Achilles tendon rupture is when the achilles tendon breaks. The achilles is
the most commonly injured tendon. Rupture can occur while performing
actions requiring explosive acceleration, such as pushing off or
jumping. The male to female ratio for Achilles tendon rupture varies between
7:1 and 4:1 across various studies. Causes
The Achilles tendon is most commonly injured by sudden plantarflexion or
dorsiflexion of the ankle, or by forced dorsiflexion of the ankle outside its
normal range of motion. Other mechanisms by which the Achilles
can be torn involve sudden direct trauma to the tendon, or sudden activation of
the Achilles after atrophy from prolonged periods of inactivity. Some
other common tears can occur from overuse while participating in intense
sports. Twisting or jerking motions can also contribute to injury.
Fluoroquinolone antibiotics, famously ciprofloxacin, are known to increase the
risk of tendon rupture, particularly Achilles.
People who commonly fall victim to Achilles rupture or tear include
recreational athletes, people of old age, individuals with previous Achilles
tendon tears or ruptures, previous tendon injections or quinolone use,
extreme changes in training intensity or activity level, and participation in a
new activity. Most cases of Achilles tendon rupture
are traumatic sports injuries. The average age of patients is 29–40 years
with a male-to-female ratio of nearly 20:1. Fluoroquinolone antibiotics, such
as ciprofloxacin, and glucocorticoids have been linked with an increased risk
of Achilles tendon rupture. Direct steroid injections into the tendon have
also been linked to rupture. Quinolone has been associated with
Achilles tendinitis and Achilles tendon ruptures for some time. Quinolones are
antibacterial agents that act at the level of DNA by inhibiting DNA Gyrase.
DNA Gyrase is an enzyme used to unwind double stranded DNA which is essential
to DNA Replication. Quinolone is specialized in the fact that it can
attack bacterial DNA and prevent them from replicating by this process, and
are frequently prescribed to the elderly. Approximately 2% to 6% of all
elderly people over the age of 60 who have had Achilles ruptures can be
attributed to the use of quinolones. Anatomy
The Achilles tendon is the strongest and thickest tendon in the body, connecting
the gastrocnemius, soleus and plantaris to the calcaneus. It is approximately 15
centimeters long and begins near the middle portion of the calf. Contraction
of the gastrosoleus plantar flexes the foot, enabling such activities as
walking, jumping, and running. The Achilles tendon receives its blood
supply from its musculotendinous junction with the triceps surae and its
innervation from the sural nerve and to a lesser degree from the tibial nerve.
Diagnosis Diagnosis is made by clinical history;
typically people say it feels like being kicked or shot behind the ankle. Upon
examination a gap may be felt just above the heel unless swelling has filled the
gap and the Simmonds' test will be positive; squeezing the calf muscles of
the affected side while the patient lies prone, face down, with his feet hanging
loose results in no movement of the foot, while movement is expected with an
intact Achilles tendon and should be observable upon manipulation of the
uninvolved calf. Walking will usually be severely impaired, as the patient will
be unable to step off the ground using the injured leg. The patient will also
be unable to stand up on the toes of that leg, and pointing the foot downward
will be impaired. Pain may be severe, and swelling is common.
Sometimes an ultrasound scan may be required to clarify or confirm the
diagnosis. MRI can also be used to confirm the diagnosis.
= Imaging = Musculoskeletal ultrasonography can be
used to determine the tendon thickness, character, and presence of a tear. It
works by sending extremely high frequencies of sound through the body.
Some of these sounds are reflected back off the spaces between interstitial
fluid and soft tissue or bone. These reflected images can be analyzed and
computed into an image. These images are captured in real time and can be very
helpful in detecting movement of the tendon and visualising possible injuries
or tears. This device makes it very easy to spot structural damages to soft
tissues, and consistent method of detecting this type of injury. This
imaging modality is inexpensive, involves no ionizing radiation and, in
the hands of skilled ultrasonographers, may be very reliable.
Magnetic resonance imaging can be used to discern incomplete ruptures from
degeneration of the Achilles tendon, and MRI can also distinguish between
paratenonitis, tendinosis, and bursitis. This technique uses a strong uniform
magnetic field to align millions of protons running through the body. these
protons are then bombarded with radio waves that knock some of them out of
alignment. When these protons return they emit their own unique radio waves
that can be analysed by a computer in 3D to create sharp cross sectional image of
the area of interest. MRI can provide unparalleled contrast in soft tissue for
an extremely high quality photograph making it easy for technicians to spot
tears and other injuries. Radiography can also be used to
indirectly identify Achilles tears. Radiography uses X-rays to analyse the
point of injury. This is not very effective at identifying injuries to
soft tissue. X-rays are created when high energy electrons hit a metal
source. X-ray images are acquired by utilising the different attenuation
characteristics of dense and less dense tissues when these rays pass through
tissue and are captured on film. X-rays are generally exposed to optimise
visualisation of dense objects such as bone while soft tissue remains
relatively undifferentiated in the background. Radiography has little role
in assessment of Achilles' tendon injury and is more useful for ruling out other
injuries such as calcaneal fractures. Treatment
Treatment options for an Achilles tendon rupture include surgical and
non-surgical approaches. Among the medical profession opinions are divided
what is to be preferred. Non-surgical management traditionally
was selected for minor ruptures, less active patients, and those with medical
conditions that prevent them from undergoing surgery. It traditionally
consisted of restriction in a plaster cast for six to eight weeks with the
foot pointed downwards. But recent studies have produced superior results
with much more rapid rehabilitation in fixed or hinged boots.
Some surgeons feel an early surgical repair of the tendon is beneficial. The
surgical option was long thought to offer a significantly smaller risk of
re-rupture compared to traditional non-operative management. Of course,
surgery imposes higher relative risks of perioperative mortality and morbidity
e.g. infection including MRSA, bleeding, deep vein thrombosis, lingering
anesthesia effects, etc. However, four recent studies have
scientifically tested the benefits of surgery, using randomized streaming of
patients into surgical and non-surgical protocols, and applying virtually
identical rehabilitation protocols to both types of patients. All four such
studies completed to date have found only small, but statistically
significant benefits from the surgery, separated from the other confounding
variables. They have all produced reasonably comparable results in
re-rupture rates, strength, and range of motion, while most have reaffirmed the
greater complication rate from surgery. Two studies showed small, but
statistically significant differences in plantarflexion strength. The surgical
group had significantly better results in the heel-rise work, heel-rise height,
concentric power, and hopping tests at the 6-month evaluation than did the
nonsurgical group. However, at the 12-month evaluation, there was a
significant between-groups difference only in the heel-rise work test.
The relative benefits of surgical and nonsurgical treatments remains a subject
of debate; authors of studies are cautious about the preferred treatment.
It should be noted that in centers that do not have early range of motion
rehabilitation available, surgical repair is preferred to decrease
re-rupture rates. = Surgery =
There are two different types of surgeries; open surgery and percutaneous
surgery. During an open surgery an incision is
made in the back of the leg and the Achilles tendon is stitched together. In
a complete or serious rupture the tendon of plantaris or another vestigial muscle
is harvested and wrapped around the Achilles tendon, increasing the strength
of the repaired tendon. If the tissue quality is poor, e.g. the injury has
been neglected, the surgeon might use a reinforcement mesh.
In percutaneous surgery, the surgeon makes several small incisions, rather
than one large incision, and sews the tendon back together through the
incision(s). Surgery may be delayed for about a week after the rupture to let
the swelling go down. For sedentary patients and those who have vasculopathy
or risks for poor healing, percutaneous surgical repair may be a better
treatment choice than open surgical repair.
= Rehabilitation = Non-surgical treatment used to involve
very long periods in a series of casts, and took longer to complete than
surgical treatment. But both surgical and non-surgical rehabilitation
protocols have recently become quicker, shorter, more aggressive, and more
successful. It used to be that patients who underwent surgery would wear a cast
for approximately 4 to 8 weeks after surgery and were only allowed to gently
move the ankle once out of the cast. Recent studies have shown that patients
have quicker and more successful recoveries when they are allowed to move
and lightly stretch their ankle immediately after surgery. To keep their
ankle safe these patients use a removable boot while walking and doing
daily activities. Modern studies including non-surgical patients
generally limit non-weight-bearing to two weeks, and use modern removable
boots, either fixed or hinged, rather than casts. Physiotherapy is often begun
as early as two weeks following the start of either kind of treatment.
There are three things that need to be kept in mind while rehabilitating a
ruptured Achilles: range of motion, functional strength, and sometimes
orthotic support. Range of motion is important because it takes into mind the
tightness of the repaired tendon. When beginning rehab a patient should perform
stretches lightly and increase the intensity as time and pain permits.
Putting linear stress on the tendon is important because it stimulates
connective tissue repair, which can be achieved while performing the “runners
stretch,”. Doing stretches to gain functional strength are also important
because it improves healing in the tendon, which will in turn lead to a
quicker return to activities. These stretches should be more intense and
should involve some sort of weight bearing, which helps reorient and
strengthen the collagen fibers in the injured ankle. A popular stretch used
for this phase of rehabilitation is the toe raise on an elevated surface. The
patient is to push up onto the toes and lower his or her self as far down as
possible and repeat several times. The other part of the rehab process is
orthotic support. This doesn’t have anything to do with stretching or
strengthening the tendon, rather it is in place to keep the patient
comfortable. These are custom made inserts that fit into the patients shoe
and help with proper pronation of the foot, which is otherwise a problem that
can lead to problems with the Achilles. To briefly summarize the steps of
rehabilitating a ruptured Achilles tendon, you should begin with range of
motion type stretching. This will allow the ankle to get used to moving again
and get ready for weight bearing activities. Then there is functional
strength, this is where weight bearing should begin in order to start
strengthening the tendon and getting it ready to perform daily activities and
eventually in athletic situations. References
External links Image sequence demonstrating Achilles
tendinosis and Achilles tendon rupture