Achilles Rupture

Contents

Definition/Description

Achilles tendon rupture is an injury that affects the back of your lower leg. It most commonly occurs in people playing recreational sports.The Achilles tendon is a strong fibrous cord that connects the muscles in the back of your calf to your heel bone. If you overstretch your Achilles tendon, it can tear (rupture) completely or just partially.If your Achilles tendon ruptures, you might feel a pop or snap, followed by an immediate sharp pain in the back of your ankle and lower leg that is likely to affect your ability to walk properly[1].

Relevant Anatomical Structures

The Achilles tendon is the insertion of two lower leg muscles, the M. Soleus and the M. Gastrocnemius. These muscles are the main plantar flexors of the ankle. The Achilles tendon is the strongest and longest tendon in the body and connects these muscles to the calcaneal tuberosity[2][3]


Epidemiology /Etiology

An injury at the Achilles tendon usually occurs during sports that involve repeated stress on the lower leg muscles, such as badminton[2][4], soccer[4][5], volleyball[4], basketball[6][5], tennis[6][5], raquetball[6], squash[6]. Eccentric movement puts an enormous amount of stress on the tendon. An Achilles tendon rupture occurs more frequently in men than women, with a ratio ranging from 1.7:1 to 12:1[2]. The injury is most common in individuals between 30 to 50 years old[7].


Characteristics/Clinical Presentation

A complete rupture of the Achilles tendon will show the following characteristics:

  • At the moment of rupture a sharp pain will be felt, as if the patient was kicked in the heel[2][7][3][8][5].
  • Often the rupture will coincide with a loud crack or pop sound[2][5].
  • When palpating the tendon, a gap may be felt[2][7][3].
  • The back of the heel will be swollen[2][7][3].
  • Walking will be nearly impossible[3].
  • Standing on the toes will be impossible[3].
  • A positive outcome of the calf muscle squeeze test or Thompson Test[2][7][3][8][5].
  • Some patients will have a history of chronic tendonitis in the heel or a prior cortisone injection[2][7][3].

Differential Diagnosis

Differential diagnosis includes:

Examination

Observation

The therapist may observe the patient in several positions:

Standing - to look for fallen arches (flat feet) and other postural complications.
Laying - usually on the front. This can be used to observe the tendon more closely for thickening, redness, swelling and nodules.
Walking and running - to look for overpronation.

Furthermore, a swollen ankle can point to a rupture of the Achilles tendon.[2][7][3]

On palpation: The Achilles tendon is easily palpable. When palpating along the entire length of the tendon, a gap may be present.[5][3]

It’s wise to compare to the healthy tendon on the other limb. Be aware that swelling can mask the gap[2][5]

Active Movements

  • One of the first ways to see if a patient has torn his/her Achilles tendon is by observing his/her gait pattern. Plantar flexion is nearly if not totally impossible, so if the patient has a lot of trouble walking, it can be an indication of an Achilles rupture.[2][5][3]
  • Instructing the patient to stand on his/her toes. With an Achilles rupture this will be impossible.[3]
  • Ask the patient to actively plantar flex the ankle.[5][3]
  • Matles test .[2][5]

Special Tests

Medical Management (Current Best Evidence)

Therapy for a patient with an Achilles tendon rupture consists of rest, pain control, and serial casting. It will involve having a plaster cast or brace for about eight weeks to protect the tendon while it heals. The plaster cast or brace is positioned so that the ankle is slightly plantar flexed, which takes the strain off the tendon.

Traditionally, crutches were used to keep weight off the leg during the first few weeks of treatment. Now there is a trend towards early mobilisation. This involves fitting a plaster or brace which one can walk on, [9] maing it more conventient as crutches will likely not be required. There is debate as to which treatment is best: surgery or conservative treatment. Conservative treatment may be suggested for older or less active people, and for people wishing to avoid surgery. But the choice of treatment depends on individual preference and circumstances. Surgery may also be recommended if there has been a delay in starting treatment.

However, new research has found surgery and conservative treatment demonstrated equally good results when patients were also given early mobilisation treatment using a brace.[9]

Physical Therapy Management (current best evidence)

Whether the tendon was treated surgically or non-surgically, the patient’s ankle will be immobilized by a cast for twelve weeks in case of surgery and 6 to 8 weeks when the condition is treated non-surgically.

Physical therapy for an Achilles tendon rupture starts immediately after the cast is removed and is mainly focused around firstly improving the range of motion (ROM) of the ankle, then increasing the muscle strength and muscle coordination[3].

Start off with gentle passive mobilization of the ankle and the subtalar joints. Later go on to active ROM exercises. After two weeks of physiotherapy, progressive resistance exercises are added. Ten weeks after the injury or surgery, start gait training exercises followed by activity specific movements. A return to activities should be expected at 4-6 months of therapy. The rate of rehabilitation greatly depends on the quality of the treatment and the motivation of the patient.[3]

When treated with an eccentric training program, the patient is more likely to be able to return faster to sport. The eccentric exercises should reduce pain an tendon thickness and should improve function of the tendon (and muscles). The eccentric calf-muscle exercises, as described below, should be executed twice daily for 12 weeks. The exercise program consists of one to three sets of 15 repetitions per exercise, according to the improvement of the patient. [10]

Not all patients benefit from an eccentric exercise program. It’s also proven that these exercises are less effective in sedentary people in comparison to athletes. [11]

Sample Exercises[6]

At the start of the therapy, 6-8 weeks after surgery, let the patient do:

  • Active flexion/extension of the ankle
  • Ankle circles (clockwise and counterclockwise)
  • Straight leg lifts
  • Hip abduction
  • Standing hamstring curl
  • Cycling on a stationary bicycle

8-12 weeks after surgery, the patient can start with a theraband exercise program (starting from least resistance and work up from there). The patient should also continue with the previous exercises.

  • Ankle eversion and eversion
  • Ankle plantar- and dorsiflexion

12-24 weeks after surgery, the first set of exercises can be executed with ankle weights. The following exercises can be added to the training program:

  • Calf stretch
  • Toe raises
  • Single leg balancing

The last step after surgery is eccentric exercise. During the eccentric part (lowering the heel), the patient has full weight on the injured foot, and during the concentric part (raising on tiptoe) only the non-injured foot is used. [10]

  • Patient takes places on a step, standing with full bodyweight on the forefoot of both feet, the knees are extended. Then he is asked to go stand on his/her toes and to raise the non-injured leg so that his/her bodyweight is on his injured leg. Now the patient slowly lowers the heel. In this way the calf muscle eccentrically guides the motion and is eccentrically trained.
  • When the patient can perform this exercise without discomfort, he/she can increase the load by adding books or other weight to a backpack, or to perform the exercise with a flexed knee.

Recent Related Research (from Pubmed)

  1. http://www.mayoclinic.org/diseases-conditions/achilles-tendon-rupture/basics/definition/con-20020370
  2. 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 Maffulli N. Rupture of the Achilles tendon. J Bone Joint Surg Am. Jul 1999;81(7):1019-36.
  3. 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 3.15 3.16 3.17 Jacobs B, Lin D, Schwartz E. Achilles tendon rupture. Medscape 2009 [accessed 2014 May 29] http://emedicine.medscape.com/article/85024-overview
  4. 4.0 4.1 4.2 Leppilaht J, et al. Incidence of Achilles tendon rupture. Acta Ortbop Scand. 1996; 67 (3): 277-279.
  5. 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 5.12 5.13 5.14 5.15 5.16 5.17 5.18 5.19 Gravlee J, Hatch R. Achilles tendon rupture: a challenging diagnosis. J Am Board Fam Med. 2000;13(5) http://www.medscape.com/viewarticle/405807
  6. 6.0 6.1 6.2 6.3 6.4 Berkson E. Achilles tendon rupture. Quincy medical center
  7. 7.00 7.01 7.02 7.03 7.04 7.05 7.06 7.07 7.08 7.09 7.10 Saglimbeni A, Fulmer C. Achilles tendon injuries and tendonitis. Medscape 2009 [accessed 2014 May 29]. http://emedicine.medscape.com/article/309393-overview
  8. 8.0 8.1 8.2 Atkinson T, Easley M. Complete ruptures of the Achilles tendon. Medscape Orthopaedics Sports Medicine 2001;5(3) [accessed 2014 May 29] http://www.medscape.com/viewarticle/408535
  9. 9.0 9.1 http://patient.info/health/achilles-tendon-rupture
  10. 10.0 10.1 Murali K. Sayana, Maffulli N., ‘Eccentric calf muscle training in non-athletic patients with Achilles tendinopathy’, Journal of Science and Medicine in Sport, Volume 10, Issue 1, Feb. 2007, p. 52-58.
  11. Roos, M.E., et al., ‘Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathy – a randomized trial with 1-year follow-up’, Scand J Med Sci Sports, 2004, 14, p. 286-295.
[1]

Reference

  1. http://www.sportsinjuryclinic.net/sport-injuries/ankle-achilles-shin-pain/achilles-tendonitis/assessment-achilles-tendinitis