Achilles tendon injury

Achilles' tendon rupture

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

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)

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.

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)

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.

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

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

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.

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.

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⁾

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