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    Achilles Tendon Rupture

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    achilles tendon rupture

    Multiple athletes, and famous individuals, have injured their achilles tendon; including Kobe Bryant, The Rock, David Beckham, Al Gore, George Clooney, and Brad Pitt. 

    However, many regular Joe’s, like you and I, have also injured this same tendon which was named after the Greek warrior, Achilles.

    achilles tendon rupture
    https://i.pinimg.com/736x/d0/08/dd/d008ddfc1f4e7f77db730766e3066ee1–achilles-stretches-calf-stretches.jpg

    An Achilles tendon tear most often results from:

    1. Stress on the tendon
    2. Natural degeneration of the tendon

    Who Will Have an Achilles Tendon Tear?

    One in every 10,000 people per year, tear their Achilles tendon, making it the third most frequent tendon disruption in the body.

    This injury most commonly occurs in those 30-50 years of age with an increased risk in those that participate in recreational athletics.

    Additional risk factors include aging, previous injury to the Achilles tendon, rapid change in exercise level, or starting a new physical activity.

    Chronic Achilles tendinitis, naturally tight muscles, genu varum, lupus, gout, RA, recent steroid injections to the tendon, and fluoroquinolone use can contribute to the injury as well.

    Patient Presentation

    A typical history finds a patient who recently exercised with a push off, jump, or misstep that caused a snapping sensation or an audible pop in the back of the leg, followed by pain.

    You’ll often hear a patient state it felt like they were hit in the back of the leg with a baseball bat.

    Associated symptoms might include weak plantar flexion, as well as swelling and bruising, with an antalgic gait.

    Approximately 25% of Achilles tendon rupture are initially misdiagnosed.

    Differential diagnoses include:

    1. Achilles tendinopathy
    2. Retrocalcaneal bursitis
    3. Ankle sprain
    4. Calcaneal avulsion fracture
    5. Partial rupture of the gastrocnemius muscle
    6. Plantaris rupture
    7. Os trigonum syndrome
    8. Plantaris rupture

    The Achilles Tendon Physical Exam

    A thorough history and physical examination, along with clinical suspicion, go a long way to aiding in the diagnosis of this injury.

    Thompson’s test provides a way to assess for complete Achilles tendon rupture.In this examination, the patient is placed in a prone position with the knees flexed.

    The provider squeezes the calf muscle, which should cause plantarflexion of the ankle.If no plantarflexion occurs, this is indicative of an Achilles tendon rupture (positive Thompson test).

    Thompson test
    Accessed from Uptodate

    A second physical exam test is Matles test.  In this test, the patient is placed in the prone position with knees flexed to 90 degrees.  If the injured foot falls to neutral or to dorsiflexion, this is indicative of an Achilles tendon rupture (positive Matles test).

    Patient’s may still be able to have some plantar flexion strength because of the action of the surrounding muscles, including the peroneus brevis, peroneus longus, tibialis posterior, flexor hallicus longus, and flexor digitorum.

    Imaging the Achilles Tendon

    Magnetic resonance imaging and ultrasound can be useful, especially if the tests above are inconclusive and clinical suspicion is high.

    Treating the Achilles Tendon Tear

    Controversy exists regarding the best approach: conservative versus surgical repair.

    But, most research shows that early surgical repair has a far better prognosis than later surgical repair.

    If conservative treatment is chosen, then a higher risk of re-rupture exists.

    Early surgical repair has been shown to allow an earlier return to full activity.

    In general, patients who are older, and more sedentary, can be treated conservatively, whereas highly paid professional athletes or younger, more active, patients should receive early intervention with surgical repair.

    Conservative treatment includes a long leg cast with the foot in 20 degrees equinovarus.  One must ensure the patient’s knee is bent during the casting process. 

    The cast is worn for approximately eight weeks, with gradual reduction of the equinovarus, with a short leg cast.

    After removal of the cast, physical therapy is started, to regain dorsiflexion of the ankle.  This casting program may take up to twelve weeks total.  The total conservative rehabilitation process may last six to nine months.

    Regarding surgery, several techniques exist to repair the ruptured Achilles tendon.  Many involve lengthening and flap down procedures to reduce the gap in the tendon.  Biologic grafts are available, which can be used to strengthen the rupture site.

    Achilles Tendon Repair
    http://www.southfloridasportsmedicine.com/images/achilles%20repair%20illus.png
    Achilles Tendon Repair
    https://i.ytimg.com/vi/-Mo6cDEj8tM/maxresdefault.jpg

    After surgery, the patient should be immobilized for six to eight weeks, followed by physical therapy.The current trend is toward a short period of nonweight-bearing.

    A recent study in the American Journal of Sports Medicine, showed that one day of non-weight-bearing, followed by six weeks of immobilization with physical therapy and ambulation, caused no increased of re-rupture or post-operatively complications (Am Fam Physician. 2002 May 1;65(9):1805-1811.)

    However, most orthopaedic surgeons are not this aggressive post-operatively.

    As mentioned above, re-rupture occurs more frequently (20% to 30%) with conservative treatment.With surgical repair, the re-rupture rates are very low (approximately 1.4%).

    Complications from Achilles tendon rupture surgery include infection and skin breakdown.

    Stretching of the legs, prior to vigorous exercise, can be done to prevent an Achilles tendon rupture.If a patient is taking a fluoroquinolone, they should reduce their training amount and intensity throughout the antibiotic course.

    This includes no sprinting, jumping, full speed scrimmages, or competition until two to four weeks after the completion of therapy.

    Runners should decrease their total mileage to 60% of normal training volumes, for the first seven days, without any hill or speed training.

    Resources

    UpToDate, Achilles Tendinopathy and Tendon Rupture, Accessed: November 20, 2017.
    Am Fam Physician. Common Conditions of the Achilles Tendon. 2002 May 1;65(9):1805-1811.
    Am Fam Physician. Management of Acute Achilles Tendon Rupture. 2015 Jun 1;91(11):794-800.
    Ferri’s Clinical Advisor, Achilles Tendon Rupture. 2017.

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    Clay Walker
    Clay Walker is a board-certified physician assistant practicing in family medicine and urgent care in rural southern Illinois. He is a graduate of Southern Illinois University School of Medicine Physician Assistant Program - class of 2016. Prior to going to PA school, Clay worked as a histology technician in southern Illinois.  From an early age, he has been interested in medicine. Clay was diagnosed as a type 1 diabetic in the first grade. He began learning about his condition and teaching others about T1DM; since then, he began to have a passion to learn medicine and make a difference in the lives of others. In his free time, Clay enjoys watching sports and going to sporting events, specifically the Chicago Cubs and Philadelphia Eagles.