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Acute Rupture of Achilles

Achilles tendon ruptures commonly occur in athletic individuals in their 30s and 40s while performing activities that require sudden changes in direction (ex. basketball, tennis, etc.). Patients usually describe a sharp pain in their heel region almost as if they were “struck in the back of the leg”. The diagnosis of an acute Achilles tendon rupture is made on clinical examination as x-rays will reveal the ankle bones to be normal. The Achilles is the largest and strongest tendon in the body. It is subject to 2-3 times body weight during normal walking so regaining normal Achilles tendon function is critical. Achilles tendon ruptures can be successfully treated non-operatively, or operatively, but they must be treated. Surgical treatment leads to a faster recovery and a lower rate of re-rupture. However, surgery can be associated with very serious complications such as an infection or wound healing problems. For this reason non-operative treatment may be preferable in many individuals, especially those patients with diabetes, vascular disease, and those who are long-term smokers.

Clinical Presentation

The Achilles Tendon is the largest and strongest tendon in the body. It functions to help control the foot when walking and running. Ruptures of the Achilles tendon commonly occur in individuals in their 30s and 40s. These ruptures commonly occur when an athlete who has a sudden change of direction feels a sharp pain in the back of their heel. Patients often initially think that they were “struck in the back of the heel” and then realize that there was no one around them. These ruptures occur as the calf muscle generates tremendous force through the Achilles tendon in the process of changing direction. It more commonly occurs in patients that are in their 30s, 40s and 50 than in younger patients. This is due to an apparent correlation with tendon degeneration leading to weakening. After the injury, patients will have some swelling. If they can walk at all, it will be with a marked limp. The rupture of the Achilles defunctions the calf muscle, which is the main muscle used for walking and running. It is very rare that a rupture of the Achilles is partial. However, a painful Achilles tendonitis or a partial rupture of the calf muscle (gastrocnemius) as it inserts into the Achilles can also cause pain in this area.

Physical Examination

The diagnosis of an Achilles tendon rupture is made entirely on physical examination. Often, there is a substantial defect in the Achilles from 2-5 cm before it inserts into the heel bone. However, the main test is to determine whether the Achilles has been ruptured is the Thompson test. This essentially involves placing the patient on their stomach and squeezing the calf muscle. If the Achilles is intact, the foot will rise [plantar flex]. If it is ruptured, the foot will not move and will tend to be in a lower lying position.

Patients will usually be able to move the foot up and down because there is no injury to the other surrounding muscles and tendons. Sensation and circulation to the foot and ankle will be normal. In addition, x-rays will be normal unless the Achilles injury involves pulling off (avulsion) of the bone on the calcaneus (heel bone). This is quite rare, occurring in only a small fraction of patients with Achilles injuries. Patients suffering this type of Achilles avulsion injury tend to be older with weaker bone.

Imaging Studies

Plain x-rays will be negative in patients who have suffered an Achilles tendon rupture. The rupture will be seen on MRI. However, an MRI is not indicated for acute ruptures unless there is some uncertainty about the diagnosis. For chronic problems of the Achilles or ruptures that are old, an MRI may be very helpful.

An ultrasound can also be used to confirm the diagnosis of an Achilles tendon rupture. It also may be used to monitor healing in some patients who are treated non-operatively.

Treatment

Achilles tendon ruptures can be treated non-operatively or operatively. Both of these treatment approaches have advantages and disadvantages. In general, younger patients with no medical problems may tend to do better with operative treatment, whereas patients with significant medical problems or older age may be best served with non-operative treatment. However, the decision of how the Achilles tendon rupture is treated should be based on each individual patient after the advantages and disadvantages of both treatment options are reviewed. It is important to realize that while Achilles tendon ruptures can be treated either non-operatively or operatively, they must be treated. A neglected Achilles tendon rupture (i.e. one where the tendon ends are not kept opposed) will lead to a marked dysfunction of the lower leg in gait, which will eventually lead to a whole host of other problems. Furthermore, late reconstruction of non-treated Achilles tendon rupture is significantly more complex than initial treatment.

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