What condition produces a patient’s symptoms?
The Achilles Tendon derives from the tendinous portions of the gastrocnemius and soleus muscles. The Achilles tendon becomes progressively rounded in cross section, to a level four centimeters proximal to the calcaneus, where it can become flatter before inserting on the superior calcaneal tuberosity. The fibers of the Achilles tendon spiral through 90 degrees during its descent, to allow for elongation and elastic recoil.1 An Achilles tendon rupture can be partial or complete. In a partial tear, the tendon is partly torn but is still joined to the calf muscle by undamaged fibers. In a complete tear, the tendon is completely torn, so that the connection between the muscle and bone is lost.2
An injury was most likely sustained to which structure?
A rupture to the Achilles tendon is dependent on the stress-strain curve for tendons. If the strain placed on the tendon is less than 4%, the fibers can regain their original arrangement once the strain is removed. If the load is between 4-8%, the fibers begin to slide past each other and the intermolecular cross-links fail, causing microtears. If the strain is greater than 8%, macroscopic rupture occurs because of the tensile failure of the fibers and interfibrillar shear failure.1
What is the most likely contributing factor in the development of this condition?
Achilles tendon rupture can occur if there is a high stress or force placed on it. This can occur with activities that involve a forceful push off with the foot, such as in football, running, basketball, diving, and tennis. The push off movement utilizes a strong contraction of the gastrocnemius and soleus, which can stress the Achilles tendon too much.3 The Achilles tendon can also be injured in falls, where the foot is suddenly forced into dorsiflexion, which stretches the tendon.1 Also, a deep laceration to the back of the ankle can reach the tendon and sever it.
Also, if the Achilles tendon is weak, it can be more susceptible to rupture. Some factors that can lead to a weakened tendon include:
- Corticosteriod medication (if used long term) or an injection near the Achilles tendon
- Adults 40-50 y.o. (M>F)
- Certain medical conditions such as Cushing’s syndrome, RA, gout and SLE
- Tendonitis of Achilles tendon
- Certain antibiotics (quinolones), such as ciprofloxacin and ofloxacin
What is the most likely clinical presentation?
- Sudden pain in the back of ankle or calf, that felt like they have been kicked or stabbed, that resolves
- hearing a pop or snap
- unable to bear weight
- weakness and/or stiffness of the affected ankle
- swelling on the posterior aspect of the lower leg
- a palpable gap just above the calcaneus.
- Palpation of the Achilles tendon to look for any signs of deformity.
- Imaging - Ultrasonography or MRI
- Thompson Test is positive if there is no calf contraction when squeezed.
- Non-operative treatment consists of 8 weeks of cast immobilization in plantar flexion to try and have the tendon heal naturally. There is an 8-39% re-rupture rate.4,5
- Operative treatment consists of percutaneous surgery or open repair. After surgery there is casting in slight planter flexion for 6-8 weeks.
The main goals of rehabilitation of the Achilles tendon after surgery are to control pain and to get the patient back to pain free ADLs. The duration and progression of the rehabilitation program should be based off the patients’ subjective and objective findings.
- Pain and inflammation management - cryotherapy, NSAIDs, PUS, TENS, LASER
- Restore ROM -Pain free ROM exercises and DTFs
- Restore strength and Proprioception -
- Water and land based rehabilitation for Achilles tendinopathy in an elite female runner.
- RECURRENT RUPTURE OF THE ACHILLES TENDON INDUCED BY CORTICOSTEROID INJECTION
- Bilateral rupture of the Achilles tendon in patients
- Clarification of the Simmonds–Thompson test
- Fluoroquinolones and risk of Achilles tendon disorders: case control study
- Treatment of Achilles tendon ruptures
- Surgical and non-surgical treatment of Achilles Tendon rupture. A prospective randomized study
- Early Motion of the Ankle after Operative Treatment of a Rupture of the Achilles Tendon. A Prospective, Randomized Clinical and Radiographic Study
- Diagnosis and Treatment of Acute Ruptures of the Achilles tendon Current Concepts Review
- Current Concepts Review Rupture of the Achilles Tendon
- Postoperative Rehabilitation Protocols for Achilles Tendon Ruptures: a Meta-analysis
1. Maffulli N. Rupture of achilles tendon. J Bone Joint Surg Am. 1999;81(7):1019-1036.
2. Agostinelli JR, Butterworth ML, Blahous EG, et al. Achilles tendon rupture. Available at: http://www.footphysicians.com/footankleinfo/achilles_tendon_rupture.htm. Accessed October 28, 2009.
3. Mazzone MF, McCue T; Common conditions of the achilles tendon. Am Fam Physician. 2002;65(9):1805-10.
4. Khan RJ, Fick D, Keogh A, et al; Treatment of acute achilles tendon ruptures. A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am. 2005;87(10):2202-10.
5. Twaddle BC, Poon P; Early motion for Achilles tendon ruptures: is surgery important? A randomized, prospective study. Am J Sports Med. 2007;35(12):2033-8.