Introduction:

A tendon is a band of tissue that connects a muscle to a bone. The Achilles tendon runs down the back of the lower leg and connects the calf muscle to the heel bone. Achilles tendon facilitates walking by helping to raise the heel off the ground.

Achilles tendon rupture is a complete or partial tear that occurs upon stretching the tendon beyond its capacity. Forceful jumping or pivoting, or sudden accelerations of running, can overstretch the tendon. This injury can also result from falling or tripping.

Achilles tendon ruptures are most often seen in “weekend warriors”, typically middle -aged people participating in sports in their spare time.

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Causes: Achilles tendon rupture occurs in the section of the tendon situated within 6 cm of the point where it attaches to the heel bone. This section might be prone to rupture because blood flow is poor, which also can impair its ability to heal.

Ruptures are often caused by a sudden increase in the stress on Achilles tendon. Common examples include:

·       Increasing the intensity of the sports participation, especially in sports that involve jumping.

·       Falling from a height

·       Stepping into a hole.

Risk factors: Factors that may increase risk of Achilles tendon rupture include:

·       Age –Peak age is 30 to 40

·       Sex- 5 times more likely to occur in men

·       Recreational sports – Sports that involve running, jumping, and sudden starts and stops, such as soccer, basketball and tennis.

·       Steroid injections- Doctors sometimes inject steroids into an ankle joint to reduce pain and inflammation. However, this medication can weaken nearby tendons and has been associated with Achilles tendon rupture.

·       Certain antibiotics- Fluoroquinolone antibiotics, such as ciprofloxacin or levofloxacin increase the risk of Achilles tendon rupture.

·       Obesity- Excess weight puts more strain on the tendon.

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

·       A sharp pain will be felt at the moment of rupture.

·       Rupture often coincides with a loud crack or pop sound.

·       A gap may be felt on palpating the tendon

·       The back of the heel will be swollen.

·       Inability to raise heel

·       Impaired gait.

·       A positive Thompson Test (calf muscle squeeze test).

Diagnosis: The diagnosis of acute Achilles tendon rupture is largely reliant on patient history and physical examination. Patients usually complain of a popping or giving way sensation in their posterior heel after pushing off. Immediate pain is present but gradually dissipates, leaving the patient to complain of difficulty with planter flexion, weight bearing, or a limb.

Examination: It includes observation, palpation, some active movements and some specific tests.

Observation: The therapist may observe patient in several positions;

1.Standing - to look for fallen arches (flat feet) and other postural complications.

2.Laying - usually on the front, used to observe tendon more closely for 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.

·       Palpation: The Achilles tendon is easily palpable, when palpated along the length of the tendon, a gap may be felt.

·       Active movements: There are several active movements:

1.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. A patient with an Achilles rupture will show an over pronation 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.

2.Instructing the patient to stand on his/her toes for making a plantar flexion. This will be impossible if the patient has an ATR.

3.Ask the patient to actively plantar flex the ankle.

4.Every active movement containing a plantar flexion of the heel will be almost, if totally not impossible.

Special Tests

There exist several special tests for the observation of an ATR:

1.Thompson Test - this test is especially useful for diagnosing complete achilles tendon ruptures and less useful for the diagnosis of partial ATR.

2.Matles Test - the patient lies in prone position and is asked to actively flex the knee through 90 degrees. The therapist 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.

3.Achilles Tendon Total Rupture (ATR-score) - the ATR-score is an important questionnaire that refers to the limitations/difficulties a patient with a tendon rupture will face.

4.Realtime achilles ultrasound thompson test - this test is as the thompson test, but under ultrasound visualisation. It can be used by surgeons with minimal training in ultrasonography. It provides improved diagnostic characteristics compared with static ultrasound.

Management:

Treatment for a ruptured Achilles tendon often depends on your age, activity level and the severity of your injury. In general, younger and more active people, particularly athletes, tend to choose surgery to repair a completely ruptured Achilles tendon, while older people are more likely to opt for nonsurgical treatment.

Recent studies, however, have shown fairly equal effectiveness of both surgical and nonsurgical management.

 

Nonsurgical treatment

This approach typically involves:

o   Resting the tendon by using crutches

o   Applying ice to the area

o   Taking over-the-counter pain relievers

o   Keeping the ankle from moving for the first few weeks, usually with a walking boot with heel wedges or a cast, with the foot flexed down

o   Nonoperative treatment avoids the risks associated with surgery, such as infection.

However, a nonsurgical approach might increase your chances of re-rupture and recovery can take longer, although recent studies indicate favorable outcomes in people treated nonsurgically if they start rehabilitation with weight bearing early.

Surgery

The procedure generally involves making an incision in the back of your lower leg and stitching the torn tendon together. Depending on the condition of the torn tissue, the repair might be reinforced with other tendons.

Complications can include infection and nerve damage. Minimally invasive procedures reduce infection rates over those of open procedures.

Rehabilitation

§  After either treatment, you'll have physical therapy exercises to strengthen your leg muscles and Achilles tendon. Most people return to their former level of activity within four to six months. It's important to continue strength and stability training after that because some problems can persist for up to a year.

§  A type of rehabilitation known as functional rehabilitation also focuses on coordination of body parts and how you move. The purpose is to return you to your highest level of performance, as an athlete or in your everyday life.

§  One review study concluded that if you have access to functional rehabilitation, you might do just as well with nonsurgical treatment as with surgery. More study is needed.

§  Rehabilitation after either surgical or nonsurgical management is also trending toward moving earlier and progressing faster. Studies are ongoing in this area also.

 

References:

·       Kolby and Kisner, therupatic exercises, edition 7th

·       The comprehensive manual of therapeutic exercises by Elizabeth Bryan, 2018