para>Diagnosis of rupture made clinically, physical exam (PE) more sensitive than MRI
Treatment
General Measures
- Tendinopathy
- Ice, nonsteroidal anti-inflammatory drugs (NSAIDs), rest (LOE: C)
- Heel lift, orthotics, appropriate footwear (LOE: C)
- Eccentric exercise (LOE: A)
- Correct training errors, stretching (LOE: C)
- Retrocalcaneal bursa: Consider injection for symptom and inflammation relief.
- If unresponsive-trial of immobilization
- Noninsertional-conservative treatment
- Insertional-treat coexisting pathologies
- Rupture
- Immediate, below the knee non-weight-bearing splint in equinus
- Rest, pain control, ice, elevation
- Conservative management vs. surgical repair (open vs. percutaneous)
- Case by case factoring point age, general health/comorbidities, activity level, and point preference
- Conservative management
- Conservative treatment using functional rehab/early range of motion with similar rerupture rates of surgery (1)[A]
- Elongated tendon can cause decreased plantar flexion power and endurance.
- Elderly/inactive, poor skin integrity, systemic illness, poor wound healing
- Traditional immobilization protocol (up to 40% rerupture rate)
- Cast immobilization — 6-10 wks
- Short leg non-weight-bearing cast in gravity equinus — 4-6 wks
- Then serial casting, gradually bringing ankle to neutral, weight bearing allowed
- Upon cast removal, rehabilitation and 2-cm heel lift in shoe for 2-4 months
- Operative repair (see following section)
- Lowers rerupture rates (0-5%), possible increased postoperative muscle strength, power, endurance
- No evidence to support claims of better functional outcome.
- Greater risk-deep infections, fistulae, necrosis of skin or tendon, sural nerve injury (percutaneous)
- Appropriate for young and athletic
Medication
First Line
NSAIDS and analgesics
Issues for Referral
- Failure of conservative management
- Young athletes/surgical candidates
Additional Therapies
- Tendinopathies
- Eccentric training (mainstay): reduction in tendon thickness, decreased pain, restoration of normal architecture (2)[A]
- Consider eccentric-concentric loading alongside/in lieu of eccentric (3).
- Steroid injections: controversial, short-term pain relief, can weaken tendon, leading to rupture (4)
- Platelet-rich plasma (PRP) injections: for refractory tendinosis (4)
- Shock wave therapy: can be helpful in combination with eccentric loading (5)[A]
- Short-term heel wedge use: weak evidence, can help with pain
- Rupture
- Physical therapy after immobilization
- several rehabilitation protocols: gentle passive ankle range of motion → progressive resistance exercises at 2 wks → aggressive gait training at 10 wks → return to activities at 4-6 months
Surgery/Other Procedures
- Tendinopathy/bursitis
- Surgery an option if failed 6 months conservative treatment
- Paratenonitis: removal/release of paratenon
- Achilles tendinosis: intratendinous debridement, retrocalcaneal bursectomy, and Haglund exostectomy
- Augmentation or local tendon transfer if extensive disease
- Rupture
- Percutaneous: sutures reapproximate ends, non-weight-bearing cast — 4 wks then weight-bearing low-heeled cast — 4 wks
- Sural nerve entrapment (up to 16%)
- More cost-effective than open with comparable outcome
- Open repair: reapproximate ends, ankle maintained in flexion via cast/rigid orthosis, gradually brought into neutral Immobilization — 4-6 wks, return to full activity within 4 months of surgery
Ongoing Care
Follow-up Recommendations
Routine follow-up until resolution of symptoms
Patient Monitoring
Achilles tendon Total Rupture Score is the only validated outcome measure.
Patient Education
- Adherence to rehab exercises key to recovery
- Healing times 4-6 months for rupture
- Stretch/strengthen calf muscles, vary exercises, increase training slowly.
Prognosis
- Tendinopathy
- Prolonged recovery wks to months, recurrences common
- Rupture
- Proper treatment and rehab = good prognosis, months to recover
- Chronic functional decrease possible
Complications
- Tendinitis
- Tendon degeneration, eventual rupture
- Rupture
- If rerupture after surgical repair, poorer outcomes
References
1.Soroceanu A, Sidhwa F, Aarabi S, et al. Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials. J Bone Joint Surg Am. 2012;94(23):2136-2143.
[]
2.Rowe V, Hemmings S, Barton C, et al. Conservative management of midportion Achilles tendinopathy: a mixed methods study, integrating systematic review and clinical reasoning. Sports Med. 2012;42(11):941-967.
[]
3.Malliaris P, Barton CJ, Reeves ND, et al. Achilles and patellar tendinopathy loading programmes: a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med. 2013;43:267-286.
[]
4.Gross CE, Hsu AR, Chahal J, et al. Injectable treatments for noninsertional achilles tendinosis: a systematic review. Foot Ankle Int. 2013;34(5):619-628.
[]
5.Al-Abbad H, Simon JV. The effectiveness of extra-corporeal shock wave therapy on chronic achilles tendinopathy: a systematic review. Foot Ankle Int. 2013;34(1):33-41.
[]
Additional Reading
- Garras DN, Raikin SM, Bhat SB, et al. MRI is unnecessary for diagnosing acute Achilles tendon ruptures: clinical diagnostic criteria. Clin Orthop Relat Res. 2012;470(8):2268-2273.
[]
- Kearney RS, Achten J, Lamp SE, et al. A systematic review of patient-reported outcome measures used to assess Achilles tendon rupture management: what's being used and should we be using it? Br J Sports Med. 2012;46(16):1102-1109.
[]
- Rees JD, Wolman RL, Wilson A. Eccentric exercises; why do they work, what are the problems and how can we improve them? Br J Sports Med. 2009;43(4):242-246.
[]
- Ribbans WJ, Collins M. Pathology of the tendo Achillis: do our genes contribute? Bone Joint J. 2013;95-B(3):305-313.
[]
Codes
ICD09
- 726.71 Achilles bursitis or tendinitis
- 727.67 Nontraumatic rupture of achilles tendon
- 845.09 Other sprains and strains of ankle
- 892.2 Open wound of foot except toe(s) alone, with tendon involvement
ICD10
- M76.60 Achilles tendinitis, unspecified leg
- S86.009A Unspecified injury of unspecified Achilles tendon, initial encounter
- S86.019A Strain of unspecified Achilles tendon, initial encounter
- S86.029A Laceration of unspecified Achilles tendon, initial encounter
- M76.61 Achilles tendinitis, right leg
- M76.62 Achilles tendinitis, left leg
- S86.001A Unspecified injury of right Achilles tendon, initial encounter
- S86.002A Unspecified injury of left Achilles tendon, initial encounter
- S86.011A Strain of right Achilles tendon, initial encounter
- S86.012A Strain of left Achilles tendon, initial encounter
- S86.021A Laceration of right Achilles tendon, initial encounter
- S86.022A Laceration of left Achilles tendon, initial encounter
- S86.091A Other specified injury of right Achilles tendon, init encntr
- S86.099A Oth injury of unspecified Achilles tendon, init encntr
SNOMED
- 11654001 Achilles tendinitis (disorder)
- 429513001 rupture of Achilles tendon (disorder)
- 22817005 strain of Achilles tendon (disorder)
- 301453009 tendon laceration (disorder)
- 202917000 Achilles tenosynovitis (disorder)
Clinical Pearl
- Achilles rupture generally a clinical diagnosis
- ~20% of acute Achilles tears become chronic.
- No single optimal treatment of complete rupture, patient dependent
- No sufficient evidence that operation leads to better functional recovery.