AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Achilles tendon rupture is a complete disruption of the Achilles tendon, observed most commonly in patients aged 30-50 years, usually occurring at a point 4-5 cm proximal to the calcaneus. This area above the calcaneus is the zone of poor blood flow in the tendon.

Achilles tendonitis is inflammation of the tendon or paratenon, usually resulting from overuse associated with a change in playing surface, footwear, or intensity of an activity. Terminology used to describe this condition currently is subject to debate. Some evidence suggests that tendinopathy or tendinosis are better terms, as inflammation, suggested by the term tendonitis, may not play a key role in this process.

Pathophysiology

Areas of degeneration may predispose patients to Achilles tendon ruptures (eg, from chronic tendonitis or tendinopathy), or prior cortisone injections may lead to tendon rupture. Common pathophysiology of overuse syndromes applies to Achilles overuse injuries.

Frequency

United States

Exact frequency varies and has been reported at 6 cases per 100,000 persons in Scotland to up to 37 cases per 100,000 persons in Denmark. The condition commonly occurs in the 30- to 44-year-old recreational athletes, and as many as 72-89% of injuries occur during athletic ventures. Some reports show Achilles tendon rupture to be the third most common tendon rupture.

Mortality/Morbidity

Mortality is unreported. Morbidity can include chronic shortening or contracture with Achilles tendon rupture and tendon degeneration with tendonitis.

Sex

Achilles tendon injuries are more prevalent in males at a ratio of 6:1, perhaps due to sports-specific involvement.

Age

This injury usually is observed in recreational athletes aged 30-50 years. As with gastrocnemius tears and strains, this population often is active only intermittently, and they often still challenge their bodies with high-force activities, predisposing them to these kinds of injuries.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Achilles tendon rupture is characterized by an acute onset of pain in the distal rear leg. The patient reports feeling like he or she has been shot, kicked, or cut in the back of the leg, resulting in an inability to ambulate further. A very strong athlete, however, usually is able to overcome that gait abnormality by using other plantar flexors to ambulate normally.
• Some patients have a history of chronic recurrent calf or Achilles tendon area pain or prior cortisone injection.
• Achilles tendonitis is seen in jumpers and correlates with the risk factors of increased intensity, participation in a new activity, or new or unsuitable footwear. Injury is observed more commonly in runners, gymnasts, cyclists, and volleyball players; hyperpronation may contribute. In cyclists, a causative factor may be low saddle height, resulting in extra dorsiflexion of the ankle with pedaling.

Physical

• Achilles tendon rupture is indicated by obvious leg swelling with a palpable defect in the Achilles tendon. Active plantar flexion is weak or absent. Some strong athletes still may be able to perform toe raises by overcoming the defect with strong peroneals, toe flexors, and posterior tibialis.
• The Thompson test generally is positive. This test is performed by having the patient lie prone with his knee passively flexed. Squeeze the calf, looking for normal foot plantar flexion. Absence of plantar flexion is considered a positive test. Comparison easily can be made to the uninjured side.
• In Achilles tendonitis, the area is tender to palpation from 2-5 cm proximal to the calcaneus. Nodules also may be palpable, as well as a "wet leather" sign of crepitation with ankle plantar flexion and dorsiflexion. This is demonstrated by gently squeezing or palpating the Achilles tendon while the athlete or patient actively plantar flexes and dorsiflexes the foot and ankle. The examiner's fingers feel the crepitus as an area of sponginess, as one would expect with "wet leather." Passive ankle dorsiflexion and active resisted plantar flexion may cause increased pain.

Causes

• Achilles tendon rupture usually comes after a forced dorsiflexion during active plantar flexion, as with gastrocnemius tears. This is commonly seen in basketball, diving, tennis, and other sports that require forceful push off from the foot. Other predisposing factors include chronic recurrent Achilles tendonitis and prior history of cortisone injections to the Achilles tendon.
• Achilles tendonitis is seen in jumpers and correlates to risk factors of increased intensity, participation in a new activity, or new or unsuitable footwear. Injury is noted more commonly in runners, gymnasts, cyclists, and volleyball players; hyperpronation may contribute. In cyclists, low saddle height, resulting in extra dorsiflexion of the ankle with pedaling, may be a causative factor.
• Higher-than-average rates of Achilles rupture have been noted in patients with blood type O, gout, systemic lupus erythematosus, and rheumatoid arthritis.
• Achilles tendon rupture is seen in patients who are using steroid medication and fluoroquinolone-type antibiotics.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Achilles tendonitis
Partial Achilles tendon rupture
Retrocalcaneal bursitis
Ankle osteoarthritis
Ruptured Baker cyst
Deep venous thrombosis
Haglund deformity (pump bump)
Gastrocnemius-soleus muscle strain or rupture

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Laboratory studies usually are not necessary in evaluating and diagnosing an Achilles tendon rupture or injury. Evaluation may help rule out some of the other possibilities in the differential diagnosis. These may include CBC count with differential, coagulopathy panel, erythrocyte sedimentation rate, and arthritis panel. Results are all normal in these injuries.

Imaging Studies

• Imaging studies are not necessary to diagnose common Achilles problems; however, they can be helpful in evaluating possibilities in the differential diagnosis and should be ordered as clinically indicated.
• Plain radiography
• • Radiographs of the tibia and fibula often are indicated when the history shows trauma that could have resulted in fracture of these long bones. In Achilles tendonitis, some calcification in the distal Achilles may be evident. With Achilles rupture, the bones appear normal and soft tissue swelling may be evident.
  • Radiographs of the knee and ankle may help discover findings of degenerative or inflammatory arthropathies.
• Ultrasonography of leg and thigh: Ultrasonography of the leg and thigh can help evaluate the possibility of deep vein thrombosis (DVT) and also can be used to rule out a Baker cyst. In experienced hands, ultrasonography also can identify a ruptured Achilles tendon or the signs of tendinopathy.
• MRI: Magnetic resonance imaging can facilitate definitive diagnosis of a disrupted tendon. This is especially useful when considering the possibility of partial disruption of the Achilles tendon. Partial disruption often is undetectable clinically and may be misdiagnosed as simple Achilles tendonitis; however, partial Achilles disruption often responds to surgical intervention. Imaging the knee can confirm a Baker cyst, as well as the probable underlying pathology causing the Baker cyst.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Rehabilitation Program

Physical Therapy

• Achilles tendon rupture
  • Physical therapy for a patient with an Achilles tendon rupture focuses primarily on postoperative care.
  • Therapy usually is initiated at 6-8 weeks following surgery with simple active range of motion (ROM) exercises, 20 minutes twice daily. The patient then progresses to isometric ankle exercises with knee and hip strengthening. Eventually toe raises and progressive resistance exercises are added, culminating with proprioceptive training. At 12 weeks, devices may be utilized to enhance ROM passively with a realistic goal for full range of motion at 6 months.
• Achilles tendonitis
  • Physical therapy for patients with Achilles tendonitis consists of several stages. The initial goal of physical therapy is to control the inflammation.
  • In the first and part of the second phase, pain is used to guide the intensity of exercise. Active ankle dorsiflexion with gentle calf stretching is performed.
  • In the intermediate phase, strengthening replaces active ROM, and neuromuscular control programs are initiated.
  • In the third phase of rehabilitation, progressive stress is applied under good control to allow the collagen to form appropriately. As pain resolves, perform aggressive stretching and active resisted motion.
  • One therapeutic modality that has gained more recent interest is performing eccentric loading exercises. A recent review article demonstrated that this modality improves pain in patients with chronic Achilles tendinopathy. Further research is ongoing in an effort to clarify the exact role of eccentric training in tendinopathies.
  • Cryotherapy is useful in all of these stages. Physical modalities, such as ultrasound and electrical stimulation, also are useful to decrease pain and inflammation.

Medical Issues/Complications

• Medical therapy for a patient with an Achilles tendon rupture consists of rest, pain control, serial casting, and rehabilitation to maximize function. Ongoing debate surrounds the issue of whether medical or surgical therapy is more appropriate for this injury.
• • Activity modification for a ruptured Achilles tendon requires crutch ambulation without weight bearing. Once initiated, serial casting dictates the activity level.
  • Orthotic therapy is useful after serial casting. Serial casting usually results in some Achilles contracture, and heel lifts are used after casting. Depending on the degree of shortening and rate and aggressiveness of physical therapy, initiate use of 1-2 inch heel lifts with gradual weekly or biweekly adjustment directed toward weaning the patient off of the heel lifts.
  • Casting is one way to treat Achilles tendon rupture. Overall healing rates are similar to those of surgical reanastomosis, yet the return-to-activity benefits of surgery are debated. Nonetheless, this is viable therapy, especially for more sedentary patients and older persons. The initial cast applied is a long-leg cast with some knee flexion and ankle plantar flexion to allow free edges of the Achilles to approximate. The cast is changed in series, decreasing the plantar flexion and eventually moving toward short-leg casts in a neutral ankle position. This treatment lasts 6-12 weeks.
  • Recently, high-energy extracorporeal shock wave therapy has shown promise as a treatment for insertional Achilles tendinopathy. A recent study demonstrated that a single treatment was more effective than traditional conservative treatment in improving pain and enabling patients to return to their activities.
  • Medical therapy for Achilles tendon rupture is concerned primarily with pain control; some of the remedies are outlined below (see Medication).
• Medical therapy for Achilles tendonitis includes activity modification, orthotic therapy, physical therapy, and analgesic anti-inflammatory medication.
  • Activity modification for Achilles tendonitis requires that the patient abstain from aggravating activities with a minimum of rest to preserve overall fitness. This may include modification of the offending activity, such as avoiding running uphill or on uneven surfaces. If the athlete is a cyclist, proper saddle adjustment can help to reduce symptoms.
  • Orthotic therapy in Achilles tendonitis also consists of the use of heel lifts; however, lifts usually are not used to the extent utilized after serial casting for rupture. The goal is eventually to use conventional shoes. Orthotic devices usually are used bilaterally to prevent a gait imbalance. Since overpronation and cavus foot deformities can cause tendonitis, custom orthotics to correct overpronation or shock absorbing shoes for cavus deformities can alleviate pain as well.
  • Casting is an option for resistant Achilles tendonitis. This is the ultimate form of rest for the Achilles tendon and is usually a last resort for this condition. A cast boot can be used.
  • Medical therapy for Achilles tendonitis includes pain control and use of anti-inflammatory medications, some of which are detailed below (see Medication).

Surgical Intervention

• Surgical techniques are varied and usually involve reapproximation of the torn ends of the Achilles tendon, sometimes reinforced by the gastrocnemius-soleus aponeurosis or plantaris tendon. Controversy exists as to whether surgical or conservative treatment is preferable.
• Advocates of conservative treatment cite the similar results between conservative and surgical treatment when looking at ROM, strength, power, and functional levels as a reason for avoiding surgery. Surgical advocates argue that full function is achieved more quickly with surgical therapy than with conservative therapy, especially for athletic individuals. The surgical approach is supported by a lower rate of rerupture, greater postoperative power, and low infection rate. Finally, conservative clinicians state that, with early application and prolonged duration of casting, the rerupture rate is decreased significantly.
• Surgery has often been applied in cases of recalcitrant Achilles tendonitis. Techniques include peritenon stripping and debridement of pathologic tissue to create an acute and better healing wound. Aftercare involves prolonged casting, and there is concern that the immobilization caused by casting is as curative as the surgical technique. Nonetheless, surgery is usually a last resort in treatment of tendonitis.
• While the reasons are not precisely known, surgery tends not to be as successful in nonathletic individuals with chronic Achilles tendinopathy. Nonathletic patients tend to have a more prolonged recovery, a greater risk of complications, and they are more likely to need further surgery than athletic individuals.

Consultations

Consultation is helpful when a DVT is diagnosed.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Two major categories of drugs used in Achilles tendon rupture and Achilles tendonitis are analgesics, both opioid and nonopioid, and nonsteroidal anti-inflammatory agents (NSAIDs). Consider side effects and patient profiles when choosing medications. Acetaminophen can result in liver damage. Opioids can result in gastrointestinal distress, constipation, and sedation and have addictive potential. NSAIDs can result in gastrointestinal upset, gastrointestinal bleeding, renal damage, and impaired coagulation. New generation of COX-2 inhibiting NSAIDs may have fewer side effects. Currently, the only available COX-2 drug is celecoxib.

Drug Category: Analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties, which are beneficial for patients who have sustained trauma or have sustained injuries.

Drug Category: Opioid analgesics

Control of moderate to severe pain.

Drug Category: Nonsteroidal anti-inflammatory drugs

Have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclo-oxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.

Drug Category: Cyclo-oxygenase II inhibitors

Control of pain and inflammation, especially in cases of contraindication to conventional anti-inflammatories. Although increased cost can be a negative factor, the incidence of costly and potentially fatal GI bleeds is clearly less with COX-II inhibitors than with traditional NSAIDs. Ongoing analysis of cost avoidance of GI bleeds will further define the populations that will find COX-II inhibitors the most beneficial.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Outpatient Care

• Follow-up care in 2 weeks allows ample time to evaluate the effect of initial therapy and anti-inflammatory measures.

Deterrence

• As with gastrocnemius-soleus muscle strains, prevention of Achilles tendon injuries involves adequate stretching and conditioning prior to physical activity, especially new activities or ones at higher levels of intensity.

Complications

• Achilles tendon contracture and/or scarring may occur from excessive immobilization. In addition, permanent weakness has been known to occur with as little as 4 weeks of immobilization.

Prognosis

• Achilles tendon injury has an excellent prognosis, allowing for some degree of morbidity through loss of ROM.

Patient Education

• Educating the patient throughout the physical therapy treatment program and at subsequent follow-up visits is very important. Include information on adequate stretching before beginning physical activity, appropriate technique, and appropriate footwear.
• For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center. Also, see eMedicine's patient education articles Ruptured Tendon, Achilles Tendon Rupture, and Tendinitis.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to discern a more severe condition, such as limb-threatening compartment syndrome or potentially life-threatening condition of DVT

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Adler RS, Finzel KC. The Complementary Roles of MR Imaging and Ultrasound of Tendons. Radiol Clin North Am. Jul 2005;43(4):771-807. [Medline].
• Alvarez-Nemegyei J, Canoso JJ. Heel pain: diagnosis and treatment, step by step. Cleve Clin J Med. May 2006;73(5):465-71.
• Brown DE. Ankle and leg injuries. In: Mellion MB, Walsh M, Shelton GL, eds. The Team Physician's Handbook, 3rd ed. Philadelphia, Pa: Hanley & Belfus; 2002:. 518-9.
• Canale T. Rupture of muscles and tendons. In: Campbell's Operative Orthopaedics. Vol 10. St. Louis, Mo: Mosby; 2003:. 2458-2468.
• Furia JP. High-energy extracorporeal shock wave therapy as a treatment for insertional Achilles tendinopathy. Am J Sports Med. May 2006;34(5):733-40.
• Humble RN, Nugent LL. Achilles'' tendonitis. An overview and reconditioning model. Clin Podiatr Med Surg. Apr 2001;18(2):233-54. [Medline].
• Johnson MD. Physiology of musculoskeletal growth. In: Essentials of Sports Medicine. Vol 1. St. Louis, Mo: Mosby; 1997:. 534-8.
• Kingma JJ, de Knikker R, Wittink HW. Eccentric overload training in patients with a chronic Achilles tendinopathy: a systematic review. Br J Sports Med. Oct 11 2006.
• Maffulli N, Testa V, Capasso G. Surgery for chronic Achilles tendinopathy yields worse results in nonathletic patients. Clin J Sport Med. Mar 2006;16(2):123-8.
• Pedowitz RA, Saglimbeni AJ. The leg. In: Safran MR, McKeag DB, Van Camp SP, eds. Manual of Sports Medicine. Vol 1. Philadelphia, Pa: Lippincott-Raven; 1998:. 460-6.
• Taunton J, Smith C, Magee DJ. Leg, foot and ankle injuries. In: Athletic Injuries and Rehabilitation. Vol 1. Philadelphia, Pa: WB Saunders; 1996:. 736-9.
• Tomczak RL. Surgery of the Achilles'' tendon. Clin Podiatr Med Surg. Apr 2001;18(2):255-71, vi. [Medline].
• Ufberg J, Harrigan RA, Cruz T, Perron AD. Orthopedic pitfalls in the ED: Achilles tendon rupture. Am J Emerg Med. Nov 2004;22(7):596-600.

Article Last Updated: Jan 26, 2007