Achilles tendon rupture/tear

Etiology

• trauma (see pathology)
• risk factors
  • poor conditioning
  • advanced age
  • fluoroquinolone antibiotics
  • corticosteroids
  • overexertion

Epidemiology

• occur in all age groups & all levels of athletes
• commly occur in men age 30-50 years who have had no previous injury or problem reported in the affected leg
• the injured are typically 'weekend warriors' who are active intermittently
• most Achilles tendon tears occur in the left leg; this may be related to handedness; right-handed individuals 'push off' more frequently with the left foot

Pathology

• most tears occur ~2-6 cm above the calcaneal insertion of the tendon
• most common mechanisms of injury include
  • sudden forced plantar flexion of the foot
  • unexpected dorsiflexion of the foot
  • violent dorsiflexion of a plantar flexed foot
• other mechanisms include
  • direct trauma
  • attrition of the tendon as a result of longstanding peritenonitis with or without tendinosis

Clinical manifestations

• heel pain
• often, the patient will feel as if they have been kicked in the ankle during walking or sport
• may be a snap, followed by posterior ankle pain
• patients often feel a mild to moderate pain at first with limited pain after a small period of time.
• patients will continue to feel unstable
• swelling and weakness in the back of the leg
• inability to walk normally
• impaired plantar flexion of the affected foot
• weak dorsiflxion
• inability to rise on the toes on the injured leg, if the tendon completely ruptured
• Thompson test may be diagnostic

Laboratory

• routine laboratory testing generally unnecessary

Radiology

• plain radiographs
  • more useful for ruling out other injuries than ruling in Achilles tendon ruptures
  • may show soft-tissue swelling, increased ankle dorsiflexion on stress views, vascular or heterotopic calcifications, accessory ossicles, calcaneal fractures, Haglund deformity, or bony metaplasia
• ultrasound can be used to determine the tendon thickness, character, & presence of a tear
• magnetic resonance imaging (MRI)
  • can discern incomplete ruptures from degeneration of the Achilles tendon
  • can distinguish between paratenonitis, tendinosis, & bursitis
  • not routinely indicated
    • history & physical examination sufficient in nearly all cases
    • ultrasound sufficient for decisions of surgery vs medical management

Differential diagnosis

• ankle fracture
• ankle sprain
• calcaneofibular ligament injury
• talofibular ligament injury
• other disorders to consider
  • Achilles tendinosis
  • calcaneus bone injuries
  • fascial tears
  • gastrocnemius tear(medial head of the gastrocnemius)
  • soleus tear
  • inflammatory arthropathy
  • inflammatory processes
  • syndesmosis
  • tennis leg (tear of the plantaris tendon)
  • vascular injuries

Management

• referral to podiatry/surgery
• surgical repair for active patient
  • 6-8 weeks with leg in a walking boot, cast, brace or splint
  • to promote healing & to avoid stretching the surgical repair, the foot may initially be positioned in plantar flexion in the boot or brace, & then moved gradually to a neutral position
  • decreased risk of rupture (2.3% vs 3.9%)
  • increased risk for complications (4.9% vs 1.6%)
• nonsurgical treatment
  • a cast or walking boot allows the ends of the torn tendon to reattach themselves on their own
  • a removable walking boot might be preferable to plaster casts
  • likelihood of re-rupture is higher with a nonsurgical approach, & recovery can take longer
  • if re-rupture occurs, surgical repair may be more difficult
• rehabilitation involving physical therapy to strengthen leg muscles & Achilles tendon
• prognosis:
  • most people return to their former level of activity within 4-6 months
  • rerupture is more common with nonoperative management
  • nerve injury is more common with surgery

More general terms

• tendon rupture

Additional terms

• Achilles/calcaneal/heel tendon (chorda magna, tendo calcaneus)