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achilles_tendon

Achilles tendon injury

Achilles' tendon rupture

Epidemiology

  • incidence in the general population is 7 per 100,000
  • average age of patients is 30–40 years (due to the combination of degeneration and recreational sport) with a male-to-female ratio 4-5:1
  • 80% of ruptures occur during traumatic sports injuries such as from running, jumping or rapid acceleration or deceleration, for example, whilst playing tennis or basketball
  • competitive athletes appear to have a lifetime incidence of Achilles tendinopathy of 24 percent (40-50% in competitive runners, 17-18% in sprinters, soccer players and decathletes, 12% in track & field jumpers and basketballers), with 18 percent sustained by athletes younger than 45 years
    • tendon rupture occurs in 8.3 percent
  • runners who strike the forefoot put 20% more forces through the ankle and Achilles' tendon with increased risk of tendonitis, foot fractures and plantar fasciitis 1)
    • in comparison, runners who are heel strikers put 16% greater load through the knee increasing knee injury risk
  • military recruits develop tendinopathy at a rate of 6.8 percent

Risk factors for tendon degeneration and thus risk of rupture include

  • tendonitis (see below)
  • oral or parenteral glucocorticoids
  • direct steroid injections
  • overuse
  • vascular diseases
  • neuropathy
  • rheumatologic diseases, particularly psoriasis and ankylosing spondylitis
  • hypertension in women
  • fluoroquinolone antibiotics, such as ciprofloxacin (12 cases per 100,000 treated or 3.2 cases of tendon problems for every 1000 years of exposure)

Diagnosis

  • Simmonds' test (aka Thompson test) will be positive:
    • squeezing the calf muscles of the affected side while the patient lies prone, face down, with his feet hanging loose results in no movement (no passive planter flexion) of the foot, while movement is expected with an intact Achilles tendon and should be observable upon manipulation of the uninvolved calf.
  • ultrasound scan may be used as a confirmatory test.
  • MRI is the study of choice for partial tears as it provides the best anatomy and the most accuracy in detecting tears.

ED management

  • immobilise lower leg with foot in equinus with the foot pointed downwards (to oppose the ends of the ruptured tendon):
    • CAM boot with wedges to achieve 30deg plantar flexion, or,
    • below knee plaster slab
  • weight bearing is permitted
  • assess VTE risk and consider prophylaxis
  • educate on need to elevate and DVT risk mitigation
  • arrange early orthopaedic follow up (eg. fracture clinic) for possible early operative repair (within 1-2 weeks preferably) - refer to ultrasound prior to orthopaedic review
  • non-operative approach has ~15% risk of re-rupture - 3x that of surgical repair but without the operative risk, although still a risk for deep venous thrombosis (DVT)

Achilles tendonitis

  • aka tendinosis, tendinopathy, paratendonitis, enthesopathy, and insertional tendonitis
  • usually occurs in casual or competitive athletes who have increased their training regimen beyond their tendon's ability to heal the microtrauma from repetitive stress, or who have been training rigorously for a long time.

risk factors

  • cold weather training
  • foot misalignment, poor running mechanics (excessive supination, inadequate dorsiflexion), inappropriate footwear, and leg length discrepancy
  • age, male gender, and obesity

differential diagnosis

  • calcaneal bursitis
  • calcaneal apophysitis (aka Sever's disease) - stress over-use fracture of calcanuem in adolescents

investigations

  • MRI may demonstrate an increased T2 weighted signal in the tendon or an increased tendon diameter.
  • MRI may reveal alternative explanations for patient symptoms, such as enlarged calcaneal bursae.
  • neither US nor MRI findings appear to correlate closely with clinically significant chronic Achilles tendinopathy.

Mx of acute tendonitis

  • Avoid aggravating activities
  • Apply ice when symptomatic
  • short course (7 to 10 days) of nonsteroidal antiinflammatory drugs (NSAIDs)
  • support the Achilles with a heel lift or bandage as needed
  • NB. injection of steroids may improve pain in the short term but does not appear to alter symptoms at 12 weeks and increases the risk of rupture.

Mx of chronic tendonitis

  • Eccentric exercise rehabilitation
  • Heel lifts, arch supports, orthotics, and running shoes that are stable and prevent oversupination are commonly prescribed, but studies supporting these interventions are lacking
  • Glucocorticoid injections are NOT recommended for chronic tendinopathy due to the risk of tendon rupture and the absence of a clear benefit2)
achilles_tendon.txt · Last modified: 2016/12/05 13:43 (external edit)