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Achilles Tendon Rupture

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Introduction

The Achilles is the strongest tendon in the body. It is located at the rear of the ankle, serving as a powerful spring for forward propulsion during locomotion, connecting the calf muscles to the calcaneus (heel bone) to point the foot and ankle. Tendinopathy of the Achilles is seen relatively often, and although the Achilles is one of the most common tendons to rupture, this injury is uncommon.

Signs & Symptoms

  • An instant pain commonly described as a ‘stab’ or a ‘kick’ in the heel / lower leg which is felt instantaneously.
  • An audible ‘crack’ or ‘pop’ sound is often recognised.
  • A distinct gap may be felt when palpated.
  • Swelling around the heel.
  • Unable or limited ability to point the ankle (plantarflex) or heel raise.
  • A noticeable limp when walking.

(Flint et al., 2014; Maffulli, Sharma & Luscombe, 2004)

 

An Achilles rupture can occur after an initial injury to the associated structures. If rupture takes place 4-6 weeks later, it is considered chronic (Flint et al., 2014). The characteristics of a chronic rupture include pain, reduced strength, stiffness in the corresponding ankle and fatigue.

 

Classification

Achilles tendon tears can be classified in to one of four groups based on how much the structures retract and the extent of the tear:

  • Type I – a tear of <50% of the cross-sectional area of the tendon.
  • Type II – Complete rupture with a gap <3cm.
  • Type III – Complete rupture, 3-6cm gap.
  • Type IV – Complete rupture, >6cm gap.

Causes

Often the mechanism of an Achilles rupture involves an overstretch of the heel during a sudden, forceful movement such as a sudden change of direction, pushing off the ball of your foot powerfully or a heavy landing. These activities are often seen in racket and ball sports such as badminton and basketball (Flint et al., 2014) and injury during sporting activity makes up 68% of all cases (Raikin, Garras & Krapchev, 2013).

Prevalence

The incidence is 7 per 100,000 per year but is more common in recreational athletes at 15-25 per 100,000 and the highest prevalence has been observed in those aged between 30-50 years (de Jonge et al., 2011) with males showing higher susceptibility (Vosseller et al., 2013). Furthermore, rupture is more likely in patients with a history of Tendinopathy in the heel or a have had previous cortisone injections.

Assessment & Diagnosis

At Pure, your Physio will take a detailed history of your symptoms followed by a thorough clinical examination to establish a working diagnosis. A fast and accurate diagnosis will mean that the most effective treatment and management plan can be implemented straight away, helping to achieve optimal outcomes. Your Physiotherapist will want to know how your condition is effecting you day to day so that your treatment can be tailored to your needs and will mean personalised goals can be established. Regular re-assessment will ascertain if your are making progress towards your goals and will allow adjustments to your treatment to be made.

Self-Management

There is currently a lack of agreement within the research pertaining to the most effective management strategy, mainly due to dispute between treatment protocols such as non-operative vs surgery in acute ruptures, most efficacious surgery methods and accelerated vs traditional exercise rehabilitation protocols.

 

Nonetheless, when planning treatment & management, many factors will be considered including age, the patient’s preference, and level of activity (Metzl, Ahmad & Levine, 2008). However, in general, surgery is deemed more suitable for younger people whereas conservative approaches are employed with elderly and less physically active patients – due to the risk of Deep Vein Thrombosis, sensation loss, scar tissue and infection (Lansdaal et al., 2007).

 

It is widely agreed upon that early weight-bearing and ankle range of motion should be encouraged following surgery (Brumann et al., 2014). However, research demonstrates greater efficacy in conservative approaches with accelerated rehabilitation, compared to surgical intervention (Willits et al., 2010; Wu et al., 2016).

 

Firstly, a period of immobilisation is required – usually with the ankle pointed in a cast and then a walking boot, to encourage the ends of the tear to re-connect and heal. Over the course of 8-12 weeks and whilst still immobilised, the ankle is progressively held in a more neutral position which should permit graduated weightbearing as healing continues (Gulati et al., 2015).

Physiotherapy

Physiotherapy input forms a crucial facet of recovery so that exercise rehabilitation can begin early to achieve the best possible outcomes.

 

Whilst immobilised, exercises in non-weight-bearing positions to maintain core, knee and hip strength are strongly encouraged. Once the period of graded immobilisation has been completed, your Physiotherapist will design a bespoke rehabilitation plan focused on the ankle which will require a lot of hard work and consistency. Included within the rehabilitation protocol will be exercises to restore ankle movement, increase strength, and practice walking mechanics. Strength exercises will be progressed from a very light resistance to heavier resistance bands, weights and ever more demanding weight-bearing actions. Your Physiotherapist can implement manual therapy techniques such as deep tissue massage and joint mobilisations to facilitate optimal recovery and modulate pain.

 

The general rule is that running may be gradually introduced at 14 weeks post-injury/surgery however this will be guided by the Surgeon & Physiotherapist. Having completed an intensive rehabilitation programme, a review of healing is recommended to check the status of the injury site. For sporting populations, a gradual return is strongly advised. For those returning to contact sports, a timeline of 6-9 months post-injury is suggested (Willits et al., 2010).

References

Brumann, M., Baumbach, S. F., Mutschler, W., & Polzer, H. (2014). Accelerated rehabilitation following Achilles tendon repair after acute rupture–Development of an evidence-based treatment protocol. Injury45(11), 1782-1790.

 

de Jonge, S., Van den Berg, C., de Vos, R.J., Van Der Heide, H.J.L., Weir, A., Verhaar, J.A.N., Bierma-Zeinstra, S.M.A. and Tol, J.L. (2011). Incidence of midportion Achilles tendinopathy in the general population. British journal of sports medicine45(13), 1026-1028.

 

Flint, J. H., Wade, A. M., Giuliani, J., & Rue, J. P. (2014). Defining the terms acute and chronic in orthopaedic sports injuries: a systematic review. The American journal of sports medicine42(1), 235-241.

 

Gulati, V., Jaggard, M., Al-Nammari, S.S., Uzoigwe, C., Gulati, P., Ismail, N., Gibbons, C. and Gupte, C. (2015). Management of achilles tendon injury: A current concepts systematic review. World journal of orthopedics6(4), 380.

 

Lansdaal, J. R., Goslings, J. C., Reichart, M., Govaert, G. A. M., Van Scherpenzeel, K. M., Haverlag, R., & Ponsen, K. J. (2007). The results of 163 Achilles tendon ruptures treated by a minimally invasive surgical technique and functional aftertreatment. Injury38(7), 839-844.

 

Maffulli, N., Sharma, P., & Luscombe, K. L. (2004). Achilles tendinopathy: aetiology and management. Journal of the Royal Society of Medicine97(10), 472-476.

 

Metzl, J. A., Ahmad, C. S., & Levine, W. N. (2008). The ruptured Achilles tendon: operative and non-operative treatment options. Current reviews in musculoskeletal medicine1(2), 161-164.

 

Raikin, S. M., Garras, D. N., & Krapchev, P. V. (2013). Achilles tendon injuries in a United States population. Foot & ankle international34(4), 475-480.

 

Vosseller, J.T., Ellis, S.J., Levine, D.S., Kennedy, J.G., Elliott, A.J., Deland, J.T., Roberts, M.M. and O’Malley, M.J., 2013. Achilles tendon rupture in women. Foot & ankle international34(1), pp.49-53.

 

Willits, K., Amendola, A., Bryant, D., Mohtadi, N.G., Giffin, J.R., Fowler, P., Kean, C.O. and Kirkley, A. (2010). Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation. JBJS92(17), 2767-2775.

 

Wu, Y., Lin, L., Li, H., Zhao, Y., Liu, L., Jia, Z., Wang, D., He, Q. and Ruan, D. (2016). Is surgical intervention more effective than non-surgical treatment for acute Achilles tendon rupture? A systematic review of overlapping meta-analyses. International Journal of Surgery36, 305-311.

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