Background of Achilles Tendon Tear
A complete tear of Achilles tendon tends to occur in middle aged patients. Partial rupture occur in trained athletes and involve the lateral aspect of the tendon. Acute tear of Achilles tendon commonly result from acute eccentric overload on the dorsiflexed ankle that has chronic tendinosis. Patients should be questioned about previous steroid injections and fluoroquinolones (possible link with tendon weakening).
Injuries to Achilles tendon result from repeated stress on the tendon, which may be caused by:
Rupture most commonly occurs in the middle-aged male athlete. As one age, the Achilles tendon weakens and become thin, making it more susceptible to injury.
Sharp pain and "pop" heard at the time of complete tear are commonly reported. Patients often describe a sensation of being kicked in the Achilles tendon.A gap or depression may be felt and seen in the tendon about 2 inches above the heel bone. Most have an immediate inability to bear weight or return to activity.
Partial rupture is associated with an acute tender, localized swelling that occasionally involves an area of nodularity.
The Thompson test is positive with complete Achilles tendon rupture.
The patient is placed prone, with both feet extended off the end of the table. Both calf muscles are squeezed by the examiner alternately and compared. If the tendon is intact, the foot will plantar flex when the calf is squeezed. If the tendon is ruptured, normal plantar flexion will not occur (positive test sign).
In some cases, an accurate diagnosis of a complete tear is difficult through physical examination alone. The tendon defect can be disguised by a large hematoma. A false negative Thompson test may also occur because of plantar flexion of the ankle caused by extrinsic foot flexors when the accessory ankle flexors are squeezed together with the contents at the superficial posterior leg compartment.
Partial ruptures are also difficult to accurately diagnose, and MRI andUltrasound should be used to confirm the diagnosis.
Both conservative and operative treatment treatments are used to restore length and tension to the tendon to optimize strength and function. High level and competitive athletes undergo primary repair. Operative repair is associated with lower re-rupture rates, quicker return to full activity and a theoretically higher level of function. The main operative risk is wound breakdown. Surgery should be avoided in patients with poor wound healing potential (diabetics); smoking is relative contraindication.
Regardless of definitive treatment, initial treatment is:
Nonoperative treatment of complete Achilles tendon tear in a 20 degree plantar flexed cast is usually reserved for chronically ill patients, poor operative candidates, elderly patients and low demand patients. The re-rupture rate is much higher in patients treated non operatively.
Nonoperative Treatment of Acute Achilles tendon tear
Operative Treatment of Complete Achilles tendon tear
Operative treatment is preferred for young, athletic, and active patients. The incision and approach are the same as for paratenonitis and tendinosis.
For high-level Athletes.
For lower-demand Athletes.