Achilles Rupture


Definition/Description[edit | edit source]

The Achilles tendon is the strong fibrous band that attaches the calf muscles to the Calcaneus bone.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title A rupture of the Achilles tendon is a common pathology and it is the most commonly ruptured tendon in the human body.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title The main causes of a rupture can be overstretching of the heel during recreational sports, a forceful plantar flexion of the heel or a fall from an important height.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title The patient will frequently present with complaints of a sudden snap in the lower calf muscles associated with acute, severe pain. We distinguish ATR’s following the way they are generated ; acute or chronic.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Relevant Anatomical Structures
[edit | edit source]

The Achilles tendon is the longest and strongest tendon in the whole human body and consists of strong, inelastic fibrous connective tissue. It is the insertion of the calf muscles ; the M. Soleus and the M. Gastrocnemius and connects these muscles to the calcaneal tuberosity. These lower leg muscles are the main plantar flexors of the ankle. When the calf muscles contract, the Achilles tendon tightens and pulls the heel bone causing the foot going in plantar flexion Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.

Fig. 1: Anatomy of the calf muscles

                 

Epidemiology /Etiology[edit | edit source]

The incidence is 7 per 100 000 per year but goes up to 15 to 25 per 100 000 per year for (recreational) athletes, with a peak incidence at the age of 30 to 50 yearsCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. ‘The literature frequently describes rupture of the Achilles tendon as a 'typical sports-related’ pathology, such as stop-and-go sports: badmintonCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, soccerCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, volleyballCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, basketballCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, tennisCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, raquetballCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, squashCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. Eccentric movement puts an enormous amount of stress on the tendon. It affects mostely 'middle-aged weekend warriors' but this etiology accounts for only about 70% of such injuries. 

Fig. 2 : Achilles Tendon Rupture



Also factors such as:
● the natural ageing processCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
● obesity Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
● use of some commonly prescribed medications Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
● poor running mechanicsCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
● over- or underpronationCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
● flat foot (pes planus)Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
● high foot arch (pes cavus)Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
● leg length discrepancyCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
● foot malalignmentCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
● FluoroquinoloneCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
● Steroid useCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Those factors can increase the risk of developing a tendinopathy and subsequent rupture, often from a seemingly insignificant incident.
However, research suggests that injuries in this patient population are more likely to be missed on first examinationCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.’An Achilles tendon rupture occurs more frequently among men than womenCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. The male-to-female ratio is about 5:1, and more than 80% of ruptures occur during sports activitiesCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.


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 stabbed in the heel with a daggerCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.
● Often the rupture will coincide with a loud crack or pop sound.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
● When palpating the tendon, a gap may be felt.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
● The back of the heel will be swollen.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
● Decreased plantar flexion of the ankle.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
● Restricted walking ability.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
● A positive outcome of the calf muscle squeeze test or Thompson Test.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
● Some patients will have a history of chronic tendonitis in the heel or a prior cortisone injection.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Three categories of indirect injury that may result in rupture are: (1) pushing off with a weight bearing forefoot while also extending the knee, as occurs at the beginning of a sprint, running, and some forms of jumping; (2) sudden and unexpected dorsiflexion of the ankle, which may occur when a person slips off a chair or a ladder, when stumbling into a hole, or suddenly falling forward; and (3) violent dorsiflexion of a plantar-flexed foot when one falls from a height.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Differential Diagnosis[edit | edit source]

In most of the available literature, an Achilles tendon rupture is described as chronic if it occurs at least 4 to 6 weeks after injury.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title The symptoms of chronic Achilles tendon rupture include pain, decreased strength, fatigue, and ankle stiffness.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Acute ATR’s represent those less than 7 days from insult.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title A correct distinction needs to be made, because the treatments differ.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Differential diagnosis includes:
● Acute Achilles tendon peritendinitis Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
● Tennis leg (medial gastrocnemius tear)Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
● Calf muscle strain or ruptureCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
● Posterior tibialis stress syndromeCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
● Ligament injuriesCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
● FractureCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
● Posterior tibialis tendon injuriesCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
● Peroneal injuriesCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Classification
[edit | edit source]

This classification proposed by Kuwada in 1904, and at the time of writing, remains the most widely used system for describing Achilles tendon rupture.
Achilles tendon tears may be grouped into 4 types, according to severity of the tear and degree of retraction:
● type I: partial ruptures ≤50%
               ○ typically treated with conservative management

● type II: complete rupture with tendinous gap ≤3 cm
              ○ typically treated with end-end anastomosis

● type III: complete rupture with tendinous gap 3 to 6 cm
              ○ often requires tendon/synthetic graft
● type IV: complete rupture with defect of >6 cm (neglected ruptures)
               ○ often requires tendon/synthetic graft and gastrocnemius recession


Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Outcome Maesures
[edit | edit source]

The outcome measures used to evaluate functional results following an ATR can be broadly divided into two types: objective measures and patient-reported measures. The former are parameters directly registered by the physiotherapist, such as ankle range of motion (ROM) or calf muscle strength measurements. These objective data, derived from the patient’s physical examination, have traditionally formed the basis of functional assessment following an ATR.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title However, over the past two decades, it has become increasingly recognized that the patient’s own appraisal of outcome is of the most important when judging the results of a treatment. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

The best choice of outcome tools for reporting the results of treatment in patients with foot and ankle disorders remains uncertain and controversial. Nevertheless, on the basis of the available evidence, a patient treated for an ATR should be assessed with a disease-specific measure, such as the ATRSCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title in combination with a generic measure, such as the SF-36 Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. The 36-item Short Form (SF-36) is a commonly used instrument for measuring the Health Related Quality of Life, it is a valid and reliable tool. The SF-36 has been proven useful in monitoring population health, estimating the burdens of different diseases, monitoring outcome in clinical practice, and evaluating medical treatment effects.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title . These patient-reported outcome scales focus on the patient’s perception of his/her health status, which has to be considered as the most important indicator of the success of a treatment. Patient-reported outcome scales should be complemented by objective indicators of function, such as muscle strength Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, calf muscle endurance Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title and return to previous activity level, in order to obtain a complete picture of the effect of the treatment. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Examination[edit | edit source]

A. Observation
For the inspection of an ATR, the therapist may observe the patient in several positions:
1. Standing - to look for fallen arches (flat feet) and other postural complications.
2. Laying - usually on the front. This can be used to observe the tendon more closely for thickening, redness, swelling and nodules.
3. Walking and running - to look for overpronation.
4. Swelling: a swollen ankle can point to a rupture of the Achilles tendon.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
5. On palpation: The Achilles tendon is easily palpable. When palpating along the entire length of the tendon, a gap may be present. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

B. Active Movements

In this part of the examination the therapist asks the patient to fulfil some active movements which can aid in the diagnosis of a tendon rupture.
There are several active movements:
● Observing the gait pattern can be an important indication for a possible rupture. A patient with an ATR can possibly not make a plantar flexion of his ankle. So if the plantar flexion movement in the walking phase is hindered and painful, it can be an indication of an Achilles rupture. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title A patient with a Achilles rupture will show an overpronation of the injured ankle. The patient will also show a lack of push-off at the end of the stance phase as a result of the dysfunction of the Gastrocnemius and Soleus muscles.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
● Instructing the patient to stand on his/her toes for making a plantar flexion. This will be impossible if the patient has an ATR. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
● Ask the patient to actively plantar flex the ankle. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
● Every active movement containing a plantar flexion of the heel will be almost, if totally not impossible. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

C. Special Test
There exist several special tests for the observation of an ATR:

1. The Thompson Test/calf squeeze test: Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
This test is especially useful for diagnosing complete Achilles tendon ruptures and less useful for the diagnosis of partial ATR. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

2.Matles Test Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

The patient lies in prone position and is asked to actively flex the knee through 90 degrees. The therapeut observes the feet and ankles throughout the movement. The test is negative when the foot displays slight plantar flexion; the test is positive if the foot falls into the neutral position or the movement results in dorsiflexion. Maffulli reports a sensitivity of 0.88. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Fig. 3 : Matles Test (1)
Fig. 4: Matles Test (2)


3. Achilles Tendon Total Rupture (ATR-score)
(level of evidence 1A) Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
The ATR-score is an important questionnaire that
refers to the limitations/difficulties a patient with
a tendon rupture will face. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title


4. Realtime Achilles Ultrasound Thompson Test
(level of evidence 2) Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
This test is exactly similar to the Thompson test, but under ultrasound visualization. It can be used by surgeons with minimal training in ultrasonography. It provides improved diagnostic characteristics compared with static ultrasound. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title


Medical Management (Current Best Evidence)[edit | edit source]

After medical diagnosis of an Achilles Tendon Rupture (ATR) different kinds of therapy can be offered and evaluated. These repair methods can be either by surgery or in a non-operative way where the tendon cures in a natural way with support of a brace and rest Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. The results of a systematic review of Wu, Yaohong, et al (level of evidence 1a) showed that when functional rehabilitation was used, the effect of non-surgical intervention was similar to surgical treatment regarding the incidence of range of motion, a future chance of rerupture, calf circumference and functional outcomes and also the incidence of other complications was reduced. Non-surgical intervention significantly increased the rerupture rate if functional rehabilitation was not considered Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.

The choice which one will be applied depends on personal factors such as age of the patient, desire to have a sportive life afterwards and the individual preference. Operative repair by sewing the torn ends of the injured Achilles tendon together will reduce risk of a future rerupture but wound infection can be a possible complication factor Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. Therefore younger persons are recommended to choose for the operative repair and elderly and less active patients will be recommended for a more conservative, natural healing process Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.
There is a difference between surgery for chronic and acute ATR.

Chronic ATR 

Fig. 5 : Treatment strategy for chronic Achilles tendon rupture


By evaluating the presence or absence of Achilles tendon stumps and the gap length of the rupture, different surgical options (V-Y advancement, gastrocnemius fascial turndown flap, or flexor halluces longus tendon transfer) can be selected for tendon repair (figure: 6) Yangjing Lin et al (level of evidence 2b)) Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.

Acute ATR
Due to a high complication rate after open surgical repair, including wound infection, abnormal sensation, adhesion and thrombosis new technics which require much smaller incisions have been developed and are published in specialised literature Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. Minimal invasive technics and percutaneous repair become more and more common because they reduce the above mentioned complications and have both a good outcome, as described in the literature of Carmont et al (level of evidence 3a) Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.
There is ongoing controversy about the best post-operative treatment. A few randomised controlled trials (level of evidence 1b) have been published comparing early mobilization with immobilization after surgery. Most studies have shown slightly better results with early mobilisation or no difference in outcome. Anyway most studies agree early functional treatment is recommended Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.

Post-operative immobilization consists of rest by wearing a protective plaster cast or brace for about 8 weeks. Partial-weight-bearing crutches can be used 6 weeks after surgery, but strenuous sports (such as running) can only be practiced 1 year postoperatively Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.

More recent studies however tend to an early mobilisation. The objective is to work actively on the recovery, to prevent muscle atrophy and to regain strength and movement after surgery as a tendon requires movement to heal Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. These exercises are performed in the first 6 to 8 weeks after surgery with a below-knee brace which allows free plantar flexion of the ankle and walking Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.

The systematic review of Wu Yaohong, et al (level of evidence 1a) concludes that the findings of meta-analyses regarding surgical versus non-surgical treatment for acute Achilles tendon rupture are inconsistent. The current best available evidence suggests that a functional rehabilitation is recommended after a non-surgical intervention. If functional rehabilitation can’t be provided by a rehabilitation centre, a surgical treatment may be preferred for the healing of an acute Achilles tendon rupture. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title


Physical Therapy Management (current best evidence)[edit | edit source]

On day 0, in the emergency department the diagnosis is made based on the following criteria :
1) a patient’s history with a clear sense of “snap” of the Achilles tendon
2) a palpable defect, usually located 3–6 cm above the calcaneal tubercle
3) a positive calf squeeze test Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. A plaster of Paris is applied to the patient’s foot in a
plantigrade position of 30–45 degrees. No weight bearing is allowed.

Week 0-6
Whether the tendon was treated surgically or non-surgically, the patient should wear a plaster cast for immobilization for at least 6 weeks on the injured ankle or a below-knee dorsal brace which allows the ankle to make a plantar flexion to start early mobilization in the first 6 weeks after injury or surgery as described in Groetelaers, René et al.(level of evidence 1b (prospective randomized trial))Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title . Lantto, Iikka, et al. level of evidence 1b (RCT) Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title .

Rehabilitation schedule and sample physiotherapy exercises Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

In general physical therapy for an Achilles tendon rupture starts immediately after the cast is removed and is mainly focused on firstly improving the range of motion (ROM) of the ankle. Later the physical therapy is focussed on increasing the muscle strength and muscle coordination Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. 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 Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.

► At the start of the therapy until 6-8 weeks after surgery :
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. Possible exercises for the patient are :
● Active flexion/extension of the ankle
● Ankle circles (clockwise and counterclockwise)
● Hip abduction
● Straight leg raise

Fig. 6 : Straight Leg Raise Test









● Standing hamstring curl

Fig. 7: Standing Hamstring Curl Test












● Cycling on a stationary bicycle


► 8-12 weeks after surgery :
Ten weeks after the injury or surgery, gait training exercises can be started, followed by activity specific movements. The patient can start with a thera-band exercise program by starting from the lowest resistance and work up from there for regaining strength. The patient should also continue with the previous exercises. 

Fig. 8: Thera-Band exercises


● Ankle range of motion : plantar flexion and dorsiflexion to 90° : 2 x 8 repetitions
● Ankle range of motion : inversion and eversion
● Ankle range of motion : pronation and supination : 2 x 8 repetitions
● One leg standing balance exercise : 3 × 30 seconds Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
● Standing heel-rise (2 × 3 seconds tempo) : 3 × 10 repetitions

Fig. 9 : Standing Heel-Rise Test













► 12-24 weeks after surgery :
The first set of exercises can now be executed with ankle weights. The following exercises can be added to the training program, but also basic exercises (described above) should still be executed :

● Calf stretch

Fig. 10 : Calf Stretch























● Toe raises
● Single leg balancing
● Walk on toes with support to start with (if needed) : 2 × 5 meters 

Fig. 11 : Heel-rise


● Standing heel-rise is performed with increased weight on injured leg :
   5 × 10 repetitions
● Heel-rise in supine position with flexed legs
   (with increased weight on injured leg) : 2 × 15 repetition
● Leg press with one leg at a time (10 repetitions maximum) : 2 × 10 repetitions
● Balance exercises on a trampoline : 2 × 45 seconds
● Walk/jog on a trampoline : 2 × 45 seconds
● Cross trainer : 1 min and 45 seconds
● The plank (core exercise) : 2 × 45 seconds

● Lunges (only with injured leg in front) : 2 × 10 repetitions

Fig. 12 : Lunges


















→ This program is performed as circle training.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title


► Starting from week 14 until the end of the therapy
The patient is able to run approximately 14 weeks after the injury or surgery.
● Running on even ground is allowed when the patient can perform 5 single-legged heel-rises with approximately 90% of the height of the
   uninjured leg. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
● Jogging upwards on stairs is allowed if the patient can walk 5 meters on their toes without the heel falling down.

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 Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.

• 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.

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 and 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 1-3sets of 15 repetitions per exercise, according to the improvement of the patient as described in . Murali K. Sayana, Maffulli N. et al, level of evidence 2b (individual cohort study) Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.
But not all patients benefit equally from an eccentric exercise program. It’s also proven that these exercises are less effective in sedentary people in comparison to athletes (Roos, M.E., et al., level of evidence 1b) Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.

► End of the therapy :
After completing the rehabilitation program, new examination of the tendon healing and functions is required. If needed, a new referral for further physiotherapy sessions can be provided to the patient. Gradual return to sports is recommended. For example before participating to contact sports, the patient should wait at least 6–9 months after the injury. (Nilsson-Helander K, et al. level of evidence 1b Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Willits K, Et al.level of evidence 1b Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title).

Key Evidence
[edit | edit source]

Links and reviews of high evidence can be added here.

Resources
[edit | edit source]

• American Journal of Sports Medicine
• American Journal of Orthopedics
• Foot and Ankle International
• The Journal of Foot and Ankle Injury
• International Journey of Surgery

Clinical Bottom Line
[edit | edit source]

An Achilles Tendon Rupture also known as ATR is described as a typical sports-related pathology. We distinguish two sorts of ruptures: a complete rupture or a partial rupture. An ATR can be treated surgically or nonsurgically. Medical therapy consists of an operative repair by sewing the torn ends of the injured Achilles tendon together. The physical rehabilitation changes from physical non-weight bearing exercises (at the beginning of the therapy) to more weightbearing exercises at the end of the revalidation.

Recent Related Research (from pubmed)[edit | edit source]

• Arverud E.D., et al., “Ageing, deep vein thrombosis and male gender predict poor outcome after acute Achilles tendon rupture.” Bone Joint J.
  2016 Dec;98-B(12):1635-1641.

• Gedam P.N., Rushnaiwala F.M. “Endoscopy-Assisted Achilles Tendon Reconstruction With a Central Turndown Flap and Semitendinosus
  Augmentation.” Foot Ankle Int. 2016 Dec;37(12):1333-1342. Epub 2016 Sep 20.

• Lantto, Iikka, et al. "A Prospective Randomized Trial Comparing Surgical and Nonsurgical Treatments of Acute Achilles Tendon Ruptures."
  The American journal of sports medicine 44.9 (2016): 2406.
   → level of evidence 1b


References[edit | edit source]