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

Ruptures of the Achilles tendon most commonly occur spontaneously in healthy, young, active individuals who are aged 30-50 years and have no antecedent history of calf or heel pain. Unlike tears or ruptures at the musculotendinous junction of the Achilles tendon (tennis leg), Achilles tendon ruptures are located within the tendon substance itself, approximately 1-2 inches proximal to its insertion into the calcaneus. Poor conditioning, advanced age, and overexertion are risk factors for this injury. However, the common precipitating event is a sudden eccentric force applied to a dorsiflexed foot. Ruptures of the Achilles tendon also may occur as the result of direct trauma or as the end result following Achilles peritenonitis with or without tendinosis.

Achilles tendon pathology, other than rupture, can be classified into a spectrum of injuries including peritenonitis, tendinosis, and peritenonitis with tendinosis. Patients with peritenonitis experience localized burning pain along the tendon during or following activities; as the disease progresses, onset of pain may occur earlier during activities, with decreased activity level, or even at rest. Tendinosis usually is comprised of an asymptomatic, noninflammatory, degenerative disease process (mucoid degeneration); patients with tendinosis may complain of a sensation of fullness or a nodule in the back of the leg. Peritenonitis with tendinosis is comprised of activity-related pain, diffuse swelling of the tendon sheath, and presence of nodules. Treatment of these entities is not discussed in this article.

Frequency

United States

The true prevalence of Achilles tendon rupture is unknown, although it occurs more commonly in men who are in their third to fifth decade of life and who participate in recreational activities.

Functional Anatomy

The Achilles tendon, coined after the mythologic Greek god, is the largest and strongest tendon in the human body. The Achilles tendon is formed from the tendinous contributions of the gastrocnemius and soleus muscles coalescing approximately 15 cm proximal to its insertion. Along its course in the posterior aspect of the leg, the tendon spirals 30-150° until it inserts into the calcaneal tuberosity. The gliding ability of the Achilles tendon is aided by a thin sheath of paratenon rather than a true synovial sheath. The sheath of paratenon is composed of a visceral layer and a parietal layer.

The blood supply of the Achilles tendon arises from its osseous insertion, its musculotendinous junction, and multiple infiltrating mesosternal vessels, which cross the layers of the anterior paratenon. Various injection and nuclear medicine studies have demonstrated a paucity of mesosternal and intratendinous vessels 2-6 cm proximal to the heel insertion (ie, the watershed area). Due to the relative lack of blood supply in this area, the tendon is less resilient to repetitive microtrauma and has a higher tendency for irritation, degeneration, and rupture.

Sport Specific Biomechanics

The entire gastrocnemius-soleus musculotendinous unit spans the knee, tibiotalar (ankle), and talocalcaneal (subtalar) joints. Contracture of this complex flexes the knee, plantar flexes the ankle, and supinates the subtalar joint. The function of the gastrocnemius-soleus musculotendinous unit is necessary in running, jumping, toe standing, and stair-climbing activities because it forcefully plantar flexes the ankle. During running, forces 10 times the body weight have been measured within the tendon substance.

CLINICAL

Section 3 of 10  

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

History

• The patient often presents with a sensation of a sudden snap in the back of the calf or heel that is associated with acute severe pain. This pain may be the result of an indirect injury (eccentric ankle contraction in a dorsiflexed foot) or a direct injury from blunt trauma to the tendon.
• Antecedent pain in the back of the calf or heel may be an indication of prior tendon damage and vulnerability (eg, tendinitis, tendinosis, tenonitis).
• The patient may limp.
• Ankle weakness or apprehension
• • The patient is unable to run, climb stairs, or stand on toes. The patient is unable to generate a strong posterior muscle contraction to plantar flex the ankle or foot.

  • Patients may have been told or may have thought the injury was a bad sprain because some active plantar flexion at the ankle may occur due to function of the intact posterior tibialis tendon, peroneal muscles, or flexor hallucis tendons; therefore, patients may present late.

  • Misdiagnosis or delayed treatment may result in a more difficult recovery period.

• Calf swelling may be evident.
• Older aged recreational athletes (ie, "weekend warriors") usually have a relatively weakened tendon substance with muscles that are deconditioned. Note any changes in training and activity or intensity level.
• History of intratendinous steroid injections or use of fluoroquinolone (eg, ciprofloxacin, levofloxacin) may lead to tendon weakness.
• The patient may have prior history of Achilles tendon rupture on the affected side. The incidence of tendon rerupture following initial conservative management is relatively high.

Physical

• Examine and palpate along the entire gastrocnemius-soleus musculotendinous unit to note tenderness, ecchymosis, swelling, and tendon defects. In patients with complete ruptures, a palpable gap along the Achilles tendon and 2-6 cm above its insertion may be noted.
• Weakness on active plantar flexion (eg, unable to stand on toes)
• Clinical tests that are believed to help diagnose Achilles tendon ruptures are as follows:
• • Hyperdorsiflexion sign: While the patient is prone and has both knees flexed to 90°, maximally dorsiflex both ankles and compare the injured side to the uninjured side.

  • Thompson test: While the patient is prone and the affected leg is extended, squeeze the calf muscles to indirectly plantar flex the foot. A positive Thompson test results if the foot does not plantar flex. A positive Thompson test helps confirm the diagnosis of a rupture.

  • O'Brien needle test: A small-gauge needle is inserted perpendicularly through the skin into the tendon substance, approximately 10 cm proximal to the calcaneal insertion of the Achilles tendon. Motion of the hub of the needle in a direction opposite the tendon during passive ankle dorsiflexion and plantar flexion confirms an intact tendon distal to the needle level.

Causes

The common precipitating event that causes an Achilles tendon rupture is a sudden eccentric force applied to a dorsiflexed foot. Ruptures of the Achilles tendon also may occur as the result of direct trauma or as the end result following Achilles peritenonitis with or without tendinosis. Risk factors associated with Achilles tendon rupture include the following:

• Recreational athlete (weekend warrior)



• Relatively older age (30-50 y)



• Prior Achilles tendon injury or rupture



• Prior tendon injections or fluoroquinolone use



• Abrupt changes in training, intensity, or activity level



• Participation in a new activity

DIFFERENTIALS

Section 4 of 10  

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

Other Problems to be Considered

Calcaneus bone injuries
Gastrocnemius/soleus tear (usually a tear of the medial head of the gastrocnemius)
Fascial tear
Tennis leg (tear of the plantaris tendon)
Inflammatory arthropathy

WORKUP

Section 5 of 10  

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

Lab Studies

• Laboratory studies are typically not necessary to diagnose Achilles tendon tears. Some laboratory studies may be indicated if the injury is not due to trauma.

Imaging Studies

• Radiographs of the ankle may show soft tissue swelling, increased ankle dorsiflexion, calcifications, calcaneal avulsion fractures, a Haglund deformity, or bony metaplasia; however, radiographs are more useful in ruling out concomitant bony injuries, anomalies, or fractures.
• Ultrasound and MRI help the physician confirm the diagnosis, but these studies are more helpful when partial tendon ruptures are suspected. Ultrasound and MRI are not routinely ordered for tendon ruptures.
• • Ultrasound is a relatively inexpensive, fast, repeatable, dynamic examination that helps determine tendon thickness and gap size. Ultrasound is operator-dependent and requires an experienced ultrasound technician and radiologist for reliable imaging.

  • MRI is more sensitive when trying to detect incomplete tendon ruptures, chronic degenerative changes, and fluid. In addition, MRI is able to discern peritenonitis, bursitis, tendon thickening, and rupture and can be used to monitor tendon healing. However, due to the high cost, limited clinical value, and inability to offer dynamic testing, MRI is not routinely indicated in patients with tendon ruptures.

TREATMENT

Section 6 of 10  

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

Acute Phase

Rehabilitation Program

Physical Therapy

An individual who ruptures his or her Achilles tendon should seek prompt medical treatment. Physical therapy generally is not indicated in the acute phase of treatment, but it later becomes a crucial part of rehabilitation once adequate healing of the tendon has occurred. The course of treatment (nonoperative vs operative) is determined on a patient-by-patient basis. Typically, both nonoperative and operative treatment options are offered to patients, with particular emphasis on the benefits and risks of each procedure. The recommendations provided in this section regarding operative versus nonoperative treatment are guidelines only and must be personalized to each patient’s needs and condition.

Surgical Intervention

The goal of the orthopedic surgeon is to restore tendon continuity and length to allow the patient to regain his or her functional and desired activity level.

• In general, the author recommends operative intervention for younger, healthier, more active individuals who desire a reliable treatment method. Individuals participating in high school, college, semiprofessional, or professional sports are strongly encouraged to have surgery to decrease the chance of rerupture.



• Acute ruptures, large partial ruptures, and reruptures are indications for surgical repair. On the other hand, patients who are more elderly and/or more inactive and those who have systemic illnesses or poor skin integrity are not optimal candidates for operative treatment and are better served with nonoperative treatment (see Other Treatment in the Acute Phase).



• Numerous operative procedures are available to repair the Achilles tendon. Open and closed (percutaneous) procedures are described. These procedures usually involve primary end-to-end tendon repair with or without fascial or tendon reinforcement.
  
  
  • Open repair
    
    
    • In an open repair of the Achilles tendon, both medial and lateral longitudinal approaches have been advocated. Medial incisions allow better visualization of the plantaris tendon and avoid injury to the sural nerve. Midline incisions have been used but have had a higher incidence of wound complications and adhesions.
    
    
    
    • A tourniquet is first used to provide hemostasis, and the rupture gap is palpated. The medial or lateral longitudinal incision is made through the skin and subcutaneous fat down to the paratenon. The paratenon is divided along the length of the incision to uncover the ruptured ends, which are then irrigated and debrided. By plantar flexing the ankle, the ends are passively reapposed and are secured with heavy nonabsorbable sutures using a modified Kessler, Krackow, or Bunnell technique.
    
    
    
    • Care is taken to not overtighten the repair. Overtightening shortens the tendon length and may lead to loss of dorsiflexion.
    
    
    
    • If the repair is insecure, it may be reinforced using a pull-out wire or multiple interrupted sutures and/or it may be augmented with a turn-down fascial graft, a weaved plantaris, or, if necessary, a flexor hallucis longus (FHL) or peroneus brevis (PB) tendon transfer.
    
    
    
    • The paratenon and skin are then closed.
       
  • Percutaneous repair
    
    
    • A percutaneous repair of the Achilles tendon uses multiple percutaneous stab incisions on either side of the ruptured ends. Keith needles and nonabsorbable sutures are passed through these stab incisions and are woven through both the proximal and distal tendon ends. The suture ends are then passed through an enlarged medial incision and are tied as the ankle is held in equinus bringing the ends together.
    
    
    
    • Postoperatively, a posterior splint or short-leg cast is placed in gravity equinus for 10-14 days to reduce tension on the incision. With each cast change, the ankle is gradually dorsiflexed, with a neutral position being reached at approximately 4 weeks postsurgery. At that time, the patient is allowed to begin weight bearing on the leg. At 6 weeks postsurgery, the cast is discontinued, and the patient is referred to physical therapy.
       
• Advantages of operative treatment include a lower rerupture rate (0-5%), a higher percentage of patients to return to sports, and a greater return of strength, endurance, and power.



• Disadvantages of operative treatment include hospitalization, high operative costs, wound complications (eg, infection, skin slough, sinus formation), adhesions, and possible sural nerve injury (especially through a lateral longitudinal approach).

Other Treatment

Nonoperative treatment usually is indicated for patients who are elderly and/or inactive and for those with systemic illnesses or poor skin integrity. Patients with diabetes, wound healing problems, vascular disease, neuropathies, or serious systemic comorbidities are encouraged to opt for nonoperative treatment because of significant risks of operative treatment (eg, infection, wound breakdown, repair dehiscence, perioperative complications).

• A short-leg cast is applied to the affected leg while the ankle is placed in slight plantar flexion (gravity equinus). By keeping the foot in this position, the tendon ends are theoretically better apposed. Cast immobilization is continued for about 6-10 weeks. Forced dorsiflexion is contraindicated. The ankle gradually may be dorsiflexed to a more neutral position after a period of immobilization (~4-6 wk). This position is sustained with serial casting or adjustable ankle orthotics. Walking in the cast is allowed at this time. Following cast removal, a 2-cm heel lift in the shoe is worn for an additional 2-4 months. During this time, a rehabilitation program is initiated.

• Advantages of nonoperative treatment include no wound complications (eg, skin breakdown, infection, scar formation, neurovascular injury), decreased hospital costs and physician fees, lower morbidity, and no exposure to anesthesia.



• Disadvantages of nonoperative treatment include higher incidence of rerupture (up to 40%) and more difficult surgical repair following rerupture. In addition, the tendon edges may heal in an elongated position because of a gap in the unapposed tendon ends resulting in decreased plantar flexion power and endurance.

Recovery Phase

Rehabilitation Program

Physical Therapy

Following cast removal, gentle passive range of motion (PROM) of the ankle and subtalar joints is initiated. After 2 weeks, progressive resistance exercises (PREs) are added to the regimen. This is followed by aggressive gait training exercises at about 10 weeks following injury (nonoperative patients) or surgery (operative patients), leading toward activity specific maneuvers and a return to activities at 4-6 months. The patient's recovery is largely dependent on the quality of the rehabilitation program, his/her motivation and focus, as well as his/her desired postinjury activity level.

MEDICATION

Section 7 of 10  

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

No medical therapy is indicated for this condition. Medication is only prescribed for symptomatic relief of pain. These medications may include acetaminophen, various nonsteroidal anti-inflammatory drugs (NSAIDs), or narcotics, depending on physician preference.

Drug Category: Nonsteroidal anti-inflammatory agents (NSAIDs)

Although most NSAIDs are used primarily for their anti-inflammatory effects, they are effective analgesics and are useful for the relief of mild to moderate pain.

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 injuries.

FOLLOW-UP

Section 8 of 10  

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

Return to Play

Return to play is dependent on the method of treatment (operative vs nonoperative). (See Treatment.)

Complications

• Following nonoperative treatment, the incidence of rerupture is higher (up to 40%).

• Surgical repair results following rerupture are poorer when compared to initial operative treatment of an acute tendon rupture.

• Operative treatments have several complications, including wound complications (eg, infection, skin slough, sinus formation), adhesions, and possible sural nerve injury (especially through a lateral longitudinal approach).

Prevention

Good conditioning and proper stretching is important in the prevention of Achilles tendon injuries. Adequate warm-up is always encouraged prior to participating in activities that place the Achilles tendon at risk.

Prognosis

With proper treatment and rehabilitation, the prognosis is good-to-excellent. Most athletes are able to return to their previous activity levels with either surgical or conservative treatment. However, individuals who undergo surgical treatment are less likely to experience rerupture of their Achilles tendons. The rerupture rate for operative treatment is 0-5%, compared to nearly 40% in those who opt for conservative treatment.

Education

Individuals should be educated on the importance of stretching and proper conditioning to prevent rerupture. Wearing appropriate and properly fitting shoes during activities also should be stressed to all athletes.

For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center. Also, see eMedicine's patient education articles Ruptured Tendon and Achilles Tendon Rupture.

MISCELLANEOUS

Section 9 of 10  

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

Medical/Legal Pitfalls

• Misdiagnosing and/or delaying treatment for an Achilles tendon rupture are potential medicolegal pitfalls. Upon presentation, patients may be able to weakly plantar flex their ankles due to the intact peroneal muscles, posterior tibialis tendon, or flexor hallucis tendons; therefore, misdiagnosis or delay in treatment may occur because the condition is believed to be just a sprain.

REFERENCES

Section 10 of 10

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

• Balasubramaniam P, Prathap K. The effect of injection of hydrocortisone into rabbit calcaneal tendons. In: Surgery of the Foot. 2^nd ed. 1965:729-734.
• Carr AJ, Norris SH. The blood supply of the calcaneal tendon. J Bone Joint Surg Br. Jan 1989;71(1):100-1. [Medline].
• Cetti R, Christensen SE, Ejsted R, Jensen NM, Jorgensen U. Operative versus nonoperative treatment of Achilles tendon rupture. A prospective randomized study and review of the literature. Am J Sports Med. Nov-Dec 1993;21(6):791-9. [Medline].
• Clement DB, Taunton JE, Smart GW. Achilles tendinitis and peritendinitis: etiology and treatment. Am J Sports Med. May-Jun 1984;12(3):179-84. [Medline].
• Keene JS. Tendon Injuries of the Foot and Ankle. Orthopaed Sport Med. 1994;2:1768-1805.
• Neuhold A, Stiskal M, Kainberger F, Schwaighofer B. Degenerative Achilles tendon disease: assessment by magnetic resonance and ultrasonography. Eur J Radiol. May-Jun 1992;14(3):213-20. [Medline].
• O'Brien T. The needle test for complete rupture of the Achilles tendon. J Bone Joint Surg Am. Sep 1984;66(7):1099-101. [Medline].
• Puddu G, Ippolito E, Postacchini F. A classification of Achilles tendon disease. Am J Sports Med. Jul-Aug 1976;4(4):145-50. [Medline].
• Saltzman CL, Tearse DS. Achilles tendon injuries. J Am Acad Orthop Surg. Sep-Oct 1998;6(5):316-25. [Medline].
• Thompson TG, Doherty JH. Spontaneous rupture of tendon of Achilles: A new clinical diagnostic test. J Trauma. 1963;12:126-129.

Article Last Updated: Apr 26, 2006