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
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 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
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
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
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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