Achilles Tendon Rupture

Fig. 53 A simple toe raise is impossible with an Achilles tendon rupture

SYMPTOMS A sharp sudden pain in the Achilles tendon during activity, often recognised by the patient and people around as a loud snap, followed by the inability to continue. Often the patient believes somebody has hit them over the calf. It is most common in middle-aged recreational athletes in impact sports such as badminton or soccer. AETIOLOGY This is a complete rupture of the Achilles tendon, two to six centimetres proximal to the distal insertion. In most cases the tendon is not healthy before the rupture but suffers from tendi-nosis changes (see Achilles tendinosis). CLINICAL FINDINGS There is local tenderness on palpation over the tendon, swelling/bruising, a palpable gap in the tendon and a positive squeeze test often referred to as Thomson's or Simmond's test. The patient lies prone with the ankle outside the stretcher. Squeeze the calf muscle; normally, the ankle should plantar flex but if the tendon is ruptured nothing will happen. To confirm the diagnosis, add resistance to an active plantar flexion. The injured patient will not be able to apply any force. Compare to the other side. Note that an active plantar flexion can be achieved by plantaris longus, despite a complete Achilles tendon rupture. However, on adding an active toe raise, the diagnosis is clear since the injured athlete is unable to stand up on their toes, due to weakness. INVESTIGATIONS Ultrasound or MRI will show the bleeding and rupture but often underestimate the extent of the injury. With the history and signs above this is always a complete rupture even though some fibres may look intact. TREATMENT In the acute phase RICE is advocated. Surgery with anatomical reconstruction is recommended for sporting people, due to lower morbidity and an earlier return to sport. Surgery is followed by a few weeks' partial immobilisation and rehabilitation before resuming sport. Early weight-bearing is allowed, if protected by an ankle brace.

Fig. 54 Squeeze the calf muscle bulk and apply some resistance to the forefoot. If the Achilles tendon is ruptured there is no consequential plantar flexion of the ankle. Compare with other side

Fig. 56 MRI showing a complete disruption of the Achilles tendon. This is an unnecessary examination in most cases, since the diagnosis can be confirmed clinically

Fig. 55 Even with a complete Achilles tendon rupture, the tiny plantaris longus tendon allows active plantar flexion, which can fool the examiner, but with resistance there is very little force

Non-surgical treatment, with eight to twelve weeks cast or brace treatment, can be sufficient for less active people or others with ailments contra-indicating surgery. The risk of re-rupture is higher for non-operated cases.

REFERRALS Refer to orthopaedic surgeon for consideration of surgery. Refer to physiotherapist for planning of a three to six months' gradual return programme.

EXERCISE PRESCRIPTION Cycling and swimming (when the wound is healed) are good alternatives to keep up general fitness.

Fig. 56 MRI showing a complete disruption of the Achilles tendon. This is an unnecessary examination in most cases, since the diagnosis can be confirmed clinically

EVALUATION OF TREATMENT OUTCOMES

Monitor clinical symptoms and signs. The tendon will remain thicker than normal after complete healing. Calf muscle strength should be similar to the other side. Objective tests with resisted toe raises are strongly suggested before resuming sport.

DIFFERENTIAL DIAGNOSES With the typical history and clinical findings above, the diagnosis should be clear. Despite this, many of these injuries are missed in clinical practice. PROGNOSIS Excellent-Good. Fewer than 3-4 per cent of injured athletes complain of persistent symptoms or re-rupture after surgery but in the non-operated group this figure is higher.

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