Achilles Tendon Rupture

 

Written by: Patrick Monahan, MD
Edited by: Timothy Khowong, MD

 

Introduction, Anatomy, and Pathophysiology

The achilles tendon connects the gastrocnemius/soleus and calcaneus. Its normal function is plantarflexion, which is important for normal walking, running, jumping, and any other activity that requires use of the feet and legs. Rupture of the Achilles tendon usually occurs with rapid forced dorsiflexion and is usually in the setting of abrupt increase in the activity of an athlete. It is usually an acutely painful condition and can lead to poor range of motion and other functionally limiting outcomes if improperly managed.


Risk Factors:

Risk factors that increase the likelihood of Achilles tendon rupture are those that decrease tendon strength or increase the force on the tendon itself. These include:

●      Obesity

●      Stop-and-go activities (soccer, basketball, etc),

●      Fluoroquinolone or steroid use

●      Male gender

●      Old age

●      Sudden increase in activity.

Diagnosis:

Diagnosis is aimed at identifying a complete tendon rupture. A partial tendon rupture may have a less obvious exam. Ultrasound may increase your ability to identify a complete or partial tendon rupture. MRI is the gold standard but is not usually obtained in the ED.

Thompson’s Test

Physical exam:

●     Thompson’s test- squeezing calf should produce plantarflexion if achilles tendon intact

●      Palpating defect at achilles tendon

●      Weakness/pain with plantarflexion

●      Hematoma, bruising around achilles tendon

Xray:

●      Look for any associated fractures from injury

●      May see thickening of achilles tendon with tendinopathy

Ultrasound:

●      Tendenopathy- may see enthesitis/tendinitis, thickening of tendon, increased vascular flow due to inflammation, fluid collections/hematomas

●      Achille’s tendon rupture- may see discontinuity in tendon

●      98-100% sensitive depending on study - can be more sensitive than MRI, but operator dependent

Longitudinal scan of active Achilles enthesitis (arrow), tendinitis (arrowhead), and retrocalcaneal bursitis (*)


Treatment:

Treatment is divided into operative and non-operative, with supportive care augmenting both. Each option has its own indications, risks, and benefits which are listed below. Orthopedic consultation is indicated for any patient that has a complete Achilles tendon rupture.

Operative:

  • Lower re-rupture rate than non-operative management (3.5% vs 12.1%)

    • Increased complications (infection, DVT/PE) (18.5% vs 7.1%)

  • Recommended for athletes etc.

Non-operative:

  • Short leg posterior splint in plantarflexion (equinus) OR walking boot with heel lift

    • 6-8 weeks total

    • Changed every 2 weeks with decreased plantarflexion each splint

  • Physical therapy

  • Rest, ice, elevation, nsaids


 
 
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