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Achilles Rupture

“It felt like I was hit or kicked in the back of the leg” is a classic description of the moment of Achilles tendon rupture. An audible pop, snap or tear may be reported with an obvious loss of foot function directly after the incident. Patients can often walk shortly afterwards using their accessory plantarflexor muscles but will describe a significant loss of power with toe push off and will often walk with a limp.

Our previous blog titled ‘The Achilles heel of the London Olympics’ told the story of the world champion hurdler, Liu Xiang, who tore his Achilles during the 110 meter hurdles at the London Olympics. Liu, 29, underwent surgical repair in London. Rumors have circulated that Liu was carrying a chronic Achilles tendinopathy which had flared up just prior to the games.

Chapter 37 of Clinical Sports Medicine (CSM4ed), ‘Pain in the Achilles region,’ describes the mechanism of injury of Achilles ruptures as a quick change of direction with a powerful calf contraction with the ankle in dorsiflexion. Typically these injuries are seen in sportspeople in their 30s and 40s, with a male to female ratio of 10:1. Approximately 80% of Achilles ruptures are seen in the region 3 to 6 cms above the calcaneal insertion2 and this is where clinicians may find a palpable gap in the initial phase of the injury prior to the accumulation of swelling. Chapter 37 (page 797) describes three other clinical signs clinicians can assess and should look out for if a ruptured Achilles is suspected. These include:

  1. The patient lying prone, feet hanging off the edge of plinth, the foot on the affected side will often hang more vertically (reduced calf tone)
  2. Strength tests of plantarflexors will be is markedly reduced on the affected side
  3. Thompson’s/Simmond’s test

Chapter 37 is co-authored by tendon specialist and orthopaedic surgeon Professor Hakan Alfredson from University of Umea, Sweden, researcher and physiotherapist Professor Jill Cook from Monash University, Australia, researcher and physiotherapist Dr Karin Silbernagel from the University of Delaware, USA and researcher and orthopaedic surgeon Professor Jon Karlsson from Sahlgrenska University Hospital, Sweden. Interestingly Professor Alfredson is known for attempting to rupture his own degenerative Achilles tendon through repeated, high-volume eccentric exercise. Famously, instead of rupturing his tendon his high-volume eccentric exercise program gave him significant pain relief. He went on to complete several research studies demonstrating the benefits of high-volume eccentric exercise and his research has led to a significant change in how tendinopathy is managed clinically today.

Intrinsic risk factors for Achilles rupture include poor tendon vascularity and pathological degenerative changes within the tendon combined with sudden acceleration and deceleration forces and some degree of muscle fatigue.1, 3 The past medical history may give clues of other contributing factors. For example corticosteriods have been linked to collagen necrosis and some medications such as fluoroquinolone antibiotics have been suggested to be toxic to tenocytes and alter matrix homeostasis.1, 3

There is some evidence that the incidence of complete Achilles tendon rupture is on the rise. A combination of sedentary lifestyles and infrequent, intense physical activity may be contributing to this increase. 3-4 Although we may assume that athletes maintain a high level of physical activity in addition to their sporting activity, should we as clinicians be routinely screening for sedentary behaviours in these patients?

Until the early 2000s, surgery was an automatic choice for ruptures in healthy individuals, who presented with no contraindications to surgery, and who wanted to return to an active lifestyle. At present there is no clear consensus on management so stay tuned for our next blog focusing on surgical versus conservative management for complete Achilles tendon ruptures.

References

  1. Jiang N, Wang B, Chen A et. al. ‘Operative versus nonoperative treatment for acute Achilles tendon rupture: a meta-analysis based on current evidence’ International Orthopaedics (SICOT) 2012 36: 765–773
  2. Kongsgaard M, Aagaard P, Kjaer M et. al. ‘Structural Achilles tendon properties in athletes subjected to different exercise modes and in Achilles tendon rupture patients’ J Appl Physiol 2005 99: 1965-1971
  3. Schepsis AA, Jones H, and Haas AL ‘Achilles Tendon Disorders in Athletes’ American Journal of Sports Medicine 2002 30(2): 287-305
  4. Wilkins R and Bisson LJ ‘Operative Versus Nonoperative Management of Acute Achilles Tendon Ruptures: A Quantitative Systematic Review of Randomized Controlled Trials’  American Journal of Sports Medicine 2012 40(9): 2154-2160

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