What is Achilles Tendon Rupture?
Achilles tendon rupture, which often happens in people between their 30s and 50s, is the most frequent type of tendon tear in the lower body. People with this injury often feel a sudden pain and can hear a “snap” or loud “pop”, likened to being kicked in the lower leg. This injury causes substantial discomfort and can greatly impact mobility.
This kind of injury is typically seen in people who exercise occasionally, often known as “weekend warrior” athletes. It generally happens during games like soccer, racket sports, or basketball. It’s important to note that these injuries can sometimes be mistakenly diagnosed as ankle sprains in 20% to 25% of cases. Doctors have noticed that prior degeneration in the tendon, usage of fluoroquinolone drugs, steroid injections, and inflammatory arthritis can increase the risk of Achilles tendon injuries. Interestingly, about 10% of patients recall having warning signs before the injury happened.
What Causes Achilles Tendon Rupture?
The Achilles tendon can rupture or tear for a few reasons. This can happen if the foot is suddenly and forcefully flexed, if there is a direct injury, or due to long-term wear and tear on the tendon. Certain sports like soccer, basketball, and racquet games are often connected to these injuries.
Certain conditions can increase the chance of the Achilles tendon rupturing. These include not being physically fit before exercise, using corticosteroids for a long time, doing too much exercise, taking certain antibiotics or medicines for osteoporosis, having a previous Achilles tendon injury, having diabetes or a condition called hyperparathyroidism, and having certain genetic factors.
People with end-stage kidney disease are also more at risk of Achilles tendon rupture for a few reasons. They often take certain antibiotics and corticosteroids before or after a kidney transplant. Moreover, they often need dialysis each week which can cause metabolic imbalances, leading to hyperparathyroidism which further increases the risk of tendon rupture.
There are several health conditions that can increase the risk of Achilles tendon injuries. These include chronic kidney failure, lack of collagen (a protein in your body), diabetes, gout, infections, lupus, parathyroid disorders, rheumatoid arthritis, and thyroid disorders.
Foot issues also increase the risk of getting an Achilles tendon injury. These include a high arch in your foot, lack of flexibility and strength in certain calf muscles, limited ankle flexibility, a certain condition of the lower leg bone (tibia vara), and issues with foot alignment and pronation (the way your foot rolls inward for impact distribution upon landing).
Risk Factors and Frequency for Achilles Tendon Rupture
Achilles tendon rupture, or a tear in the strong tendon at the back of your ankle, appears to be happening more frequently, with recent studies reporting up to 40 cases per 100,000 people each year. This increase over the past ten years is thought to be due to more people, especially those over 30 years old, participating in sports. In fact, 75% of these injuries happen to men in their thirties and forties during sports.
It’s harder to know exactly how common Achilles tendinosis is (this is when the tendon thickens and becomes painful) as it’s often misdiagnosed. What we do know is that it seems to be more common among athletes. The incidence among runners is 7% to 18%, among dancers it’s 9%, gymnasts have a rate of 5%, tennis players 2%, and less than 1% in American football players. Overall, Achilles disorders affect around 1 million athletes every year.
- Achilles tendon ruptures are increasing, with up to 40 cases per 100,000 people yearly.
- This rise is thought to be linked to more people over 30 taking part in sports.
- 75% of these injuries occur in men in their 30s and 40s during sports.
- The true incidence of Achilles tendinosis isn’t certain as it’s often misdiagnosed.
- Achilles injuries are more common among athletes: 7-18% in runners, 9% in dancers, 5% in gymnasts, 2% in tennis players, and under 1% in American football players.
- About 1 million athletes get Achilles disorders every year.
Signs and Symptoms of Achilles Tendon Rupture
Individuals experiencing a rupture in the Achilles tendon commonly have sudden, sharp pain in the region of the Achilles tendon. This is usually associated with playing sports. Doctors will ask about the patient’s symptoms, when they started, and if they have worsened over time. It is also important to discuss any prior injuries, as well as the patient’s overall health and lifestyle. For instance, treatment could be different for athletes versus non-athletes due to their different lifestyles and the potential for the tendon to tear again.
During a physical examination, someone with a ruptured Achilles tendon might not be able to stand on their toes or show a significant loss of strength in ankle movement. Feeling the area could also reveal a gap where the tendon should be, or signs of bruising around the back of the ankle.
Doctors will conduct a Thompson test to determine if there’s an Achilles tendon rupture. In this test, the patient lies down on their stomach, flexing the same knee as the potentially damaged Achilles tendon to about 90 degrees, letting the foot and ankle relax. The doctor then squeezes the calf to observe if the foot and ankle flex. This result is compared to the other foot and ankle. If the test is positive, meaning that the foot doesn’t flex when the calf is squeezed, this strongly points to a ruptured Achilles tendon.
Testing for Achilles Tendon Rupture
After a detailed review of your medical history and a physical examination, a doctor can usually determine whether you’ve ruptured your Achilles tendon. They’ll mainly rely on a test called the Thompson test, which is between 96% to 100% successful at detecting a rupture, and 93% to 100% reliable in confirming its absence. However, it is important to note that up to 20% of Achilles tendon ruptures are mistakenly undiagnosed.
To support the diagnosis and exclude the possibility of other injuries, the doctor might ask for an X-ray, MRI, or ultrasound. X-rays are helpful in checking if there has been any bone fracture in the lower leg due to trauma. MRI and ultrasound, on the other hand, can more definitively confirm whether the Achilles tendon has been ruptured.
However, keep in mind that the physical tests doctors use to check for Achilles tendon ruptures are often more reliable than MRI tests. Also, MRIs can be expensive, take a considerable amount of time, and potentially delay any surgical treatment needed. Therefore, they are usually only recommended in cases where the diagnosis is uncertain or in situations of lingering or chronic injuries to help plan any surgery required.
Treatment Options for Achilles Tendon Rupture
The debate continues over the benefits and risks of surgery for Achilles tendon ruptures. Both surgical and non-surgical treatment methods have been shown to yield satisfactory results. Traditionally, non-surgical methods had higher rates of ruptures reoccurring. With improved rehabilitation programs, however, the difference in re-rupture rates has decreased significantly. At the same time, surgical treatment can lead to complications, like wound dehiscence and infection.
Non-surgical treatment typically includes rest, raising the leg, using pain medication, and wearing a special brace. This type of treatment delivers similar healing rates to surgical intervention, but it may take patients a bit longer to get back to work. Physical therapy is essential in both cases to strengthen muscles and improve ankle movement. Non-surgical treatment is generally recommended for patients with serious accompanying health conditions or those who lead less active lifestyles. The key advantages of this approach are the absence of hospital costs and complications related to the surgery or anesthesia. The most significant downside is a higher risk of the rupture happening again.
Surgical treatment can be performed using a variety of techniques, all with the same goal: to reconnect the torn ends of the tendon. These can include open repair, where the doctor makes larger incisions, mini open repair, where smaller incisions are made to prepare the tendon and interlocking stitches, and minimally invasive repair, which involves tiny incisions and a special suturing device. Despite its initial popularity, minimally invasive surgery has seen an 18% rate of nerve injury when the nerve isn’t exposed during surgery. This approach may only be beneficial when reinforced by other muscle tendons.
The healing rates are comparable between surgical and non-surgical treatments. The primary advantage of surgery is a quicker return to activity and a lower risk of re-rupture. The main disadvantage includes potential surgical complications. Because of the enhanced recovery and results after surgery, athletes are usually advised to choose this approach.
Biological therapy has also been researched with mixed results. Some studies found that treatments using Platelet-Rich Plasma (PRP), a type of concentrated blood plasma, produced better muscle performance, improved ankle movement, and higher functionality. However, others found no significant difference. More consistent results have been found in sport-active patients who recover their motion earlier and return to activity faster with PRP. Bone Marrow Aspirate Concentrate (BMAC) treatments have also shown improved function and pain management without serious side effects.
In the end, the choice between surgical and non-surgical treatment should be based on a thorough conversation between the patient and surgeon. This should include discussions of the healing rates, recovery times, risks of re-injury, and potential complications of each method.
What else can Achilles Tendon Rupture be?
When trying to work out if someone has ruptured their Achilles tendon, doctors might also have to rule out the following conditions which can cause similar symptoms:
- Inflammation of the Achilles tendon bursa (Achilles bursitis)
- Broken ankle bone (Ankle fracture)
- Compression or squeezing of the ankle joint (Ankle impingement syndrome)
- Arthritis in the ankle (Ankle osteoarthritis)
- Ankle sprain
- Injuries of the calf muscle
- Damage to the ligament on the outer side of the ankle (Calcaneofibular ligament injury)
- Fractures of the heel bone (Calcaneus fractures)
- Blood clot in the deep veins (Deep venous thrombosis or DVT)
- Pain caused by overuse or exertion in a muscle compartment (Exertional compartment syndrome)
- Tears in the connective tissue around muscles and organs (Fascial tears)
- Strain or rupture in the calf muscles (Gastrocnemius or soleus muscle strain or rupture)
- Deformity in the heel bone (Haglund deformity)
- Tear in the small tendon that runs down the back of your calf to your heel (Plantaris tendon tear)
- Type of arthritis linked to the skin condition psoriasis (Psoriatic arthritis)
- Reactive arthritis which includes eye, urinary tract and joint infections (Reiter syndrome)
- Inflammation in the bursa located above the heel (Retrocalcaneal bursitis)
- Rupture of a fluid-filled cyst behind the knee (Ruptured Baker cyst)
- Injury in the fibrous connection between the two bones of the lower leg (Syndesmosis)
- Injury to the ligament that connects the ankle and foot bones (Talofibular ligament injury)
Doctors carefully consider these possibilities and perform suitable tests to make sure they have the right diagnosis.
Surgical Treatment of Achilles Tendon Rupture
Original: In the United States, appendiceal neoplasms, or tumors in the appendix, occur at a rate of 1.2 cases per 100,000 people. Almost one-third of these patients experience severe stomach pain. The most common types of these tumors are gastroenteropancreatic neuroendocrine or carcinoid tumors (GEP-NETs), goblet cell carcinoma (GCC), colonic-type adenocarcinoma, and mucinous neoplasm.
Gastroenteropancreatic Neuroendocrine Tumors (GEP-NETs) are the most common type of tumors found in the appendix. They rarely spread to other parts of the body, but when they do, they usually spread to the liver and lymph nodes. So, if a patient is suspected to have GEP-NETs, doctors need to check their liver and lymph nodes. The treatment usually depends on the size of the tumor. If the tumor is smaller than 1 cm, removal of the appendix is sufficient. However, if the tumor is bigger than 2 cm, a more extensive surgery, called a right hemicolectomy, which involves removing a portion of the colon, is needed. The best treatment for tumors that are between 1 to 2 cm is still uncertain.
Goblet Cell Carcinoma is also common in cases of appendiceal malignancies. This type of cancer is unique because it shares features of both adenocarcinoma and neuroendocrine tumors found in the appendix. Treatment may involve a thorough examination of the lining of the abdominal cavity and removal of part of the colon. This is especially beneficial in cases where the disease hasn’t spread or the tumor is larger than 2 cm.
Non-Hodgkin lymphoma, including a type called Mucosa-Associated Lymphoid Tissue (MALT) lymphoma, can sometimes present itself as acute appendicitis. The best treatment for this rare appendiceal malignancy is simply removing the appendix. Yet, doctors should conduct a comprehensive evaluation to check for spread to other parts of the body.
Adenocarcinoma of the appendix is a rare type of tumor, often mistaken for acute appendicitis. The standard treatment involves removing a part of the colon, regardless of the size of the tumor or if it has spread to the lymph nodes.
Mucocele and Mucinous Neoplasm are conditions where cysts or fluid-filled sacs form in the appendix, which can mimic the symptoms of acute appendicitis. Identifying these conditions might require careful analysis of radiology reports and further examination during surgery. The best treatment includes avoiding rupture while removing the appendix and careful examination of the lining of the abdominal cavity. Laparoscopic, or minimally invasive surgery, is recommended for patients where the cyst appears to be uniform.
What to expect with Achilles Tendon Rupture
In general, patients with an Achilles tendon rupture have a great chance of recovery. However, some non-athletes might experience limited mobility even after recovery. Athletes typically return to their sports without any restrictions. But it’s worth noting that non-surgical treatments have a much higher rate of the injury occurring again, nearly 40%, compared to just 0.5% for patients who undergo surgery.
Possible Complications When Diagnosed with Achilles Tendon Rupture
Rerupture is a concern when managing these injuries. Although recent evidence indicates that the rates of rerupture are similar regardless of whether it’s managed nonoperatively or with surgery, earlier studies suggested a significantly higher chance of rerupture with nonoperative management (10% to 40%) compared to surgery (1% to 2%). A study by Lantto and team showed comparable Achilles tendon performance scores between patients managed with or without surgery, but the group that had surgery showed a slight improvement in calf muscle strength and better health-related quality of life in terms of physical functioning and less bodily pain.
Following surgery, there can also be issues with wound healing, with a reported risk of complications between 5% to 10%. Factors that can increase the chance of these wound complications include:
- Smoking (the most common and most significant risk factor)
- Being female
- Steroid use
- Opting for an open surgical technique as opposed to percutaneous procedures
Another possible complication post-surgery is Sural Nerve Injury, which is more often associated with the percutaneous procedure compared to the open technique.
Recovery from Achilles Tendon Rupture
No matter what kind of treatment you get for a tendon rupture, it’s crucial to engage in regular exercise. Activities like swimming, cycling, jogging, or walking can enhance muscle strength and flexibility.
Rehabilitation will change based on whether surgery or nonsurgical methods are used, and the specific instructions of your referring physician. This is why good communication between your therapist and your doctor is really important to get the best care. Such communication is especially necessary for managing brace use and weight-bearing status, which can greatly vary.
The duration of immobilization, meaning when you have to limit movement, depends on the type of approach used. With surgery, you’re typically immobilized for 2 to 4 weeks. Without surgery, immobilization can range from 3 to 9 weeks, with the use of supports based on your orthopedic protocol. During this time, position changes from plantarflexion to neutral are used, though the best positioning is still debated. An important point to keep in mind is avoiding hyper dorsiflexion to prevent any elongation of the Achilles tendon and long-term disability.
If nonsurgical methods are chosen, therapy starts during the immobilization phase, focusing on training and exercises that help preserve strength in rest of the affected limb. Recent studies have shown that usage of functional casts along with early weight bearing can facilitate a faster return to activity and improved ankle dorsiflexion. This practice was traditionally associated with surgical treatment, which allows for earlier weight bearing and exercise initiation, but it varies and is determined by your referring doctor.
Here is a typical rehabilitation plan for nonsurgical patients following an acute Achilles tendon rupture:
* 0 to 2 weeks: Non-weight bearing, using crutches.
* 2 to 4 weeks: Wearing a walking boot with maximum heel lifts, gradual protected weight bearing with crutches (25% increments each week), exercises for ankle motion and strength, along with methods to control swelling, physical therapy 2 to 3 times a week, non-weight bearing cardio exercises like biking.
* 4 to 6 weeks: Weight bearing in the boot as tolerated, maintain activities from previous weeks with the addition of electrical muscle stimulation, physical therapy 2 to 3 times a week.
* 6 to 8 weeks: Gradually remove heel lifts (as tolerated), full weight bear in the boot now, physical therapy 2 times per week.
* 8 to 12 weeks: Gradual transition off the boot.
For patients having surgery, rehabilitation exercises usually begin 2 to 4 weeks after surgery. Over the past decade, there’s been a move toward less rigid immobilization, earlier weight-bearing, and a quicker return to function after surgery. Post-immobilization therapy consists of progression with exercises, including ankle range of motion, strengthening, cardiovascular, and balance exercises. Unfortunately, there’s no standard accelerated protocol for the therapy following Achilles tendon surgery and more research is needed to evaluate risks vs. benefits.
The focus is generally on low-impact exercises for the first 6 months, with more high-impact exercises introduced after 6 months. There is also a need for a heavy focus on calf strengthening within the first year following the injury, as studies have shown a reduction in strength gain potential after one year from the injury.
Preventing Achilles Tendon Rupture
Active people and sports enthusiasts can typically get back to their usual activities and work after medical or surgical treatment for their injuries. However, professional athletes often find that their performance is not as good as before, even after the recovery period, regardless of the treatment method used.
A 2017 study from the American Journal of Sports Medicine looked at how professional athletes in the NBA, NFL, MLB, and NHL performed 1 and 2 years after receiving surgery between 1989 and 2013. Here are some of the findings:
- More than 30% of athletes were unable to return to their sport.
- For those who did return within the first year, they played fewer games, had less time on the court or field, and didn’t perform as well.
- If athletes returned within two years, there was no significant difference in how well they performed than before their injury.
So, athletes who can get back to their game within a year of their injury should aim to gradually improve until they are back to their pre-injury level of play by the next season.