1. Achilles tendon rupture
Sport Injuries by Haroun Cherif

2. Overview
Achilles tendon rupture

3. 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

4. Achilles tendon

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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.

11. Func?onal anatomy
Achilles tendon rupture

12. 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

13. 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

14. 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

15. 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

16. 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

17. Injury Evalua?on
Achilles tendon rupture

18. 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

19. 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

20. 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

21. 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

22. Differen?al diagnosis
 Ankle fracture
 Ankle sprain
 Calcaneofibular ligament injury
 Talofibular ligament injury

23. 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

24. Rehabilita?on Program
Achilles tendon rupture

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. Preven?on
 Good condi?oning and proper stretching is important in the preven?on of
Achilles tendon injuries
 Adequate warm‐up!

32. 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

33. 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