Achilles tendinopathy and tendon rupture

Essentials

  • Non-surgical treatment with an orthosis is recommended for acute Achilles tendon ruptures.
  • Surgery should be considered in competing athletes (take-off foot).
  • Surgery is also recommended for chronic ruptures.
  • When treating Achilles tendinopathy, physical exercise causing symptoms should be replaced by suitable types of sports.
  • Peritendinous glucocorticoid injections are not recommended.

Definition

  • Inflammation of the tissues surrounding the Achilles tendon was formerly termed peritendinitis and inflammation of the tendon tendinitis, both of which are histopathological diagnoses.
  • These two terms have been replaced in clinical use by the term tendinopathy, which is characterised by Achilles tendon pain, swelling, and impaired performance.
  • Depending on 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 activities such as long distance running, jogging or orienteering).
  • The incidence of Achilles tendon rupture has increased. Tendon rupture occurs typically in men aged 30–50 years during active 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 when used concomitantly with a glucocorticoid [Evidence Level: C].

Symptoms and diagnosis

Tendinopathy

  • Pain and swelling around the Achilles tendon
  • Pain when calf muscles are contracted or 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 describes feeling as if he or she was kicked in the back of the lower leg. 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 will prevent palpation of the depression.
  • There are also tests available for clinical use.
    • In the Thompson test the patient lies prone with his/her ankle unsupported. Squeezing the calf will not cause plantar flexion of the ankle.
    • 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 diagnosis. Magnetic resonance imaging can be used, if necessary, to obtain more information in partial ruptures of the proximal tendon and in old ruptures.

Treatment

Conservative treatment of tendinopathy

  • The patient must abstain from sporting activities that trigger the symptoms; suitable alternative activities include swimming, aqua jogging and using an exercise bicycle.
  • Eccentric exercises for the gastrocnemius-soleus complex (Eccentric training for the calf muscle-Achilles tendon complex):
    • 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.
  • Extracorporeal shock wave therapy (ESWT)
  • For insertional tendinitis, analgesia
    • A heel insert to relieve pressure at the insertion site
    • Anti-inflammatory analgesic
  • Local glucocorticoid injections are not recommended for the treatment of tendinosis. They may be considered for the treatment of isolated retrocalcaneal bursitis.
  • There are many forms of treatment for which there is no evidence available, such as nocturnal splinting, platelet-rich plasma (PRP) injections, kinesio taping and deep fascia massage.

Surgical treatment of tendinopathy

  • Open debridement and decompression
  • There is no evidence available for the therapeutic usefulness of calf release, percutaneous/mini-invasive procedures or flexor hallucis longus tendon transfer.

Tendon rupture

  • Non-surgical treatment with a Walker® or Vacoped® orthosis is recommended for acute Achilles tendon ruptures.
  • Surgery should be considered in competing athletes (take-off foot).
  • Surgical treatment is preferred for chronic and recurring ruptures.
    • 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 measures of ankle function were detected but surgical treatment provided faster recovery of calf muscle strength and the difference remained at 18 months after the injury.
    • Patients treated with surgery were also more satisfied concerning pain and physical functioning based on a quality of life index.

Non-surgical treatment

  • With a Walker® orthosis
    • Weeks 0–2: Three 0.5-cm heel wedges in the orthosis. Weight bearing as permitted by pain. Moving toes around.
    • Weeks 3–4: Two 0.5-cm heel wedges in the orthosis. Full weight bearing. Moving toes around.
    • Weeks 5–6: One heel wedge in the orthosis. Full weight bearing. Moving toes around.
    • Weeks 7–8: Orthosis without heel wedge. Full weight bearing. Moving toes around.
    • Weeks 8–14: Follow-up appointment with an orthopaedist at week 8. Heel insert in the shoe until 14 weeks from injury, compression sock as necessary for swelling. Start resistance band exercises. Physiotherapy, as necessary.
  • With a Vacoped® orthosis
    • Weeks 0–1: A cast is applied for a week with the ankle in the equinus position.
    • Weeks 2–3: At one week, a Vacoped® orthosis is placed, with the ankle first in 30° extension (plantar flexion) for 2 weeks. Full weight bearing is allowed with the orthosis.
    • Weeks 4–5: Ankle in orthosis in 15° angle for 2 weeks
    • Weeks 6–8: Ankle in free 0–30° extension
    • Weeks 9–: Follow-up appointment with an orthopaedist. After removal of the orthosis, a 1 cm heel wedge is used for 1 month. The ankle and calf should be rehabilitated by the patient him-/herself using resistance band exercises and calf exercises of increasing intensity according to home exercise instructions.
    • Week 12: Jogging is allowed.
    • Week 24: Full-scale physical exercise can be resumed.

Surgical treatment

  • Factors favouring surgical treatment include
    • recurring ruptures
    • avulsions at the insertion site
    • ruptures over 2 weeks old, in which the depression does not disappear when the ankle is in equinus position
    • ruptures in competing athletes (take-off foot).
  • Surgical procedure: tendon suturing without reinforcement
    • Postoperative treatment with Walker® or Vacoped® orthosis: 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 tendon defect

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. KFahlström M, Jonsson P, Lorentzon R et al. Chronic Achilles tendon pain treated with eccentric calf-muscle training. Knee Surg Sports Traumatol Arthrosc 2003;11(5):327-33.  [PMID:12942235]
3. Nørregaard J, Larsen CC, Bieler T et al. Eccentric exercise in treatment of Achilles tendinopathy. Scand J Med Sci Sports 2007;17(2):133-8.  [PMID:17394474]
4. 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;39(11):838-42; discussion 838-42.  [PMID:16244194]
5. Lantto I, Heikkinen J, Flinkkila T et al. A Prospective Randomized Trial Comparing Surgical and Nonsurgical Treatments of Acute Achilles Tendon Ruptures. Am J Sports Med 2016;44(9):2406-14.  [PMID:27307495]
6. Roche AJ, Calder JD. Achilles tendinopathy: A review of the current concepts of treatment. Bone Joint J 2013;95-B(10):1299-307.  [PMID:24078523]
7. Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet 2010;376(9754):1751-67.  [PMID:20970844]
8. Heikkinen J, Lantto I, Flinkkilä T et al. Augmented Compared with Nonaugmented Surgical Repair After Total Achilles Rupture: Results of a Prospective Randomized Trial with Thirteen or More Years of Follow-up. J Bone Joint Surg Am 2016;98(2):85-92.  [PMID:26791028]
9. Chimenti RL, Cychosz CC, Hall MM et al. Current Concepts Review Update: Insertional Achilles Tendinopathy. Foot Ankle Int 2017;38(10):1160-1169.  [PMID:28789557]
10. Paavola M, Kannus P, Paakkala T et al. Long-term prognosis of patients with achilles tendinopathy. An observational 8-year follow-up study. Am J Sports Med 2000;28(5):634-42.  [PMID:11032217]

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