Achilles Tendon Rupture

Normal Anatomy

  • Tendinous contributions of gastrocnemius and soleus
  • Both tendons coverage approximately 15cm proximal to the insertion site
  • Approximately 90% type 1 collagen with a small amount of elastin
  • Type I collagen gives good tensile strength (pulling forces)

Pathology

  • Two theories can lead to Achilles Tendon Rupture
  • Degenerative Theory –changes in the tendon microstructure (increase type V collagen, increase in elastin) lowers the threshold for collagen tears increasing the risk of damage
  • Mechanical Theory – violent contraction of the musculature could exceed the limit of the structure leading to damage and rupture

Mechanism of Injury

Traumatic

  • Forced ankle dorsiflexion
  • Eccentric contraction of Achilles tendon
  • Push off phase of running with knee extended

Examination

Subjective

  • Sporting history with sudden starting and stopping (tennis, basketball, badminton)
  • Traumatic dorsiflexion or eccentric contraction
  • Traumatic push off phase of running
  • Sensation of being kicking or shot in back of heel
  • Popping sensation or sound
  • Inability to weight bear
  • Push off during walking absent
  • Initially painful which may subside over a period of time

Objective

  • Weakness plantarflexion
  • Visible defect of tendon with swelling
  • Loss of resting plantarflexion
  • Palpable gap

Special Tests

  • Thompsons Test

Further Investigations

  • Ultrasound
  • MRI

Management

  • Conservative management considered in those less active or high risk factors for infection following surgery
  • Ideally started ASAP following rupture
  • Overall rehab programme approximately 7 – 8 months
  • Rehab programmes for conservative and non-conservative management consultant led
  • See (Thevendran, Sarraf et al. 2013) for more details

Conservative

  • Reduce pain, inflammation and protect healing
  • Equinius cast to allow healing of the tendon for approximately 4 weeks then removable brace for 2 weeks
  • NSAID’s
  • Ice
  • Massage
  • Restore Normal Range of Movement
  • Knee, Hip (avoid stretching the calf)
  • Massage
  • Joint mobilisations
  • Joint manipulations
  • stretches
  • Restore Normal Muscle Activation
  • Isometrics in pain free range
  • Maintain strength of knee, hip, lumbopelvic spine
  • Restore Dynamic Stability (once normal ROM achieved)
  • Proprioceptive training
  • Sport specific training

Plan B

  • Surgical repair using a variety of different techniques

References

(Stavrou, Seraphim et al. 2013, Barfod 2014, Freedman, Gordon et al. 2014, Gulati, Jaggard et al. 2015)

Barfod, K. W. (2014). "Achilles tendon rupture; assessment of nonoperative treatment." Dan Med J61(4): B4837.

Freedman, B. R., J. A. Gordon and L. J. Soslowsky (2014). "The Achilles tendon: fundamental properties and mechanisms governing healing." Muscles Ligaments Tendons J4(2): 245-255.

Gulati, V., M. Jaggard, S. S. Al-Nammari, C. Uzoigwe, P. Gulati, N. Ismail, C. Gibbons and C. Gupte (2015). "Management of achilles tendon injury: A current concepts systematic review." World Journal of Orthopedics6(4).

Stavrou, M., A. Seraphim, N. Al-Hadithy and S. C. Mordecai (2013). "Review article: Treatment for Achilles tendon ruptures in athletes." J Orthop Surg (Hong Kong)21(2): 232-235.

Thevendran, G., K. M. Sarraf, N. K. Patel, A. Sadri and P. Rosenfeld (2013). "The ruptured Achilles tendon: a current overview from biology of rupture to treatment." Musculoskelet Surg97(1): 9-20.

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