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Achilles tendon rupture Sport Injuries by Haroun Cherif
Overview Achilles tendon rupture
Overview The Achilles tendon is a large band of fibrous ?ssue in the back of the ankle that connects the powerful calf muscles to the heel bone (calcaneus)
This Achilles tendon is the largest tendon in our body
When the calf musles contract, the Achilles tendon is ?ghtened, pulling the heel
It is vital to such ac?vi?es as walking, running, and jumping
Achilles tendon
Causes This tendon can grow weak and thin with age and lack of use
At this stage it becomes prone to injury or rupture
Certain diseases (ex. Arthri?s, diabetes) and medica?ons (ex. Cor?costeroids and some fluoroquinolone an?bio?cs) can increase the risk of rupture
Causes The most common mechanisms of injury include sudden forced plantar flexion of the foot, unexpected dosiflex?on of the foot, and violent dorsiflexion of the foot
Direct trauma
AKri?on of the tendon as a result of longstanding peritenoni?s with or without tendinosis
Causes Sudden, eccentric force applied to a dorsiflexed foot
May occur as the result of direct trauma or as the end result following Achilles peritenoni?s, with or without tendinosis
Risk factors: reacrea?onal athlete, age (30‐50 years), previous tendon injury, previous tendon injec?ons or fluoroquinolone use, abrupt changes in training (intensity, ac?vity level), par?cipa?on in a new ac?vity
Peritenoni?s with tendinosis Will generally present with ac?vity‐related pain, swelling, and some?mes crepita?on along the tendon sheath
With or without the presence of nodularity
More severe symptoms may include pain at rest
Tendinosis Lage‐stage manisfesta?on of this problem
Characterized by mucoid degenera?on of the achilles tendon itself, with a lack of inflammatory response and symptoms
A sense of fullness or nodularity in the posterior aspect of the tendoachilles
Epidemiology Although the worldwide frequency of Achilles tendon ruptures is not known data collected from Finland es?mates that it occurs in 18 per 100000 people yearly
The male‐to‐female ra?o of rupture is es?mated from 1.7:1 to 12:1.
Func?onal anatomy Achilles tendon rupture
Func?onal Anatomy The largest and strongest tendon in the human body
Formed from the tedninous contribu?ons of the gastrocnemius and soleus muscles
The tendons converge appr. 15 cm proximal to the inser?on at the posterior calcaneus
Func?onal Anatomy When viewed in cross sec?on, the right Achilles tendon appears to spiral counterclockwise 30‐150º toward its inser?on at the calcaneus
The spiraling of the tendon as it reaches the calcaneus allows for elonga?on and elas?c recoil within the tendon, facilita?ng storage and release of energy during movement
This also allows higher shortening veloci?es and greater instantaneous muscle power than could be generated by the gastrocnemius and soleus complex alone
Func?onal Anatomy Because the ac?n and myosin present in the tenocytes, tendons have almost ideal mechanical proper?es for the transmission of force from muscle to bone
Tendons are s?ff, but possess a high tensile strength
They have the ability to strecth up to 4% before damage occurs
With a stretch greater than 8% occurs macroscopic rupture
Blood supply for the tendon Derived from the posterior 4bial artery and its contribu?ons to the musculotendinous junc?on, as well as the mesosternal vessels which cross the paratenon, infiltra?ng the tendon and the bone‐tendon junc?on at the calcaneus
The watershed zone is an area 2‐6 cm proximal to the calcaneus, in which the blood supply is less abundant and becomes even sparser with age
It is in this part that most degenera?on and therefore rupture of the Achilles tendon occurs
Sport‐specific biomechanics The peak Achilles tendon force (F) and the mechanical work (W) by the calf muscles are respec?vely appr. 2200N and 35J in the squat jump, 1900N and 30J in the countermove jump, and 3800N and 50J when hopping
The es?mated peak load is 6‐8 ?mes the body weight during running with a tensile force of greater than 3000N
On average, achilles tendons in women have a small cross‐sec?onal area than in men
This suggests that less force is generated in a woman’s Achilles tendon, which may account for the lower rate of rupture in women
Injury Evalua?on Achilles tendon rupture
History Pa?ents with an Achilles tendon rupture frequently present with complaints of a sudden snap in the lower calf associated with acute sever pain
The pa?ent may be able to ambulate with a limp, but he or she is unable to run, climb stairs, or stand on their toes
Loss of plantar flexion power in the foot
May be swelling of the calf
History There may be a history of a recent increase in physical ac?vity/training volume
There may be a history of recent use of fluoroquinolones, coir?costeroids or of cor?costeroid injec?ons
There may have been a previous rupture of the affected tendon
Physical evalua?on Examine the en?re length of the gastrocnenmius‐soleus‐achilles complex
Evaluate any tenderness, swelling, ecchymosis, and tendon defects
Some?mes a palpable gap in the Achilles tendon may be found
The pa?ent will be unable to stand on the toes on the affected leg
Clinical tests “Hiperdorsiflexion” sign – With the pa?ent prone and knees flexed to 90º, maximal passive dorsiflexion of both feet may reveal excessive dorsiflexion of the affected leg
Thompson test: with the pa?ent prone, squeezing the calf of the extended leg may demonstrate no passive plantar flexion of the foot if its Achilles tendon is ruptured
O’Brien needle test: insert a needle 10 cm proximal to the calcaneal inser?on of the tendon. With passive dorsiflexion of the foot, the hub of the needle will ?lt rostrally when the Achilles tendon is intact
Differen?al diagnosis Ankle fracture
Ankle sprain
Calcaneofibular ligament injury
Talofibular ligament injury
Imaging studies Radiographs are useful in ruling out other injuries (may show sog‐?ssue swelling, increased ankle dorsiflexion on stress views, vascular or heterotopic calcifica?ons, accessory ossicles, calcaneal fractures, Haglund deformity, bony metaplasia)
Musculoskeletal ultrasonography can be used to determine the tendon thickness, character, and presence of a tear
MRI: can be used to discern incomplete ruptures from degenera?on of the Achilles tendon, can dis?nguish between paratenoni?s, tendinosis, and bursi?s
Rehabilita?on Program Achilles tendon rupture
Physical Therapy A person who ruptures the Achilles tendon should seek prompt medical treatment
Physical therapy is generally not indicated in the acute phase of the treatment, but later becomes a crucial part of the rehabilita?on once adequate healing of the tendon has occurred
A nonopera4ve vs opera4ve treatment is determined on a pa?ent‐by‐pa?ent basis
Typically, both nonopera?ve and opera?ve treatment op?ons are offered to pa?ents, with par?cular emphasis on the benefits and risks of each procedure
Surgical Interven?on Controversy exists regarding whether to conserva?vely manage a first‐?me Achilles tendon rupture or to surgically reconstruct the ruptured tendon
According to Kahn et al. There was a consistent finding of an appr. 33% higher rate of complica?ons in those treated surgically
Nonopera?vely treated pa?ents had a rerupture rate appr. 3 ?mes higher than those treated surgically, but these pa?ents had minimal risk for other complica?ons
Listed complica?ons resul?ng from open surgical repair included deep infec?ons (1%), fistulae (3%), necrosis fo the skin or tendon (2%), rerupture (2%), and minor complica?ons
Surgical interven?on Studies indicate that pa?ents who had a percutaneous rather than an open surgical approach had a minimal rate of infec?on
But it was also demonstrated that there were rela?vely high rates of injury to the sural nerve
Conserva?ve repair Early reports of rerupture in conserva?vely treated pa?ents noted rates as high as 40%
In newer protocols with shorter immobiliza?on periods, the rates of rerupture apprear to be much less and are comparable to the rerupture rate for surgically repaired tendons
Physical Therapy Following cast removal, gentle passive range of mo?on of the ankle and subtalar joints is ini?ated
Ager 2 weeks, progressive resistance exercises (PREs) are added to the therapy
This followed by agrressive gait training exercises at about 10 weeks following the injury (nonopera?ve pa?ents) or surgery, leading toward ac?vity‐specific maneuvers and a return to aci?vi?es at 4‐6 months
The pa?ent’s recovery is largely dependent on the quality of the rehabilita?on program, the pa?ent’s mo?va?on and focus, his/her desired pos?njury ac?viy level
Medica?on No medical therapy is indicated for this condi?on
Medica?on is only described for the symptomatoc relief of pain
These medica?ons may include acetaminophen,various nonsteroidal an?‐inflammatory drugs (NSAIDs), or narco?cs, depending on physician preference
Preven?on Good condi?oning and proper stretching is important in the preven?on of Achilles tendon injuries
Adequate warm‐up!
Prognosis With proper treatment and rehabilita?on, the prognosis following an Achilles tendon rupture is good to excellent
Most athletes are able to return to their previous ac?vity levels with either surgical or conserva?ve treatment
Individuals who undergo surgical treatment are less likely to experience rerupture of their Achilles tendons
The rerupture rate for opera?ve treatment is 0‐5%, compared with neary 40% in those who opt for conserva?ve treatment
Educa?on Pa?ents should be educated on the importance of stretching and proper condi?oning to prevent rerupture of the Achilles tendon
Wearing appropriate and properly filng shoes during ac?vi?es also should be stressed to all athletes
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