Achilles Rupture: Difference between revisions
No edit summary |
|||
| Line 1: | Line 1: | ||
<div class="noeditbox">Welcome to [[Vrije Universiteit Brussel Evidence-based Practice Project|Vrije Universiteit Brussel's Evidence-based Practice project]]. This is a wiki created by and for the students in the Rehabilitation Sciences and Physiotherapy program of the Vrije Universiteit Brussel, Brussels, Belgium. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div> <div class="editorbox"> | <div class="noeditbox">Welcome to [[Vrije Universiteit Brussel Evidence-based Practice Project|Vrije Universiteit Brussel's Evidence-based Practice project]]. This is a wiki created by and for the students in the Rehabilitation Sciences and Physiotherapy program of the Vrije Universiteit Brussel, Brussels, Belgium. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div><div class="editorbox"> | ||
'''Original Editors ''' - [[User:Sam Verhelpen|Sam Verhelpen]] | '''Original Editors '''- [[User:Sam Verhelpen|Sam Verhelpen]] | ||
'''Lead Editors''' - Your name will be added here if you are a lead editor on this page. [[Physiopedia:Editors|Read more.]] | '''Lead Editors''' - Your name will be added here if you are a lead editor on this page. [[Physiopedia:Editors|Read more.]] | ||
</div> | </div> | ||
== Search Strategy == | == Search Strategy == | ||
| Line 16: | Line 16: | ||
== Definition/Description == | == Definition/Description == | ||
add text here <br> | add text here <br> | ||
== Relevant Anatomical Structures<br> == | == Relevant Anatomical Structures<br> == | ||
| Line 30: | Line 30: | ||
A complete rupture of the Achilles tendon will show the following characteristics: | 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<ref name="one" /><ref name="four" /><ref name="five">Jacobs B, MD, FACSM, Lin D, MD, Schwartz E, MD. Achilles Tendon Rupture (2009). fckLRhttp://emedicine.medscape.com/article/85024-overview</ref><ref name="six">Atkinson T, MD, Easley M, MD. Complete Ruptures of the Achilles Tendon (2001). Medscape Orthopaedics &amp; Sports Medicine. 2001;5(3) © 2001 Medscape.fckLRhttp://www.medscape.com/viewarticle/408535</ref><ref name="seven" />.<br>- Often the rupture will come with a loud crack or pop<ref name="one" /><ref name="seven" />.<br>- When palpating the tendon, a gap can be felt<ref name="one" /><ref name="four" /><ref name="five" />. This is not always the case however.<br>- The back of the heel will be swollen<ref name="one" /><ref name="four" /><ref name="five" />.<br>- Walking will be nearly impossible<ref name="five" />.<br>- Standing on the toes will be impossible<ref name="five" />.<br>- A positive outcome of the calf muscle squeeze test or [http://www.physio-pedia.com/index.php5?title=Thompson_Test Thompson’s test]<ref name="one" /><ref name="four" /><ref name="five" /><ref name="six" /><ref name="seven" />.<br>- Some patients will have a history of chronic tendonitis in the heel or a prior cortisone injection<ref name="one" /><ref name="four" /><ref name="five" />.<br><br> | - At the moment of rupture a sharp pain will be felt, as if the patient was kicked in the heel<ref name="one" /><ref name="four" /><ref name="five">Jacobs B, MD, FACSM, Lin D, MD, Schwartz E, MD. Achilles Tendon Rupture (2009). fckLRhttp://emedicine.medscape.com/article/85024-overview</ref><ref name="six">Atkinson T, MD, Easley M, MD. Complete Ruptures of the Achilles Tendon (2001). Medscape Orthopaedics &amp;amp; Sports Medicine. 2001;5(3) © 2001 Medscape.fckLRhttp://www.medscape.com/viewarticle/408535</ref><ref name="seven" />.<br>- Often the rupture will come with a loud crack or pop<ref name="one" /><ref name="seven" />.<br>- When palpating the tendon, a gap can be felt<ref name="one" /><ref name="four" /><ref name="five" />. This is not always the case however.<br>- The back of the heel will be swollen<ref name="one" /><ref name="four" /><ref name="five" />.<br>- Walking will be nearly impossible<ref name="five" />.<br>- Standing on the toes will be impossible<ref name="five" />.<br>- A positive outcome of the calf muscle squeeze test or [http://www.physio-pedia.com/index.php5?title=Thompson_Test Thompson’s test]<ref name="one" /><ref name="four" /><ref name="five" /><ref name="six" /><ref name="seven" />.<br>- Some patients will have a history of chronic tendonitis in the heel or a prior cortisone injection<ref name="one" /><ref name="four" /><ref name="five" />.<br><br> | ||
== Differential Diagnosis == | == Differential Diagnosis == | ||
| Line 54: | Line 54: | ||
== Medical Management (current best evidence) == | == Medical Management (current best evidence) == | ||
add text here <br> | add text here <br> | ||
== Physical Therapy Management (current best evidence) == | == Physical Therapy Management (current best evidence) == | ||
| Line 61: | Line 61: | ||
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.<ref name="five" /> | 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.<ref name="five" /> | ||
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. <ref name="Murali">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.</ref><br>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. <ref name="Roos">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.</ref> | |||
<u>'''Some examples of exercises that can be given to the patient<ref name="three" />'''</u> | <u>'''Some examples of exercises that can be given to the patient<ref name="three" />'''</u> | ||
| Line 66: | Line 68: | ||
At the start of the therapy, 6 to 8 weeks after the surgery, let the patient do: | At the start of the therapy, 6 to 8 weeks after the surgery, let the patient do: | ||
*Active flexion/extension of the ankle | |||
*Ankle circles (clockwise and counterclockwise) | |||
*Straight leg lifts | |||
*Hip abduction | |||
*Standing hamstringcurl | |||
*Cycling on a stationary bicycle | |||
8 through 12 weeks after the surgery, the patient can start with a theraband exercise program. (start with the theraband with the least resistance and work your way up from there.) The patient should also continue with the previous exercises. | 8 through 12 weeks after the surgery, the patient can start with a theraband exercise program. (start with the theraband with the least resistance and work your way up from there.) The patient should also continue with the previous exercises. | ||
*Ankle eversion and eversion | |||
*Ankle plantar- and dorsiflexion | |||
12 through 24 weeks after the surgery, the first set of exercises can be executed with ankle weights. The following exercises can be added to the training program: | 12 through 24 weeks after the 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 in rehabilitation the patient can start with eccentric exercises. During the eccentric part (lowering the heel), the patient had full weight on the injured foot, and during the concentric part (go on tiptoe) only the non-injured foot was used. <ref name="Murali" /> | |||
*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 toes and to raise his non-injured leg so that his bodyweight is on his injured leg. Now the patient slowly lowers his 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 can increase the load by adding books or other weight to a backpack, or to perform the exercise with a flexed knee. | |||
== Key Research == | == Key Research == | ||
add links and reviews of high quality evidence here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br> | add links and reviews of high quality evidence here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br> | ||
== Resources <br> | == Resources <br> == | ||
add appropriate resources here <br> | add appropriate resources here <br> | ||
== Clinical Bottom Line == | == Clinical Bottom Line == | ||
add text here <br> | add text here <br> | ||
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) == | == Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) == | ||
| Line 92: | Line 107: | ||
see tutorial on [[Adding PubMed Feed|Adding PubMed Feed]] | see tutorial on [[Adding PubMed Feed|Adding PubMed Feed]] | ||
<div class="researchbox"> | <div class="researchbox"> | ||
<rss>Feed goes here!!|charset=UTF-8|short|max=10</rss> | <rss>Feed goes here!!|charset=UTF-8|short|max=10</rss> | ||
</div> | </div> | ||
== Reference == | == Reference == | ||
<references /> | <references /> | ||
Revision as of 18:02, 18 May 2011
Original Editors - Sam Verhelpen
Lead Editors - Your name will be added here if you are a lead editor on this page. Read more.
Search Strategy[edit | edit source]
Searchwords
- Achilles rupture
- Achilles tendon rupture
- Tendon rupture
- Tendon injuries
- Achilles rupture treatment/physical therapy/physiotherapy
- Achilles tendon rupture treatment/physical therapy/physiotherapy
- Tendon rupture treatment/physical therapy/physiotherapy
- Tendon injuries treatment/physical therapy/physiotherapy
- Achilles tendon incidence
Search databases
- PEDro
- Pubmed
- Web of knowledge
- Medscape
- Google Scholar
Definition/Description[edit | edit source]
add text here
Relevant Anatomical Structures
[edit | edit source]
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 of our body and connects these muscles to the tuber calcanei[1][2]
Epidemiology /Etiology[edit | edit source]
An injury at the Achilles tendon usually occurs during sports with repeated stress on the lower leg muscles such as badminton[1][3], soccer[3][4], volleyball[3], basketball[5][4], tennis[5][4], raquetball[5], squash[5]. An eccentric movement will put 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 depending on the article[1]. The injury is most common in patients from 30 to 50 years old[6].
Characteristics/Clinical Presentation[edit | edit source]
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[1][6][2][7][4].
- Often the rupture will come with a loud crack or pop[1][4].
- When palpating the tendon, a gap can be felt[1][6][2]. This is not always the case however.
- The back of the heel will be swollen[1][6][2].
- Walking will be nearly impossible[2].
- Standing on the toes will be impossible[2].
- A positive outcome of the calf muscle squeeze test or Thompson’s test[1][6][2][7][4].
- Some patients will have a history of chronic tendonitis in the heel or a prior cortisone injection[1][6][2].
Differential Diagnosis[edit | edit source]
Differential diagnosis includes:
- Acute Achilles tendon peritendinitis[6][4]
- Tennis leg (medial gastrocnemius tear)[6][4]
- Calf muscle strain or rupture[2][4].
- Posterior tibialis stress syndrome[4]
- Ligament injuries[2][4]
- Fracture[6][4]
- Posterior tibialis tendon injuries[4]
- Peroneal injuries[4]
Examination[edit | edit source]
Inspection
- A swollen ankle can point to a rupture of the Achilles tendon.[1][6][2]
- The Achilles tendon is easily palpable. When palpating along the entire length of the tendon, a gap may be present.[4][2] It’s wise to compare to the healthy tendon. Be aware that swelling can mask the gap[1][4]
Active
- One of the first ways to see if a patient has torn his Achilles tendon is de way he or she walks. 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.[1][4][2]
- Instructing the patient to stand on his toes. With an Achilles rupture this will be impossible.[2]
- Ask the patient to actively execute a plantar flexion.[4][2]
- Matles test .[1][4]
Passive
- Thompson test (calf squeeze test). [1][4][6][2][7]
Medical Management (current best evidence)[edit | edit source]
add text here
Physical Therapy Management (current best evidence)[edit | edit source]
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 was 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[2].
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.[2]
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. [8]
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. [9]
Some examples of exercises that can be given to the patient[5]
At the start of the therapy, 6 to 8 weeks after the surgery, let the patient do:
- Active flexion/extension of the ankle
- Ankle circles (clockwise and counterclockwise)
- Straight leg lifts
- Hip abduction
- Standing hamstringcurl
- Cycling on a stationary bicycle
8 through 12 weeks after the surgery, the patient can start with a theraband exercise program. (start with the theraband with the least resistance and work your way up from there.) The patient should also continue with the previous exercises.
- Ankle eversion and eversion
- Ankle plantar- and dorsiflexion
12 through 24 weeks after the 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 in rehabilitation the patient can start with eccentric exercises. During the eccentric part (lowering the heel), the patient had full weight on the injured foot, and during the concentric part (go on tiptoe) only the non-injured foot was used. [8]
- 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 toes and to raise his non-injured leg so that his bodyweight is on his injured leg. Now the patient slowly lowers his 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 can increase the load by adding books or other weight to a backpack, or to perform the exercise with a flexed knee.
Key Research[edit | edit source]
add links and reviews of high quality evidence here (case studies should be added on new pages using the case study template)
Resources
[edit | edit source]
add appropriate resources here
Clinical Bottom Line[edit | edit source]
add text here
Recent Related Research (from Pubmed)[edit | edit source]
see tutorial on Adding PubMed Feed
Extension:RSS -- Error: Not a valid URL: Feed goes here!!|charset=UTF-8|short|max=10
Reference[edit | edit source]
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 Maffulli N. Rupture of the Achilles tendon. J Bone Joint Surg Am. Jul 1999;81(7):1019-36.
- ↑ 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 2.14 2.15 2.16 2.17 Jacobs B, MD, FACSM, Lin D, MD, Schwartz E, MD. Achilles Tendon Rupture (2009). fckLRhttp://emedicine.medscape.com/article/85024-overview
- ↑ 3.0 3.1 3.2 Leppilaht J, et al. Incidence of Achilles tendon rupture. Acta Ortbop Scand. 1996; 67 (3): 277-279.
- ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 4.15 4.16 4.17 4.18 4.19 Gravlee, J, MD, Hatch, R, MD, MPH. Achilles Tendon Rupture: A Challenging Diagnosis. J Am Board Fam Med. 2000;13(5) © 2000 American Board of Family Medicine.fckLRhttp://www.medscape.com/viewarticle/405807
- ↑ 5.0 5.1 5.2 5.3 5.4 Berkson E. Achilles tendon rupture. Quincy medical center
- ↑ 6.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.09 6.10 Saglimbeni A, MD, Fulmer C, DO. Achilles Tendon Injuries and Tendonitis (2009). fckLRhttp://emedicine.medscape.com/article/309393-overview
- ↑ 7.0 7.1 7.2 Atkinson T, MD, Easley M, MD. Complete Ruptures of the Achilles Tendon (2001). Medscape Orthopaedics &amp; Sports Medicine. 2001;5(3) © 2001 Medscape.fckLRhttp://www.medscape.com/viewarticle/408535
- ↑ 8.0 8.1 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.
- ↑ 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.
