Achilles tendinopathy and tendon rupture

Essentials

  • Surgery is favoured in competing athletes and in cases where the rupture has become chronic.
  • Conservative treatment is a good alternative for managing acute ruptures in normally active patients as well as in elderly and non-active patients.

Definition

  • Inflammation of the tissues surrounding the Achilles tendon was formerly termed peritendinitis and the inflammation of the tendon tendinitis, which are both histopathological diagnoses. During the last few years, these two terms have been replaced in clinical use by the term tendinopathy, which is characterised by Achilles tendon pain, swelling, and impaired performance.
  • According to the duration of symptoms, tendinopathy may be classified as being acute (< 2 weeks), subacute (2–6 weeks), subchronic (6 weeks – 6 months) or chronic (> 6 months).

Aetiology

  • Achilles tendinopathy is a stress injury (caused by, for example, long distance running, jogging or orienteering).
  • The incidence of Achilles tendon rupture has been on the increase during the last few decades. Tendon rupture occurs typically in men aged 30–50 years during exercise, particularly during ball games.
  • A rupture may be partial or complete.
  • The ruptured tendon almost invariably shows degenerative changes, although most patients have had no preceding symptoms.
  • The use of fluoroquinolone antibiotics increases the risk of Achilles tendon rupture, particularly in patients aged over 60 years and during concomitant use with steroids C.

Symptoms and diagnosis

Tendinopathy

  • Pain and swelling around the Achilles tendon
  • Pain when calf muscles are contracted and stretched
  • Local tenderness to palpation on both sides of the Achilles tendon
  • Occasionally a lump along the mid-third section of the tendon

Tendon rupture

  • Tendon rupture causes acute pain that soon eases. The patient felt as if someone had kicked him/her from behind. Some ruptures may be painless.
  • The patient is unable to stand on his/her toes. Partial plantar flexion may still be possible as the flexor tendons of the toes and peroneal tendons are still functioning.
  • A depression may be felt at the site of the rupture. The longer the time interval from the rupture to the examination the more likely it is that swelling and haematoma prevent the palpation of the depression.
  • The following tests can be used for diagnosis:
    • In the Thompson test the patient lies prone with his/her foot extended beyond the end of the table, and the examiner squeezes the calf. Lack of plantar flexion can indicate a rupture of the Achilles tendon.
    • In the Copeland test the patient lies prone with his/her knee in 90-degree flexion. A blood pressure cuff is placed around the calf and inflated to 100 mmHg. Passive dorsiflexion of the ankle does not increase the pressure in the injured leg, whereas a rise of approximately 40 mmHg is observed in the unaffected leg.
  • An ultrasound examination is helpful in uncertain cases and when a long time has elapsed between the trauma and the investigation. Magnetic resonance imaging can be used, if necessary, to obtain more information in partial ruptures of the proximal tendon and in old ruptures.

Treatment

Tendinopathy

  • The patient must abstain from sporting activities that cause the symptoms to emerge; suitable alternative activities include swimming, aqua jogging and using an exercise bicycle.
  • Eccentric exercises for the gastrocnemius-soleus complex (picture 1):
    • Standing on the edge of a step, the patient performs a calf rise with the weight of the body on the unaffected foot. The weight is then transferred to the affected foot and the patient lowers the heel of this foot below the edge of the step. The exercise is carried out both with the knee straight (3 × 15 repetitions) and with the knee slightly flexed (3 × 15 repetitions) twice a day for 3 months.
  • Stretching exercises for the calf muscle and Achilles tendon. A heel insert may be beneficial.
  • In case of acute peritendinitis crepitans, empirical treatment consists of low molecular weight heparin (e.g. Fragmin®) 100 i.u./kg subcutaneously on three consecutive days. The patient should be advised about the increased tendency to bruise. Haemorrhagic diathesis is a contraindication to heparin therapy. Because heparin therapy requires several visits to the doctor and is associated with a slightly increased risk of haemorrhagic complications, its use should be reserved for competitive athletes who need to recover rapidly.
  • Anti-inflammatory drugs are always recommended if the symptoms are obvious C; however not in conjunction with heparin (paracetamol should be used instead).
  • If tendinopathy becomes chronic, 1–2 glucocorticoid injections (up to 3 if indicated) can be administered in the peritendineum with an interval of a few weeks between each injection (never into the tendon itself due to an increased risk of rupture). After glucocorticoid injections, a resting period of at least 2 weeks is necessary before resuming strenuous activities, and the intensity must be increased gradually.
  • Surgical treatment is indicated if chronic tendinopathy does not respond to conservative treatment.

Tendon rupture

  • Achilles tendon rupture may be treated either with or without surgery. The decision on treatment should be made individually, taking into account the patient’s needs and risks. In recent ruptures, conservative treatment is very appropriate for most patients, but those with high level of physical activity will probably benefit from surgery.
    • In a randomized trial comparing patients treated with surgery or no surgery and with acute (less than 1 week old) Achilles tendon rupture, no differences in the clinical measurements of the ankle were detected, surgical treatment provided faster recovery of the calf muscle strength and the difference remained at 18 months after the injury.
    • Those treated with surgery were also more satisfied concerning pain and physical functioning.
Non-surgical treatment

  • Factors favouring non-surgical treatment include
    • acute closed ruptures in which the ends of the tendon can be brought together and the depression in the calf disappears when the ankle is in the equinus position (= ankle fully extended to plantar flexion)
    • smoking
    • arteriosclerosis obliterans (ASO)
    • advanced age
    • ample underlying diseases
    • substance abuse problems.
  • In non-surgical treatment, a cast is applied for a week with the ankle in the equinus position. After one week, an orthosis (e.g. Vacoped®) is used. The ankle is first in 30° plantar flexion for 2 weeks, then in 15° angle for 2 weeks and finally in free 0–30° plantar flexion for 2–3 weeks. Full weight bearing is allowed immediately with the orthosis.
    • Follow-up appointments during orthosis treatment every 2 weeks
    • After removal of orthosis, a 1 cm heel wedge is used for 1 month.
    • The ankle and calf should be rehabilitated by the patient him-/herself using rubber band exercises against force and calf exercises adding power according to home exercise instructions.
    • Jogging is allowed 3 months after the rupture.
    • Cycling and swimming are favoured

Surgical treatment

  • Factors favouring surgical treatment include
    • activity of the patient
    • recurring ruptures
    • avulsions in the insertion site
    • over 2 weeks old ruptures, in which the depression does not disappear when the ankle is in equinus position.
  • After surgery of an acute rupture, an orthosis is used with full weight bearing for 6 weeks, after which, if needed, a heel wedge is used for 1 month and further rehabilitation as in non-surgical treatment.
    • Return to full sport activity 6 months after the injury
    • In chronic ruptures, orthosis treatment after surgery and further rehabilitation individually depending on the size of the repaired defect in the tendon

Evidence Summaries

References

1. Maffulli N, Khan KM, Puddu G. Overuse tendon conditions: time to change a confusing terminology. Arthroscopy 1998 Nov-Dec;14(8):840-3.  [PMID:9848596]

2. Kangas J, Pajala A, Siira P, Hämäläinen M, Leppilahti J. Early functional treatment versus early immobilization in tension of the musculotendinous unit after Achilles rupture repair: a prospective, randomized, clinical study. J Trauma 2003 Jun;54(6):1171-80; discussion 1180-1.  [PMID:12813340]

3. Kangas J, Pajala A, Ohtonen P, Leppilahti J. Achilles tendon elongation after rupture repair: a randomized comparison of 2 postoperative regimens. Am J Sports Med 2007 Jan;35(1):59-64.  [PMID:16973901]

4. Kangas J. Outcome of total Achilles rupture repair, with special reference to suture materials and postoperative treatment. Thesis. Acta Universitatis Ouluensis, D Medica 922. University of Oulu, 2007

5. Leppilahti J. Achilles tendon rupture with special reference to epidemiology and results of surgery. Thesis. Acta Universitas Ouluensis, D Medica 383. University of Oulu, 1996

6. Paavola M. Achilles tendon overuse injuries. Thesis. Acta Universitatis Tamperensis 824. University of Tampere, 2001

7. Fahlström M, Jonsson P, Lorentzon R, Alfredson H. Chronic Achilles tendon pain treated with eccentric calf-muscle training. Knee Surg Sports Traumatol Arthrosc 2003 Sep;11(5):327-33.  [PMID:12942235]

8. Nørregaard J, Larsen CC, Bieler T, Langberg H. Eccentric exercise in treatment of Achilles tendinopathy. Scand J Med Sci Sports 2007 Apr;17(2):133-8.  [PMID:17394474]

9. Kayser R, Mahlfeld K, Heyde CE. Partial rupture of the proximal Achilles tendon: a differential diagnostic problem in ultrasound imaging. Br J Sports Med 2005 Nov;39(11):838-42; discussion 838-42.  [PMID:16244194]

10. Lantto I, Heikkinen J, Flinkkilä T et al.Surgery restores strength better. A prospective randomized trial comparing surgery and conservative treatment in acute Achilles tendon ruptures (Accepted Am J Sports Med)


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