Achilles Rupture
Original Editors - Sam Verhelpen as part of the Vrije Universiteit Brussel's Evidence-based Practice project
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Definition/Description[edit | edit source]
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Relevant Anatomical Structures
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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[1][2]
Epidemiology /Etiology[edit | edit source]
An injury at the Achilles tendon usually occurs during sports that involve 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]. 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[1]. The injury is most common in individuals between 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 coincide with a loud crack or pop sound[1][4].
- When palpating the tendon, a gap may be felt[1][6][2].
- 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 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[edit | edit source]
- 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 on the other limb. Be aware that swelling can mask the gap[1][4]
Active Movements[edit | edit source]
- One of the first ways to see if a patient has torn his Achilles tendon is by observing his 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.[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[edit | edit source]
Medical Management (current best evidence)[edit | edit source]
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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][edit | edit source]
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]
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Resources
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Clinical Bottom Line[edit | edit source]
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Recent Related Research (from Pubmed)[edit | edit source]
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, Lin D, Schwartz E. Achilles tendon rupture. Medscape 2009 [accessed 2014 May 29] http://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, Hatch R. Achilles tendon rupture: a challenging diagnosis. J Am Board Fam Med. 2000;13(5) http://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, Fulmer C. Achilles tendon injuries and tendonitis. Medscape 2009 [accessed 2014 May 29]. http://emedicine.medscape.com/article/309393-overview
- ↑ 7.0 7.1 7.2 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
- ↑ 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.
