Achilles Tendon Rupture
"Achilles Tendon Rupture," Is It a Common Injury?
Yes, it is one of the most common injury of lower leg in athletes and non-athlete individuals1.
Is Injury More Common in Male or Female?
Achilles tendon rupture is more common in male then female2. Male to female injury ratio is about 5:1.
What is the Anatomy of Achilles Tendon (AT)?
Achilles tendon is a distal part of calf muscles called gastrocnemius and soleus muscles. It is a strong fibrous tendon attached to calcaneus bone at the bottom of foot. Tendon is firmly attached to calcaneus bone, around bursae. Bursa is a jelly like fluid sacs which lies between tendon and calcaneus bone. It is one of the strongest muscle in human body.
What are the Functions of the Achilles Tendon (AT)?
Calf muscles and tendon is consistently used in ambulation, jogging and as well as bouncing activities of ankle joint.
What Causes Rupture of Strong Tendon like Achilles Tendon (AT)?
Average weight of 50 to 65 kg is transmitted through legs and thus Achilles tendon. Tendon is made up of fibrous tissue and has limited blood supply despite being strong tendon. Ischemic changes (less blood supply) or over stretching of the calf muscles and Achilles Tendon (AT) ligament can cause injury to Achilles Tendon (AT). Tendon rupture is either partial or complete.
Which is the Most Common Anatomical Site for Tear or Rupture of Tendon?
Tendon may rupture anywhere along the length of the tendon, which you can palpate from bottom of calf muscle mass to attachment at calcaneus bone. Most common location of rupture tendon is about 2.5 inch above the attachment of the tendon to calcaneus bone.
What are the Causes of Rupture of Achilles Tendon?
Achilles Tendon rupture occurs following fall, tripping or direct injury with sharp or blunt object to tendon.
What are the Risk Factors Associated with Achilles Tendon Rupture?
- More common in male.
- Seen more often in individual of age 30 to 40 years.
- Sporting activities like jogging, tennis, soccer, basketball and football may cause severe force and torque over tendon while twisting and movement of ankle causing tear or fracture of tendon.
- Frequent steroid injection for tendinitis can cause steroid induced weakening of tendon and may lead to fracture.
- Tendon rupture is often seen when treated with antibiotics like Fluoroquinolone, ciprofloxacin (Cipro) or levofloxacin (Levaquin).
What are the Symptoms of Ruptured Achilles Tendon?
Immediate symptoms are:
- Sharp excruciating pain at the back of ankle and calf muscles.
- Unable to walk or put weight on foot or ankle or leg of injured side.
- Popping sound felt or heard just before the injury.
Delayed symptoms are:
- Severe intractable pain.
- Ankle swelling on the back of tendon.
- Hemorrhagic discoloration.
- Unable to bend or twist foot at ankle joint.
- Unable to walk or put pressure on injured leg.
What should I do if I feel I had Rupture of Achilles Tendon?
You should avoid putting any weight on your foot or ankle. You should ambulate with assistive device until you see your doctor or visit ER. You should see primary care physician (PCP) either family physician or internal medicine doctor as soon as possible. Immediate immobilization of joint and foot may be necessary to prevent further damage in case of tear. If you cannot see your PCP, you should go to ER immediately.
What are the Different Diagnostic Tests?
Diagnostic clinical examination and lab studies are as follows:
- Simmond's test also known as Thomson test. Normal test indicates when calf muscle is squeezed muscle contraction pulls Achilles tendons and causes plantar flexion (foot bends down). Test is performed in prone position (lying dawn on stomach). Test is positive if plantar flexion is not observed as seen in cases of rupture Achilles tendon patient.
- O'Brien Test - 23 or 25 G sterile needle passed through the skin into tendon, after skin is prepped with antiseptic Betadine. Test is considered positive if movement of needle is observed leaning towards the toes.
- X-ray is used to diagnose fracture or dislocation of ankle joint as a cause of pain.
- MRI studies can differentiate tendon rupture, tendinitis and bursitis as a cause of pain.
- Ultrasound- determines muscle thickness, tear and hematoma (blood clot).
What are the Choices of Treatment?
Conservative non-invasive treatment for contusion or minor rupture3:
- Pain and anti-inflammatory medications- Motrin, Naproxen and Celebrex.
- Ankle braces or plaster cast for 4 to 6 weeks depends on extent of injury.
- Physical therapy after wound is healed and pain subsides.
- Rehab treatment may be necessary in few cases. Rehab is necessary for gaining strength of lower leg, correction of any abnormal gait and if necessary to teach how to use prosthetic shoes or walking aid like cane or walker.
Invasive treatment for minor rupture:
- Acupuncture treatment.
- Local anesthesia injection without cortisone.
Invasive treatment - Surgery
Indication for surgical repair of Ruptured Achilles Tendon:
- Major tendon rupture.
- Fracture and separation of tendo-achilles.
- Repeated tear after conservative treatment.
- Percutaneous surgery4.
- Open surgery.
- Direct suturing of the ruptured tendon.
- After direct suturing of the ruptured tendon, tendon is reinforced by wrapping harvested muscles around the tendon. There are two different types of surgeries; open surgery and percutaneous surgery.
- Instead of wrapping muscles around tendon after suturing rupture tendon, surgeon may use a mesh made up of collagen or artelon to reinforce the tendon.