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Achilles Tendinopathies and Rupture

- 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

- 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

- 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 - Proper treatment and rehab = good prognosis, months to recover - Chronic functional decrease possible

para>Diagnosis of rupture made clinically, physical exam (PE) more sensitive than MRI

Treatment

General Measures

  • TendinopathyIce, 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 immobilizationNoninsertional-conservative treatmentInsertional-treat coexisting pathologies
  • RuptureImmediate, below the knee non-weight-bearing splint in equinusRest, pain control, ice, elevationConservative management vs. surgical repair (open vs. percutaneous)Case by case factoring point age, general health/comorbidities, activity level, and point preferenceConservative managementConservative 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 healingTraditional immobilization protocol (up to 40% rerupture rate)Cast immobilization — 6-10 wksShort leg non-weight-bearing cast in gravity equinus — 4-6 wksThen serial casting, gradually bringing ankle to neutral, weight bearing allowedUpon cast removal, rehabilitation and 2-cm heel lift in shoe for 2-4 monthsOperative repair (see following section)Lowers rerupture rates (0-5%), possible increased postoperative muscle strength, power, enduranceNo 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

  • TendinopathiesEccentric 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
  • RupturePhysical therapy after immobilizationseveral 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/bursitisSurgery an option if failed 6 months conservative treatmentParatenonitis: removal/release of paratenonAchilles tendinosis: intratendinous debridement, retrocalcaneal bursectomy, and Haglund exostectomyAugmentation or local tendon transfer if extensive disease
  • RupturePercutaneous: sutures reapproximate ends, non-weight-bearing cast — 4 wks then weight-bearing low-heeled cast — 4 wksSural nerve entrapment (up to 16%)More cost-effective than open with comparable outcomeOpen 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

  • TendinopathyProlonged recovery wks to months, recurrences common
  • RuptureProper treatment and rehab = good prognosis, months to recoverChronic functional decrease possible

Complications

  • TendinitisTendon degeneration, eventual rupture
  • RuptureIf 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.

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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.

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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.

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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.

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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.

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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.