Achilles Tendon Rupture | Diagnosis & Treatment

Epidemiology

Achilles tendon ruptures are mostly seen in high-impact sports and occur more often in the male population. A study in Denmark reports an increase from 25.95/100.000 persons in 1994 to 31.13/100.000 in 2013 (Ganestam et al. 2016).

The literature lists a couple of risk factors that may predispose an individual to ruptures of the Achilles tendon (Jarvinen et al. 2005, McQuillan et al. 2005, Seeger et al. 2006, Kraemer et al. 2012)
These are:

• Tendon degeneration
• Poor tendon vascularity
• Corticosteroid use
• Fluoroquinolone use
• Previous contralateral rupture

Clinical Presentation & Examination

If the tendon ruptures, patients report a distinct “pop”, “snap” or “crack” sound and immediate pain. The latter resolves rather quickly (Leppilahti et al. 1998). The patient may show gait abnormalities due to limited plantar flexion caused by the compromised tendon. This can be masked by overactivity of the posterior tibial, peroneal, and plantar muscles (Kauwe 2017).

Interestingly, 66% of all Achilles tendon ruptures are asymptomatic or patients have no pain, stiffness, or dysfunction in the tendon prior to rupture. Despite this, it is the case that 98% of all ruptured Achilles tendons show signs of degeneration. In 2014, Reiman et al published a systematic review including a meta-analysis on the diagnostic accuracy of various clinical assessments for diagnosing Achilles tendon ruptures. Probably the most widely used test is the Thompson test. With a sensitivity of 96% and specificity of 93%, it has a high clinical value in the diagnosis as well as in the exclusion of Achilles tendon ruptures.

To perform the test, the patient lies on the bench with the lower legs extended in the prone position. The patient’s ankles extend beyond the edge of the bench. Now compress the calf with one hand and pay attention to the movement of the foot. If compression of the calf results in plantar flexion of the foot, it can be assumed that the tendon is intact. However, if there is a lack of some degree of preload on the plantar flexion in the prone position and no further plantar flexion occurs due to compression of the calf, a rupture is likely.

Other commonly used orthopedic tests are:

• Matle’s Test
• Copeland Test
• Gap Palpation Test

Treatment

A recent systematic review comparing the rate of re-rupture, functional outcomes, complication rate, return to sports and work, as well as differences between early and delayed weight-bearing concluded that the differences in these factors were non-significant across multiple RCTs and observational studies (Ochen et al. 2019). However, the decision remains with the patient and treating physician as no decision algorithms are available to date.

In the videos below you will find a couple of exercises a patient can do after Achilles tendon rupture repair from the acute phase onto later rehab phases.

Interestingly enough, these same principles are applied in patients who are receiving conservative management (Ollson et al. 2013, Lantto et al 2016).

The Achilles tendon is the biggest and strongest tendon in the human body and is formed by the tendons of the soleus and gastrocnemius muscles which both insert at the calcaneus. We mostly see ruptures of the Achilles tendon in high-impact sports predominantly in the male athlete.

While a scientific review from the year 2017 showed no significant differences in the outcomes of surgical and conservative management the re-rupture rate of conservatively managed tendons was higher and conservative management might not be suitable for every injury depending on its severity. However, there is a clear benefit of an accelerated rehab program including early mobilization versus immobilization as has been researched by Brumann et al. (2014).

In the 1st phase post-surgery, usually lasting about two weeks, the goal should be to properly educate the patient on the expected course. Make sure that the wound heals properly and swelling is under control The patient will likely wear a walker boot with 30° of plantar flexion, but should be able to walk with full weight-bearing. Your aim is going to be to strengthen the surrounding muscles.

So let’s look at what this could look like:

Having no pain at rest and no increase in swelling the patient may progress to more ankle mobility. In the second phase which can last up to three weeks, your goal should be to obtain a neutral ankle position and full plantarflexion range of motion. Make sure that the wound is healing properly and swelling continues to decrease, as well as work on restoring a normal gait pattern. You can continue to load the exercises from phase 1. But in phase 2 we are going to focus more closely on the ankle.

The 3rd stage – Late Achilles Tendon Rupture Repair Rehab – which can last up to 9 weeks will aim to restore the full function of the angle in terms of the range of motion. Proprioception, balance, and coordination as well as further increased strength to prepare the individual for possible sports-specific rehab.

So let’s take a look at what kind of exercises one could do here:

Would you like to learn more about Achilles Tendon Ruptures? Check out the following resources:

• Rehabilitation Regimen for Non-Surgical Treatment of Achilles Tendon Rupture (Research Review)
• Podcast Episode 040 – Achilles Tendon Rupture Rehab with Liz Marlow
• The Role of Shockwave Therapy in the Management of Chronic Tendinopathy – Common Q&As

References

ARNER, ORED, A. Lindholm, and S. R. Orell. “Histologic changes in subcutaneous rupture of the Achilles tendon; a study of 74 cases.” Acta Chirurgica Scandinavica 116.5-6 (1959): 484-490.
Ganestam, Ann, et al. “Increasing incidence of acute Achilles tendon rupture and a noticeable decline in surgical treatment from 1994 to 2013. A nationwide registry study of 33,160 patients.” Knee Surgery, Sports Traumatology, Arthroscopy 24.12 (2016): 3730-3737.

Giddings, Virginia L., et al. “Calcaneal loading during walking and running.” Medicine & Science in Sports & Exercise 32.3 (2000): 627-634.

Järvinen, Tero AH, et al. “Achilles tendon disorders: etiology and epidemiology.” Foot and ankle clinics10.2 (2005): 255-266.

Kraemer, Robert, et al. “Analysis of hereditary and medical risk factors in Achilles tendinopathy and Achilles tendon ruptures: a matched pair analysis.” Archives of orthopaedic and trauma surgery 132.6 (2012): 847-853.

Lantto, Iikka, et al. “A prospective randomized trial comparing surgical and nonsurgical treatments of acute Achilles tendon ruptures.” The American journal of sports medicine 44.9 (2016): 2406-2414.

Maffulli, N. (1998). The clinical diagnosis of subcutaneous tear of the Achilles tendon. The American journal of sports medicine, 26(2), 266-270.

McQuillan, Regina, and Paul Gregan. “Tendon rupture as a complication of corticosteroid therapy.” Palliative medicine 19.4 (2005): 352-353.

Moon Y, Choi KY, Ahn JH.  “Acute Achilles tendon rupture”.  Arthrosc Orthop Sports Med (2017): 59-65

Ochen, Yassine, et al. “Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis.” bmj 364 (2019): k5120.

Olsson, Nicklas, et al. “Stable surgical repair with accelerated rehabilitation versus nonsurgical treatment for acute Achilles tendon ruptures: a randomized controlled study.” The American journal of sports medicine 41.12 (2013): 2867-2876.

Seeger, John D., et al. “Achilles tendon rupture and its association with fluoroquinolone antibiotics and other potential risk factors in a managed care population.” Pharmacoepidemiology and drug safety15.11 (2006): 784-792.