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

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

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

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

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

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

Closed suture of the Achilles tendon – Center for Traumatology and Orthopedics

The essence of the closed suture of the Achilles tendon is closed (using a minimally invasive approach) suturing of the torn tendon and fixing it to the calcaneus with special absorbable materials (without nodal fixation), or suturing both ends of the torn tendon tendons and stitching them together.

Achilles tendon rupture – injury to athletes, slamming while jumping or while running. Swelling, pain, loss of functionality. For such patients, we try to shorten the preparation time for surgery as much as possible. Only a quick intervention (within a day) and a minimally invasive technique can provide a quick recovery.

In our center, in case of rupture of the Achilles, an operation is performed using a minimally invasive technique of closed suture of the Achilles tendon using the Pars system. This technique avoids postoperative complications and reduces the rehabilitation period from 12 to 4 months.

You can make an appointment with an operating orthopedic traumatologist by calling 8(495)414-20-64 , or by filling out the appointment form on the website.

Anatomy

The Achilles tendon is where the calf muscle attaches to the calcaneus. Achilles provides all the functional movements of the foot and lower leg.

The Achilles tendon does not have a tendon sheath and therefore has a very poor blood supply. For this reason, degenerative changes can occur throughout life. Often there are spontaneous subcutaneous ruptures. Most often, patients who lead an active lifestyle do a lot of sports.

Etiology and symptoms of ruptured Achilles

Healthy Achilles – does not tear. This happens against the backdrop of degenerative wear and tear. And the reason is usually sports activity: jump, plantar flexion of the foot. Usually the patient hears a pop and feels discomfort in the area of ​​the Achilles tendon, swelling pain.

Sometimes patients are not even aware of an Achilles tendon rupture. Clinical manifestations are not pronounced. Complaints go to inexplicable weakness in the foot area. The patient may say I am lame and cannot understand why.

Diagnostic methods

Diagnosis is established on the basis of patient complaints, examination data and objective examination. Complaints are mainly about pain in the area of ​​the Achilles tendon, discomfort, gait disturbance. In history, this is often an injury (while playing team sports). Cotton while jumping, running.

Clinically – swelling in the area of ​​the tear, swelling, pain on palpation, often retraction on palpation. The manifestation of Thompson’s symptom (the patient kneels or lies on his stomach and does not move during palpation of the gastrocnemius muscle of the foot).

Objective data: MRI can visualize the soft tissues in the Achilles area and determine the extent and nature of tendon rupture.

Achilles tear. When is an operation needed?

A rupture of the Achilles tendon can be partial (there is a large rupture of the tendon) or a complete transverse rupture of the Achilles. Less common are cases of bilateral rupture of the Achilles tendon (during his life, the patient did a lot of sports, as a result of which degeneration of the tendon occurs in the region of the 5-6th decade with possible double ruptures).

If the patient leads an active lifestyle, goes in for sports, and it is necessary to reduce the rehabilitation period, then the main method of treatment is surgical treatment.

If surgery is not performed, the range of motion of the ankle joint will not be fully restored. The damaged Achilles tendon has a poor and poor blood supply. The chances that the tendon will heal without surgery are negligible. Injury to limb function in most cases leads to disability.

At the same time, it is very important in what terms the operation is performed after the injury, and what technique is used in the surgical intervention. Late appeal to the surgeon – complicates the treatment. We have to consider options for reconstructive operations (lengthening of the Achilles tendon – Achilloplasty), and these are usually open operations, in which the risk of deep postoperative infection and suture failure increases.

How is the Achilles tendon 9 covered suture performed?0015

The essence of the closed suture of the Achilles tendon is closed (using a minimally invasive approach) suturing of the torn tendon and fixing it to the calcaneus with special absorbable materials (without nodal fixation), or suturing both ends of the torn tendon and suturing them together.

It usually takes about a day to prepare a patient. We are preparing special splints that immobilize the injured lower limb along its anterior part in the position of plantar flexion of the foot and the knee joint. The patient is admitted to the clinic, examined by an anesthesiologist, in the absence of absolute contraindications, under spinal anesthesia in the position of the patient lying on his stomach, an Achilles tendon suture is performed.

The early timing of the operation allows the use of a minimally invasive technique: closed subcutaneous suture of the Achilles tendon using the Pars system (subcutaneous suture machine). This technique allows for reliable fixation, avoiding postoperative complications, reducing swelling in the area of ​​damage, and most importantly, reducing the time and complexity of rehabilitation and restoring the full functionality of the injured limb.

Recovery and rehabilitation

flexion of the foot and knee, another 4 weeks in the splint on the foot in the position of the foot at 90 degrees). During this period, walking on crutches without load and stepping on the injured limb.

Then the rehabilitation process begins. The timing depends on the following factors:

• whether physiotherapists are involved
• the interval between surgery and injury (the shorter the better)
• the general condition of the patient (how active he is before and after the operation)
• types of rupture and the chosen method of surgery

If it is a closed Achilles tendon suture, which we use in our center, if the operation is performed at an early stage, if the patient is active and motivated, it will be possible to start training 4-6 months after the operation. In other cases, rehabilitation may take 7-12 months.

Consult with our specialists or request a second opinion from an orthopedic traumatologist on recommendations already received.

Achilles tendon injury recovery

The recovery period after any injury is considered the most difficult and responsible. After a tendon rupture, it takes an average of a year of conscientious rehabilitation to restore the previous level of training. If the recovery is not complete, then the function of the leg will remain impaired, the person may become disabled. Therefore, you need to stock up on patience and willpower.

Patients who have not undergone surgery should also be closely monitored by physicians. The risk of rupture, which then requires surgery, remains high. Complications can develop both after conservative and after surgical intervention.

Early rehabilitation in the first two weeks after surgery is described in detail in the corresponding article. The criteria for moving on to subsequent stages of recovery is functional progress. In any case, when exactly to move on to the next rehabilitation stage, only the attending physician decides!

1. First stage – healing (lasts from 2 to 6 weeks)

If in the early recovery period the foot required complete rest, now it is possible to introduce a minimal load on the calcaneal tendon. The foot can already be lowered more often, but you should still try to keep it horizontally. There should be no active actions, since the result of operations can be reduced to “no”. It is important to strike a balance between activity and rest. The doctor should systematically check the condition of the tendon. In a month (approximately) it will be possible to wear a special boot or orthosis (brace), which fixes the foot in the equinus position for 14-21 days with its gradual removal from the position of 120 degrees to an angle of 90 degrees. Gradual contraction of the ligament is carried out in accordance with medical requirements. The correct setting of the angle depends on the level of stretching of the tendon and the speed of its recovery. At 5-6 weeks, the leg is set to a 90-degree position.

2. Second stage – movement (from 7-12 weeks)

A strong scar is already formed at the site of the tear. To restore the mobility of the leg, a little physical activity is needed. In a special orthosis, it is already possible to take small walks, but walking should not cause serious pain, crutches must be used. Gradually, you can switch to one crutch, leaning on the operated leg. The crutch should be held in the opposite side of the diseased foot. It is necessary to train the toes and gradually shift the center of gravity to the affected leg. After 3 months, the patient should walk independently and work out the correct gait. The calf muscles, muscles of the foot and ankle should be strengthened. It is important at this stage not to bend the foot yet, as the tendon is too weak. You can work on an exercise bike (without dorsiflexion of the foot), an elliptical trainer, a cardio machine.

3. Third stage – full load (from 13 to 17 weeks).

After 13-15 weeks, the same loads on the healthy and diseased legs are already allowed. You can start intensive training with your own weight. The victim did not lean on the foot for a long time, the ligaments are stretched. This stage is one of the most dangerous, as the tendon is elongated more than on a healthy leg. There is an imbalance that brings certain problems and increases the risk of injury. At this stage, it is necessary to restore the tendon and bring it closer to the parameters of the tendon on a healthy leg. This stage may be delayed, but in no case should you force events yourself, even if you feel good. You need to keep working on the treadmill, cardio machine, to regain the sense of confidence that was lost when the tendon was torn. At this stage, regular monitoring by a rehabilitologist and a doctor for exercise therapy is mandatory.

4. Final stage (up to 12 months)

The last stage of recovery is coming. It lasts up to a year. The patient must get used to the operated foot. Ideally, if he does not feel any difference between a healthy and diseased limb. If the previous stages returned the tendon to its normal state, now all efforts should be directed to restoring the strength of the fibers. After 6 months, you can move on to strengthening the muscles of the ankle and the fibers of the Achilles tendon. Zigzag, sideways running is welcome. With such transverse movements, the strength of the Achilles tendon is tested. You can return to your previous workouts, but you must remember the increased vulnerability of the foot and control yourself all the time.

Warning!

1. The load should be gradual, the complication is adequate to the condition.
2. During the entire rehabilitation period, do not forget about general strengthening exercises.

The development of the joint gradually leads to a normal load, supported by physiotherapy, exercise therapy and protected orthopedic stable shoes with a high heel, which slowly decreases during the rehabilitation process. Important classes in the pool, step aerobics, training on special simulators.

The indicator of recovery is the complete restoration of the functionality of the injured leg, the absence of pain during normal training. The amplitude of her movements should not differ from the amplitude of a healthy one.

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With a severe sprain and partial torn ligament, recovery usually takes three to six months. After surgery with a complete rupture – up to one year. In 60-90 percent of those who have been injured, after twelve weeks of rehabilitation, the ability to train is at the same level as before the accident. In any case, it is necessary to observe a rehabilitologist within 12 months. The prognosis for rupture of an isolated outer tendon band with early functional treatment is good. But most experts believe that once damaged, the tendon cannot return to its original state. Therefore, after any Achilles pathology, one must be extremely careful and remember the likelihood of complications, if one does not reduce the level of physical activity and ignore the recommendations of orthopedists.