Achilles tendon rupture

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Achilles tendon rupture

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.

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 that are often associated with Achilles tendon rupture include diving, tennis, basketball, and track. Risk factors for a rupture of the Achilles tendon include poor conditioning before exercise, prolonged use of corticosteroids, 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 individuals who are right-handed, the left Achilles tendon is most likely to rupture and vice versa.

Epidemiology

• The incidence rates of Achilles tendon ruptures varies in the literature, with recent studies reporting a rate of 18 patients per 100,000 patient population annually.  In regard to athletic populations, 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. It is believed that about a million athletes suffer from Achilles tendon injuries each year.

Signs and symptoms

• Patients often present with acute, sharp pain in the region of the Achilles tendon. On physical exam, patients with Achilles tendon rupture are unable to stand on their toes, walk or have very weak plantarflexion of the ankle. Palpation may reveal a tendon discontinuity or signs of Bruising around the posterior ankle.
• Patients commonly relate feeling as though they were "hit in the back of the leg with a bat".
• A positive (abnormal) Thompson test is strongly associated with Achilles rupture.

Positive Matles test

Diagnosis

Approximately 25% of Achilles tendon ruptures are misdiagnosed initially. A thorough history and physical examination, coupled with high clinical suspicion, can prevent this from happening.

• Thompson's test: The patient is placed in a prone position with the knees flexed. Plantarflexion of ankle should be obtained when the examiner squeezes the calf muscles. No plantarflexion indicates rupture of the tendon. ( a positive test )
• Matles test: The patient is placed in a prone position with the knees flexed in 90 degrees. If the injured foot falls to neutral or dorsiflexed position, the Achilles tendon is ruptured. (a positive test)
• MRI (Magnetic resonance imaging) and Ultrasound may be useful when clinical suspicion is high, but clinical tests are inconclusive.

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Repair of ruptured Achilles tendon

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 surgical Anastomosis of the tendon, but return to work may be slightly prolonged in patients treated medically. All patients require physical and orthotic therapy to help strengthen the muscles and improve range of motion of the ankle.
• Rehabilitation is critical to regaining maximal ankle function.
• Patients with significant medical co-morbidity or those with relatively sedentary lifestyles are often recommended for nonoperative management.
• There are several techniques for Achilles tendon repair, but all involve re-approximation of the torn ends. Sometimes the repair is reinforced by the plantaris tendon or the gastrocsoleus 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 6-12 weeks. Benefits of a non-surgical approach include no hospital admission costs, no wound complications and no risk of anesthesia. The biggest disadvantage is a risk of re-rupture which is as high as 40%.

Differential diagnosis:

• Achilles Bursitis
• Ankle fracture
• Ankle sprain
• Ankle impingement syndrome
• Ankle Osteoarthritis
• calcaneus fractures
• Plantaris tendon tear

Prognosis

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

Complications

• Re-rupture: higher chances with non-surgical treatment.
• Wound healing complications: 5-10% risk following surgery. Risk factors include smoking, female gender, steroid use, open technique (vs Percutaneous procedures).
• Sural nerve injury: increased occurrence with percutaneous procedure.

References

• Alan G. Shamrock; Matthew Varacallo. Achilles Tendon Rupture[Updated August 8,2020]. In StatPearls[Internet]. Available at: https://www.ncbi.nlm.nih.gov/books/NBK430844/
• Ochen Y, Beks RB, van Heijl M, Hietbrink F, Leenen LP, van der Velde D, et al. (January 2019). "Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis". Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6322065/

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