Achilles Tendon Rupture- Orthopedics

The Achilles tendon is the thick band of fibrous tissues that connect the calf muscles to the heel bone (calcaneus). It is the longest, largest, and strongest tendon in the human body and consists of strong, inelastic fibrous connective tissue. The Achilles tendon, also referred to as the heel cord, helps raise the heel off the ground while walking, running, and jumping. Although this tendon is strong enough to withstand great stresses from these activities, it is also prone to injuries under extreme stress.

Achilles Tendon Rupture

Tendon rupture refers to the tearing and separation of the tendon fibers such that the tendon can no longer perform its normal function. Despite being the body's strongest tendon, Achilles tendon ruptures (ATR) are fairly common, and they occur in the lower limbs. When the Achilles tendon is stretched past its capacity, it can rupture completely or partially

Signs and Symptoms

A person with a torn Achilles tendon might experience one or more of the following:

• Sudden onset ankle or calf pain resembling a kick or stab may occur in acute cases, often subsiding into a dull ache.
• A characteristic "snapping" or audible "pop" heard at the site of injury.
• Swelling between the calf and the heel on the back of the leg.
• Trouble rising to one's toes and difficulty walking, particularly upstairs or uphill.

Achilles tendinopathy usually has a detrimental effect on physical and mental well-being.

Causes

An injury to the tendon is mostly caused by overstretching the heel during recreational sports, forceful jumping or pivoting, sudden accelerations while running, or a fall from a height or tripping. Such injuries are commonly seen in "weekend warrior" athletes, typically middle-aged people participating in sports in their spare time. Less frequently, drugs such as steroids or specific antibiotics may weaken the tendon and cause ruptures, as may conditions like rheumatoid arthritis.

Risk factors

Certain factors may increase the risk of Achilles tendon rupture, including:

• Age: Most Achilles tendon injuries are seen between the third and fifth decade.
• Sex: Achilles tendon injuries are more common in men than women, with men five times more likely to rupture their Achilles tendon. This might be due to greater participation in sports-related activities.
• Recreational sports: Injuries to the Achilles tendon are more common in sports that include running, jumping, and quick starts and stops.
• The injury is most commonly associated with sports like football, basketball, cycling, running, volleyball, and gymnastics.
• Steroid injections: In order to lessen discomfort and inflammation, steroid injections are typically administered into the ankle joint. However, steroids have been linked to Achilles tendon injury and can weaken adjacent tendons.
• Systemic Factors: Certain illnesses such as chronic kidney disease, rheumatoid arthritis, lupus, infections, collagen disorders, gout, thyroid disorders, diabetes, etc., are associated with a weakened Achilles tendon that is vulnerable to injuries.
• Foot factors: If an individual has any problems with the alignment of the foot, such as cavus foot, tibia vara, etc., then that defect is associated with an increased risk of Achilles tendon rupture.
• Certain antibiotics: Fluoroquinolone antibiotics, such as ciprofloxacin or levofloxacin, raise the risk of a ruptured Achilles tendon.
• Obesity: Extra weight places extra strain on the tendon, increasing the risk of injury.

Diagnosis

While diagnosing an Achilles tendon rupture, the doctor will inquire how and when the injury happened and whether there was a history of similar injury or symptoms. On physical examination, palpation of the foot and ankle may reveal a defect in the tendon or signs of bruising around the posterior ankle. Range of motion and muscle strength will be evaluated and compared to the uninjured foot and ankle. Patients with Achilles tendon rupture cannot stand on their toes or have very weak ankle plantar flexion.

Simmonds' test (aka Thompson test) is a common physical exam performed by a doctor to diagnose Achilles rupture. In this test, the subject must be positioned on their stomach, facing down, with their feet hanging from the edge of the examination table. If there is no passive plantar flexion of the foot while the calf muscles on the affected side are contracted, the test is positive, and the person has a ruptured Achilles tendon.

An Achilles tendon rupture diagnosis is usually straightforward and can be made through clinical history and physical exam. Sometimes the surgeon will ask for an MRI, USG, or other advanced imaging tests to determine the extent of the injury.Prevention

Accidental injuries such as an Achilles tendon rupture are not always preventable. However, these steps can be taken to reduce the risk of rupturing the Achilles tendon:

• Warm-up exercise before a workout or game. Warming up before exercising or playing any sports sets the tone and prepares the body for the high-intensity activity level. This eventually reduces the risk of subsequent physical injuries, including an Achilles tear.
• Stretch and strengthen calf muscles. Stretching the calf until a noticeable pull is felt without bouncing and causing any pain is key to injury prevention. Calf-strengthening exercises can help the muscle and tendons absorb more force and prevent injury.
• Follow a dynamic exercise regime. Alternating high-impact sports, such as running, with low-impact sports, such as walking, biking, or swimming, can greatly affect training safety. Avoiding activities that put too much strain on the Achilles tendons, like hill running and jumping, can help to prevent injury.
• Choose running surfaces carefully. Activities like running on hard or slippery surfaces should be avoided or limited as much as possible.
• Injury risk can be decreased by dressing appropriately for the weather and training, as well as by donning sports shoes with the right fit and proper heel cushioning.
• Increase training intensity slowly. Injury to the Achilles tendon frequently follows a sudden increase in training load. Increasing the distance, duration, and frequency of the training by no more than 10 percent every week can steadily build up the pace while reducing the risk of any injuries.

Treatment

An individual with symptoms of Achilles tendon injury requires immediate medical attention to avoid further damage. The initial management includes the RICE method, which involves:

• Rest: The patient should rest the injured foot and ankle to prevent pain or further damage.
• Ice: A bag of ice covered with a thin towel should be applied over the injured area to reduce the swelling.
• Compression: To prevent further swelling, the foot and ankle should be wrapped in an elastic bandage.
• Elevation: The injured leg should be elevated to even with or slightly above the heart level to prevent further swelling.

Along with these methods, pain management with oral or intravenous analgesics should be done as soon as possible.

The degree of the rupture, the patient's health, age, and their activity level will determine if surgery is necessary or not. To repair a completely ruptured Achilles tendon, younger, more active individuals, especially athletes, tend to prefer surgery. On the other hand, elderly individuals are more likely to choose nonsurgical treatment.

Studies have demonstrated good functional results and patient satisfaction with both operative and nonoperative modalities.

Non-surgical treatment

 Nonsurgical treatment involves:

• Resting the injured leg with the use of crutches
• Analgesics for pain management
• Using a cast, walking boot, or brace to limit movement and promote tendon healing

Nonsurgical treatment is selected for minor/partial ruptures, patients with a relatively sedentary lifestyle, and those with significant medical comorbidities that prevent them from undergoing surgery. Nonoperative treatments avoid the risks associated with surgery, such as infection. But it might increase the chances of re-rupture, and recovery might take longer. However, recent research has indicated that patients treated non-surgically who begin weight-bearing rehabilitation early in their care had better outcomes.

Surgical treatment

There are a variety of surgical techniques available to repair the ruptured tendon. The operating surgeon will select the procedure best suited to the patient’s condition. The operation often entails an incision in the back of the lower leg and stitching the damaged tendon back together. Other tendons may be involved in reinforcing the repair, depending on the state of the damaged tissue.

Usually, younger, more active individuals with better health status opt for surgical interventions. Surgery offers important potential health benefits to patients. With a far lower chance of re-rupturing the Achilles tendon, the recovery is quicker than with non-surgical repair. Additionally, surgery often increases the patient’s push-off strength and improves muscle function and ankle movement.

Complications associated with surgical repair include incision-healing difficulties, re-rupture of the tendon, nerve damage or nerve pain after the surgery, anesthesia-related complications, wound-related complications such as surgical site infections, etc. Compared to open treatments, minimally invasive techniques have lower infection rates.After surgery, the foot and ankle are immobilized in a cast or walking boot. The surgeon will determine when the patient can begin weight bearing.

Rehabilitation

Whether one opts for a surgical repair or a non-surgical intervention, the patient should have physical therapy exercises to strengthen the leg muscles and Achilles tendon. It is an important component of the healing process and helps improve the range of motion in the foot and ankle. Most people take four to six months to get back to their previous level of activity. However, it is important to continue strength and stability training even afterward, as some of the problems can persist for up to a year.

Functional rehabilitation is a type of rehabilitation that also focuses on the coordination of body parts and movement of the body. The purpose of this specific therapy is to reinstate the individual’s highest level of performance, as an athlete or in day-to-day life.

One review concluded that with access to functional rehabilitation, one might do just as well with nonsurgical treatment as with surgery. Rehabilitation following surgical or nonsurgical treatments is more effective if it begins early in the course of treatment.Prognosis

For most patients with Achilles tendon rupture, the prognosis is excellent. With proper treatment, most Achilles tendon ruptures fully heal within four to six months. But in some non-athletes, residual deficits, such as a reduced range of motion, might persist for longer. The majority of athletes can resume their previous sporting activity without any limitations. It is crucial to remember that non-surgical treatment has a re-rupture rate of around 40% compared to 0.5% with surgery.

Summary

One of the most common tendon injuries is an Achilles tendon rupture. It is more common in athletes who play sports that involve running, frequent stopping, and starting and changing directions. It is always better to take necessary precautions before exercising or playing to prevent Achilles tendon injuries. Maintaining good health with proper diet, exercise, and treatment of any underlying illness is key to avoiding non-traumatic injuries to the Achilles tendon. However, if an individual experiences any such symptoms, then they should seek immediate medical assistance to reduce the damage to the tendon. For optimal results, a team of trauma surgeons, an orthopedic surgeon, a rehabilitation specialist, and a sports physician should be consulted for the definitive treatment of the Achilles tendon rupture. With proper treatment, Achilles tendon injuries heal within a span of a few months.

References:

• Shamrock AG, Varacallo M. Achilles Tendon Rupture. [Updated 2022 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430844/

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