Randomized Trial Comparing Surgical and Nonsurgical Treatments of Acute Achilles Tendon Ruptures. Am J Sports Med. 2016 Sep;44(9):2406-14. [PubMed: 27307495]
14.: Park SH, Lee HS, Young KW, Seo SG. Treatment of Acute Achilles Tendon Rupture. Clin Orthop Surg. 2020 Mar;12(1):1-8. [PMC free article: PMC7031433] [PubMed: 32117532]
15.: Saxena A, Giai Via A, Grävare Silbernagel K, Walther M, Anderson R, Gerdesmeyer L, Maffulli N. Current Consensus for Rehabilitation Protocols of the Surgically Repaired Acute Mid-Substance Achilles Rupture: A Systematic Review and Recommendations From the “GAIT” Study Group. J Foot Ankle Surg. 2022 Jul-Aug;61(4):855-861. [PubMed: 35120805]
16.: Yang X, Meng H, Quan Q, Peng J, Lu S, Wang A. Management of acute Achilles tendon ruptures: A review. Bone Joint Res. 2018 Oct;7(10):561-569. [PMC free article: PMC6215245] [PubMed: 30464836]
17.: Amendola F, Barbasse L, Carbonaro R, Alessandri-Bonetti M, Cottone G, Riccio M, De Francesco F, Vaienti L, Serror K. The Acute Achilles Tendon Rupture: An Evidence-Based Approach from the Diagnosis to the Treatment. Medicina (Kaunas). 2022 Sep 01;58(9) [PMC free article: PMC9500605] [PubMed: 36143872]
18.: Zellers JA, Christensen M, Kjær IL, Rathleff MS, Silbernagel KG. Defining Components of Early Functional Rehabilitation for Acute Achilles Tendon Rupture: A Systematic Review. Orthop J Sports Med. 2019 Nov;7(11):2325967119884071. [PMC free article: PMC6878623] [PubMed: 31803789]
19.: Trofa DP, Miller JC, Jang ES, Woode DR, Greisberg JK, Vosseller JT. Professional Athletes’ Return to Play and Performance After Operative Repair of an Achilles Tendon Rupture. Am J Sports Med. 2017 Oct;45(12):2864-2871. [PubMed: 28644678]
20.: Hertel G, Götz J, Grifka J, Willers J. [Achilles tendon rupture : Current diagnostic and therapeutic standards]. Orthopade. 2016 Aug;45(8):709-20. [PubMed: 27405457]
21.: Song YJ, Chen G, Jia SH, Xu WB, Hua YH. Good outcomes at mid-term following the reconstruction of chronic Achilles tendon rupture with semitendinosus allograft. Knee Surg Sports Traumatol Arthrosc. 2020 May;28(5):1619-1624. [PubMed: 30128686]
22.: Westin O, Nilsson Helander K, Grävare Silbernagel K, Samuelsson K, Brorsson A, Karlsson J. Patients with an Achilles tendon re-rupture have long-term functional deficits and worse patient-reported outcome than primary ruptures. Knee Surg Sports Traumatol Arthrosc. 2018 Oct;26(10):3063-3072. [PMC free article: PMC6154022] [PubMed: 29691618]
23.: Becher C, Donner S, Brucker J, Daniilidis K, Thermann H. Outcome after operative treatment for chronic versus acute Achilles tendon rupture – A comparative analysis. Foot Ankle Surg. 2018 Apr;24(2):110-114. [PubMed: 29409231]
24.: Holm C, Kjaer M, Eliasson P. Achilles tendon rupture–treatment and complications: a systematic review. Scand J Med Sci Sports. 2015 Feb;25(1):e1-10. [PubMed: 24650079]
25.: Xergia SA, Tsarbou C, Liveris NI, Hadjithoma Μ, Tzanetakou IP. Risk factors for Achilles tendon rupture: an updated systematic review. Phys Sportsmed. 2022 Jun 10;:1-11. [PubMed: 35670156]
26.: Humbyrd CJ, Bae S, Kucirka LM, Segev DL. Incidence, Risk Factors, and Treatment of Achilles Tendon Rupture in Patients With End-Stage Renal Disease. Foot Ankle Int. 2018 Jul;39(7):821-828. [PMC free article: PMC6023765] [PubMed: 29582683]
27.: Meulenkamp B, Stacey D, Fergusson D, Hutton B, Mlis RS, Graham ID. Protocol for treatment of Achilles tendon ruptures; a systematic review with network meta-analysis. Syst Rev. 2018 Dec 23;7(1):247. [PMC free article: PMC6304227] [PubMed: 30580763]
28.: Edama M, Takabayashi T, Yokota H, Hirabayashi R, Sekine C, Maruyama S, Otani H. Classification by degree of twisted structure of the fetal Achilles tendon. Surg Radiol Anat. 2021 Oct;43(10):1691-1695. [PubMed: 34263342]
29.: Hijazi KM, Singfield KL, Veres SP. Ultrastructural response of tendon to excessive level or duration of tensile load supports that collagen fibrils are mechanically continuous. J Mech Behav Biomed Mater. 2019 Sep;97:30-40. [PubMed: 31085458]
30.: Cao S, Teng Z, Wang C, Zhou Q, Wang X, Ma X. Influence of Achilles tendon rupture site on surgical repair outcomes. J Orthop Surg (Hong Kong). 2021 Jan-Apr;29(1):23094990211007616. [PubMed: 33845659]
31.: Lorimer AV, Hume PA. Achilles tendon injury risk factors associated with running. Sports Med. 2014 Oct;44(10):1459-72. [PubMed: 24898814]
32.: Nichols AEC, Oh I, Loiselle AE. Effects of Type II Diabetes Mellitus on Tendon Homeostasis and Healing. J Orthop Res. 2020 Jan;38(1):13-22. [PMC free article: PMC6893090] [PubMed: 31166037]
33.: Winnicki K, Ochała-Kłos A, Rutowicz B, Pękala PA, Tomaszewski KA. Functional anatomy, histology and biomechanics of the human Achilles tendon – A comprehensive review. Ann Anat. 2020 May;229:151461. [PubMed: 31978571]
34.: Ho JO, Sawadkar P, Mudera V. A review on the use of cell therapy in the treatment of tendon disease and injuries. J Tissue Eng. 2014;5:2041731414549678. [PMC free article: PMC4221986] [PubMed: 25383170]
35.: Freedman BR, Gordon JA, Soslowsky LJ. The Achilles tendon: fundamental properties and mechanisms governing healing. Muscles Ligaments Tendons J. 2014 Apr;4(2):245-55. [PMC free article: PMC4187594] [PubMed: 25332943]
36.: Reiman M, Burgi C, Strube E, Prue K, Ray K, Elliott A, Goode A. The utility of clinical measures for the diagnosis of achilles tendon injuries: a systematic review with meta-analysis. J Athl Train. 2014 Nov-Dec;49(6):820-9. [PMC free article: PMC4264655] [PubMed: 25243736]
37.: Garras DN, Raikin SM, Bhat SB, Taweel N, Karanjia H. MRI is unnecessary for diagnosing acute Achilles tendon ruptures: clinical diagnostic criteria. Clin Orthop Relat Res. 2012 Aug;470(8):2268-73. [PMC free article: PMC3392388] [PubMed: 22538958]
38.: Ochen Y, Beks RB, van Heijl M, Hietbrink F, Leenen LPH, van der Velde D, Heng M, van der Meijden O, Groenwold RHH, Houwert RM. Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis. BMJ. 2019 Jan 07;364:k5120. [PMC free article: PMC6322065] [PubMed: 30617123]
39.: Carmont MR, Rossi R, Scheffler S, Mei-Dan O, Beaufils P. Percutaneous & Mini Invasive Achilles tendon repair. Sports Med Arthrosc Rehabil Ther Technol. 2011 Nov 14;3:28. [PMC free article: PMC3227582] [PubMed: 22082172]
40.: Oksanen MM, Haapasalo HH, Elo PP, Laine HJ. Hypertrophy of the flexor hallucis longus muscle after tendon transfer in patients with chronic Achilles tendon rupture. Foot Ankle Surg. 2014 Dec;20(4):253-7. [PubMed: 25457661]
41.: Myhrvold SB, Brouwer EF, Andresen TKM, Rydevik K, Amundsen M, Grün W, Butt F, Valberg M, Ulstein S, Hoelsbrekken SE. Nonoperative or Surgical Treatment of Acute Achilles’ Tendon Rupture. N Engl J Med. 2022 Apr 14;386(15):1409-1420. [PubMed: 35417636]
42.: Deng S, Sun Z, Zhang C, Chen G, Li J. Surgical Treatment Versus Conservative Management for Acute Achilles Tendon Rupture: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Foot Ankle Surg. 2017 Nov-Dec;56(6):1236-1243. [PubMed: 29079238]
43.: Mansfield K, Dopke K, Koroneos Z, Bonaddio V, Adeyemo A, Aynardi M. Achilles Tendon Ruptures and Repair in Athletes-a Review of Sports-Related Achilles Injuries and Return to Play. Curr Rev Musculoskelet Med. 2022 Oct;15(5):353-361. [PMC free article: PMC9463425] [PubMed: 35804260]
44.: Indino C, D’Ambrosi R, Usuelli FG. Biologics in the Treatment of Achilles Tendon Pathologies. Foot Ankle Clin. 2019 Sep;24(3):471-493. [PubMed: 31370998]
45.: Bachir RM, Zaia IM, Santos GS, Fonseca LFD, Boni G, Guercia RF, Ferreira GF, Lana JFSD. Bone Marrow Aspirate Concentrate Improves Outcomes in Adults With Osteochondral Dissecans of the Talus and Achilles Rupture. Arthroscopy. 2023 Mar;39(3):881-886. [PubMed: 36543662]
46.: Stein BE, Stroh DA, Schon LC. Outcomes of acute Achilles tendon rupture repair with bone marrow aspirate concentrate augmentation. Int Orthop. 2015 May;39(5):901-5. [PubMed: 25795246]
47.: Glazebrook M, Rubinger D. Functional Rehabilitation for Nonsurgical Treatment of Acute Achilles Tendon Rupture. Foot Ankle Clin. 2019 Sep;24(3):387-398. [PubMed: 31370992]
48.: Gould HP, Bano JM, Akman JL, Fillar AL. Postoperative Rehabilitation Following Achilles Tendon Repair: A Systematic Review. Sports Med Arthrosc Rev. 2021 Jun 01;29(2):130-145. [PubMed: 33972490]

: Disclosure: Alan Shamrock declares no relevant financial relationships with ineligible companies.
: Disclosure: Matthew Varacallo declares no relevant financial relationships with ineligible companies.