Medical

Achilles tendinopathy and tendon rupture

Achilles tendinopathy and tendon rupture

INTRODUCTION — Pain of the Achilles tendon commonly affects both competitive and recreational athletes, and the sedentary. The largest tendon in the body, the Achilles tendon, endures strain and risks rupture from running, jumping, and sudden acceleration or deceleration. Overuse, vascular diseases, neuropathy, and rheumatologic diseases may cause tendon degeneration. The hallmarks of Achilles tendon problems seem to be damaged, weak, inelastic tissue.

This topic review will discuss the mechanism, diagnosis, and management of Achilles tendinopathy and tendon rupture. A general discussion of treatments for tendinopathy is provided separately. (See “Overview of the management of overuse (chronic) tendinopathy”.)

TERMINOLOGY — Tendonitis, tendinosis, tendinopathy, paratendonitis, enthesopathy, and insertional tendonitis are among the terms used to characterize acute or chronic tendon pain. The common term tendonitis is confusing because inflammation is often not seen on histopathology. Throughout this review, we will use the term tendinopathy to refer to acute and chronic pain associated with an Achilles tendon injury other than tendon tear or rupture.

EPIDEMIOLOGY AND RISK FACTORS — Achilles tendinopathy affects competitive and recreational athletes as well as people who are not active [1]. The incidence of Achilles tendon rupture in the general population is 7 per 100,000 [2,3]. Over 80 percent of ruptures occur during recreational sports. Approximately 10 percent of patients who sustain an Achilles tendon rupture had preexisting Achilles tendon problems [4].

Observational data suggest that competitive athletes have a lifetime incidence of Achilles tendinopathy of 24 percent, with 18 percent sustained by athletes younger than 45 years [5]. Tendon rupture occurs in 8.3 percent. Among competitive runners, the lifetime incidence of Achilles tendinopathy may be as high as 40 to 50 percent.

Competitive athletes with a high lifetime incidence of tendon rupture include sprinters (18 percent), decathletes (17 percent), soccer players (17 percent), track and field jumpers (12 percent), basketball players (12 percent), and ice hockey players (9 percent) [5]. Achilles tendinopathy in recreational runners, although less likely to involve rupture, accounts for 6 to 17 percent of all running injuries [6]. Military recruits develop tendinopathy at a rate of 6.8 percent [7].

Cold weather training is associated with higher rates of tendon pain [7]. Foot misalignment, poor running mechanics (excessive supination, inadequate dorsiflexion), inappropriate footwear, and leg length discrepancy are associated with tendon pain [8,9].

Age, male gender, and obesity are risk factors for Achilles tendon problems (table 1) [10]. The peak age for rupture is 30 to 40 years for both men and women; this may be when degenerative changes and occasional high stress from sports coincide. Rupture is four to five times more common in men than women [2]. As participation in recreational sports has increased over the past 50 years, so has the rate of tendon rupture [11].

Fluoroquinolone antibiotics are rarely associated with tendinopathy. The incidence of rupture is estimated at 12 per 100,000 treatment episodes (OR 1.3; 95% CI 1.0-1.8) [12,13]. The mechanism is unknown. A study of 46,776 patients treated with fluoroquinolones found 3.2 cases of tendon problems for every 1000 years of exposure. Past use does not confer future risk. Concurrent use of fluoroquinolones and systemic steroids further increases risk [14,15]. (See “Fluoroquinolones”, section on ‘Tendinopathy and tendon rupture’.)

Oral glucocorticoids alone increase the risk of tendinopathy, although studies estimating the precise risk in primary care populations are lacking. Local glucocorticoid injection causes tendon damage in animal models, and there are case reports in humans of tendon rupture following glucocorticoid injection [16].

In women, hypertension is associated with Achilles tendinopathy [10]. Other diseases associated with tendinopathy include psoriasis and ankylosing spondylosis [17]. Heel pain is rarely the presenting symptom in patients with these systemic diseases [18].

ANATOMY — The soleus and gastrocnemius muscles converge to form the Achilles tendon, which inserts posteriorly on the calcaneus (picture 1). Contraction of these muscles, along with the actions of the tibialis posterior and peroneus longus and brevis, causes the foot to plantar flex. The subcutaneous and subtendinous calcaneal bursae cushion the insertion area anteriorly and posteriorly. Most pain and tendon ruptures occur where the blood supply of the gastrocnemius-soleus muscle complex is poorest, 2 to 6 cm above the insertion point. A peritendinous sheath of connective tissue allows the tendon to slide relative to surrounding tissue.

MECHANISM OF INJURY AND PATHOPHYSIOLOGY — Acute Achilles tendon pain generally develops when athletes abruptly increase their activity (eg, runners who start training for a marathon). Chronic tendon pain (>3 months) may result from sustained stress, poor running mechanics (eg, supination, heel misalignment), or improper footwear [11,19]. Some experts claim a role for excessive pronation in Achilles tendinopathy among runners, but others dispute this.

Recurrent microtrauma causes degeneration of the Achilles tendon [11,20]. The relative hypovascularity of the tendon 2 to 6 cm from its insertion point may prevent adequate healing. Although inflammation is often not seen on histopathology, clinical signs similar to those seen with inflammation (such as swelling, warmth, and pain) may occur. Damaged tendons become calcified, thickened, inelastic, and fibrotic. Abnormal neovascularization of tissue may be seen on ultrasound. Aging and vascular disease decrease collagen density, break collagen cross-links, and reduce the elasticity of the tendon sheath and tendon itself. Rupture occurs when a sudden shear stress (eg, cutting during a basketball game) is applied to an already weakened or degenerative tendon.

DIFFERENTIAL DIAGNOSIS

Overview — Apart from Achilles tendinopathy, pain arising from the region between the posterior calcaneus and the gastrocnemius-soleus muscle complex may be caused by several other conditions (table 2). Ankle sprain is the most common misdiagnosis when tendon rupture is the actual cause of pain [21]. Differentiating the two can be difficult. In contrast to ankle sprains, where injury occurs with landing, symptom onset with tendon rupture generally occurs as the patient is pushing off with their foot. Do NOT assume rupture is absent because the patient can plantar flex or walk. (See ‘Physical examination’ below and “Ankle sprain”.)

Calcaneal bursitis — Calcaneal bursitis (subcutaneous or subtendinous) typically occurs in middle-aged or elderly patients. Patients may complain of pain where the back of a hard shoe or a strap rubs against the heel at the Achilles tendon insertion point. Sports in which athletes wear hard-backed footwear or repeatedly strike their heels against walls (eg, indoor soccer, hockey) may cause bursitis. Bursitis generally resolves with basic measures: heel lifts, avoiding bothersome footwear, rest, ice, and NSAIDs. Heel pain may also stem from an injury or strain at the Achilles tendon insertion (ie, enthesopathy). (See “Bursitis: An overview of clinical manifestations, diagnosis, and management”.)

Calcaneal apophysitis — Calcaneal apophysitis (ie, Sever’s syndrome) is a stress fracture overuse injury in young athletes aged 8 to 15 years. Patients with calcaneal apophysitis have activity related pain in the posterior aspect of the heel, which may be unilateral or bilateral. Symptoms generally resolve within three to six weeks with conservative treatment. (See “Clinical features and management of heel pain in the young athlete”, section on ‘Calcaneal apophysitis’.)

CLINICAL PRESENTATION

Tendinopathy — Patients with Achilles tendinopathy typically complain of pain or stiffness 2 to 6 cm above the posterior calcaneus. They are likely to be casual or competitive athletes who have increased their training regimen beyond their tendon’s ability to heal the microtrauma from repetitive stress, or who have been training rigorously for a long time. A history of excessive supination, increased speed work or hill training, or improper or worn out footwear may be found.

The pain is usually described as burning. The pain is worse with activity and relieved after a period of rest.

Tendon rupture — Tendon rupture occurs when sudden forces are exerted upon the Achilles tendon during strenuous physical activities that involve sudden pivoting on a foot or rapid acceleration (eg, stop and go sports such as tennis, basketball, or softball). Many patients feel as if they were struck violently in the back of the ankle. Some hear a “pop” and experience severe acute pain, although the absence of pain does not rule out rupture. As an example, a small case series found that one-third of patients with tendon rupture did not report pain [21]. In contrast to ankle sprains, where injury occurs with landing, symptom onset with tendon rupture generally occurs as the patient is pushing off with their foot.

PHYSICAL EXAMINATION

General evaluation — Examination of the Achilles tendon is usually straightforward because the tendon is easily identified and palpated. However, potential pitfalls exist (table 3). Of note, a sizable minority of patients with complete tendon rupture are able to ambulate.

Patients should be examined lying prone with their feet hanging off the end of the examination table. Inspect the region of the Achilles tendon for bruising (blood tracking beneath the malleolus suggests fracture, sprain, or tendon rupture), swelling, or foot misalignment. Assess patients for signs of peripheral artery disease, such as decreased pulsations, decreased capillary refill in the heel or toes, loss of hair, increased skin pigmentation, or edema.

Palpate the Achilles tendon for tenderness, thickening, or a defect, recognizing that edema or a hematoma may mask a defect. Patients with tendinopathy typically have localized tenderness 2 to 6 cm above the insertion point of the Achilles tendon. In comparison, pain at the insertion point suggests either calcaneal bursitis or enthesopathy (strain of tendon insertion). Palpation has a sensitivity of approximately 73 percent and specificity of 89 percent in detecting a partial tendon tear [22]. Comparison to the unaffected side is useful.

SEE MORE:  Nutritional Personal Consultation

The tendon should also be palpated as the patient dorsi-flexes and plantar-flexes the foot. The presence of crepitus suggests tendinopathy. Isolating the subtendinous or subcutaneous bursa and palpating for tenderness may identify bursitis.

Examine the patient’s footwear, looking for signs of excessive breakdown (eg, disproportionate wear on the inner or outer edge) or other evidence of poor running mechanics. Examine the architecture of the patient’s foot. The presence of flat feet (pes planus), heel malalignment, high arches (pes cavus), or leg length discrepancy can contribute to poor running mechanics [23]. If possible, assess the patient’s gait or running stride looking for abnormalities or asymmetry.

Special tests — The calf squeeze or Thompson test provides an accurate means for detecting complete Achilles tendon rupture (picture 2). To perform the test, the patient either lies prone with their feet hanging off the end of the examination table, or kneels on a chair. The clinician squeezes the gastrocnemius muscle belly while watching for plantar flexion. The absence of plantar flexion when squeezing the gastrocnemius muscle marks a positive test indicative of rupture.

The calf squeeze test is a more reliable indication of tendon rupture than the inability to plantar flex, since patients may be able to plantar flex the foot using accessory muscles (eg, tibialis posterior, peroneals). Twenty to thirty percent of Achilles tendon ruptures are missed at the initial visit because the clinician was falsely reassured by the patient’s ability to plantar flex or walk.

In a series of 174 patients with a clinical diagnosis of unilateral complete Achilles tendon tear and 28 patients with unilateral suspected but no actual Achilles tendon tear, the Thompson test had a sensitivity of 96 percent and a specificity of 93 percent, using MRI or ultrasound (US) as a gold standard [22]. A negative test can miss up to 10 percent of ruptures (assuming a 75 percent pretest probability of rupture). Thus, MRI or orthopedic consultation is useful when the Thompson test is negative but clinical suspicion remains high.

The Matles test is another means of assessing Achilles tendon rupture. To perform the test, the patient lies prone with knees flexed to 90 degrees. Observe whether the affected foot is dorsiflexed or neutral (both are abnormal) compared with the uninjured side, where the foot should appear plantar-flexed. The sensitivity and specificity of the Matles test was 88 percent and 85 percent, respectively, in the above study [22].

RADIOGRAPHIC FINDINGS — Achilles tendinopathy (without rupture) is a clinical diagnosis. Imaging is NOT often necessary except to rule out other conditions, such as a stress fracture or tendon rupture.

Plain radiographs are generally unhelpful in the assessment of Achilles tendon pathology, but may reveal a heel spur or bony bump (called a Haglund’s deformity or “pump bump”) consistent with both tendinopathy and calcaneal bursitis.

Ultrasound (US) imaging is increasingly used to assess tendon appearance and function. US may reveal normal tendon, tendon thickening, or signs of more significant tendon pathology, such as hypoechogenicity, disordered fibers, tissue gaps, and fluid [24].

Magnetic resonance imaging (MRI) is often used to assess musculoskeletal complaints and is the study of choice when tendon rupture is suspected. With tendinopathy, MRI may demonstrate an increased T2 weighted signal in the tendon or an increased tendon diameter [25]. MRI may reveal alternative explanations for patient symptoms, such as enlarged calcaneal bursae.

Neither US nor MRI findings appear to correlate closely with clinically significant chronic Achilles tendinopathy. In one small prospective study, US detected abnormal morphology in 37 of 57 symptomatic Achilles tendons, while MRI detected abnormalities in 19 of 34 (MRI was performed in a subset of 25 consecutive patients) [26]. Better baseline MRI appearance was associated with a successful return to sport and symptomatic benefit after 12 months, but baseline US findings were not. Further study of these diagnostic tests is needed to determine their appropriate role in the management of Achilles tendinopathy.

Achilles tendon rupture, partial or complete, may be diagnosed solely by clinical examination [22]. MRI is the best test to confirm tendon rupture because it provides greater anatomic detail and greater accuracy in detecting partial Achilles tendon tears [27].

INDICATIONS FOR REFERRAL — All complete tendon ruptures merit referral for surgical consultation. Partial tendon tears and chronic tendinopathy that fail to improve with three to six months of conservative treatment may benefit from consultation with a specialized runners’ clinic, physical medicine and rehabilitation specialist, physical therapist, or orthopedic surgeon [28]. (See ‘Tendon rupture’ below.)

TREATMENT

Acute tendinopathy — Treatment of acute Achilles tendinopathy generally consists of the following:

  • Avoid aggravating activities
  • Apply ice when symptomatic
  • Take a short course (7 to 10 days) of nonsteroidal antiinflammatory drugs (NSAIDs)
  • Support the Achilles with a heel lift or bandage as needed

The goal of therapy is to relieve symptoms and enable a return to activity. Although the approach described here appears reasonable, there is little evidence to support it.

A systematic review of treatments for “Achilles tendinitis” identified three small controlled trials comparing oral NSAIDs to placebo [29]. Although there is no compelling evidence that NSAIDs enable patients to return to full activity sooner, these drugs are a reasonable choice for short-term pain relief in patients with acute Achilles tendinopathy.

Topical NSAIDs may also be used, although further study is needed. Niflumic acid gel was found to be effective for tendinitis in one small randomized trial [30]. NSAID preparations available in the US include ibuprofen and diclofenac gel and cream.

The systematic review cited above found that injection of a glucocorticoid (eg, methylprednisolone 2 to 10 mg) along the tendon improves pain in the short-term, but does not appear to improve symptoms or function at 12 weeks compared with placebo [29,31]. In addition, there are case reports of tendon rupture after glucocorticoid injection in patients with chronic tendinopathy [16].

Once acute healing has begun, most patients begin some form of rehabilitation. Basic therapy regimens, including such interventions as physical therapy, deep-friction tissue release, and ultrasound, may reduce symptoms over several weeks [32]. Patients should perform an adequate warmup before and stretch following inciting activities, once these are resumed. Rehabilitation for chronic Achilles tendinopathy and prevention strategies are discussed below. (See ‘Chronic tendinopathy’ below and ‘Prevention’ below.)

Small randomized trials have found no benefit from low dose heparin injections or heel pads, but such pads may reduce pain from calcaneal bursitis [29].

Chronic tendinopathy — Chronic Achilles tendinopathy exists when pain persists beyond three months. In addition to the basic interventions for acute exacerbations described above, treatment of chronic midportion Achilles tendon pain involves regular physical therapy, including eccentric exercise with heavy loads. A general discussion of treatments for tendinopathy is provided separately. (See “Overview of the management of overuse (chronic) tendinopathy”.)

Eccentric exercise rehabilitation — Eccentric exercise is the application of a load (ie, muscular exertion) during the lengthening of a muscle. Conversely, concentric exercise involves muscle shortening (or contraction) against a load. A table describing the most rigorously studied eccentric training rehabilitation protocol is provided (table 4) [6].

Small controlled and uncontrolled studies have found that eccentric exercise involving the gastrocnemius and soleus muscles reduces pain at 12 weeks and 2 years and shortens the time needed to return to sports [6,33-35]. A systematic review found there was higher quality evidence supporting the use of eccentric exercise than alternative treatments for midportion (ie, NOT insertional) Achilles tendinopathy [36]. Ultrasound examinations during long-term follow-up of patients who participate in eccentric rehabilitation often show normalization of tendon tissue.

Patients may perform regular exercise while participating in the eccentric rehabilitation program, provided that the activities do not exacerbate symptoms. Mild discomfort is permissible. It is not known whether eccentric exercise prevents tendon injury in runners prior to the development of tendinopathy. (See ‘Prevention’ below.)

Other interventions — Various treatments have been prescribed for chronic Achilles pain. According to a systematic review, high quality evidence supporting these interventions is lacking [36]. Some are suggested as adjuncts to eccentric exercise:

  • In a small randomized trial sponsored by the manufacturer of the AirHeel brace, use of the brace improved symptoms and function in patients with chronic Achilles tendinopathy [37]. The results did not differ between patients managed with the AirHeel brace or eccentric rehabilitation.
  • Heel lifts, arch supports, orthotics, and running shoes that are stable and prevent oversupination are commonly prescribed, but studies supporting these interventions are lacking [38]. Night splinting is not beneficial [39].
  • Small randomized trials suggest that low-level laser therapy is a useful adjunct to eccentric exercise, reducing pain during activity [40].
  • A small randomized trial found that adjunct treatment with platelet-rich plasma injection did not improve outcomes compared with saline injection [41]. Patients in both groups participated in eccentric exercise rehabilitation.
  • Glucocorticoid injections are NOT recommended for chronic tendinopathy due to the risk of tendon rupture and the absence of a clear benefit [1,29].
  • Further study is needed to determine the role of shock wave therapy and topical nitrates [42-44].Surgical treatment for chronic tendinopathy may be considered in refractory cases, but has not been well studied [29].

Tendon rupture

Complete tendon rupture — Surgical consultation should be obtained for all complete Achilles tendon ruptures. The efficacy of surgery was evaluated in a systematic review in which the following findings were noted [45]:

  • Surgical repair reduced the risk of repeat tendon rupture compared with nonoperative management (12/240 (5.0%) versus 30/249 (12.0%); risk ratio (RR) 0.41, 95% CI 0.21 to 0.77). These findings were based upon a subset of six studies, involving 536 patients, which directly compared operative and nonoperative management.
  • Assessments of recuperation time and patient satisfaction varied among studies and no clear conclusions could be drawn.
  • The overall complication rate significantly increased with surgery. Complications included infection (RR 4.89, 95% CI 1.09 to 21.9), abnormal sensation (numbness, hypersensitivity, and tingling), adhesions, and thrombosis.
  • All relevant studies but one found no significant difference in the percentage of patients treated surgically or nonoperatively who were able to return to their preinjury level of sporting activity (RR 1.03; 95% CI 0.76 to 1.39) [46].
  • Four studies included in the review found that percutaneous surgical repair reduced postoperative wound infections compared with open repair (0/68 versus 12/66; RR 9.32, 95% CI 1.77 to 49.2), without affecting rerupture rates. The results of a subsequent study are consistent with this finding [47].
SEE MORE:  Overview of anesthesia and anesthetic choices

Surgery typically requires two to three months off from work. Athletes typically return to sports by three to six months.

According to a randomized trial of 110 patients with surgically repaired Achilles tendon rupture, early weight-bearing starting two weeks after surgery improves quality of life scores in the early postoperative period (first six weeks) without impairing healing [48]. At six months, quality of life scores were not different between the early mobilization and standard treatment groups.

Nonathletes and older patients may forego surgery and elect to be treated with immobilization using a plantar flexion short leg cast or a functional brace with a heel lift for six to eight weeks. These patients should be informed of the greater risk of repeat rupture. Ideally, casting should be performed within 48 hours of injury.

For patients who are found to have ruptured their Achilles tendon many weeks or months prior to diagnosis, immobilization with a brace followed by physical therapy is a reasonable management approach.

Partial tendon rupture — The clinical diagnosis of partial Achilles tendon tear or rupture is imperfect, and studies to determine optimal management are lacking. The increasing use of ultrasound and MRI may improve this situation. It remains unclear whether surgery or conservative management leads to better outcomes [49,50]. We treat most cases of partial Achilles tear nonsurgically, as we would chronic tendinopathy. (See ‘Chronic tendinopathy’ above.)

FOLLOW-UP CARE — Prevention of reinjury is central to follow-up care. Ten percent of Achilles tendon ruptures occur in previously injured tendons. Prevention of Achilles tendon injury is discussed immediately below.

Although no studies demonstrate the benefit of eccentric exercise in the prevention of acute Achilles tendon injury, we suggest that patients continue to perform these exercises once rehabilitation has been completed and symptoms have resolved. We believe this may be of particular benefit to athletes embarking upon a more intense training regimen. (See ‘Chronic tendinopathy’ above.)

PREVENTION — Several interventions may reduce the risk of developing new or recurrent Achilles tendinopathy. We suggest that runners and other athletes do the following:

  • Perform a proper warmup before training
  • Avoid cold weather training or wear appropriate running attire (eg, running tights) if such training is unavoidable
  • Avoid or limit running on hard surfaces
  • Increase training in gradual increments
  • Replace running shoes before the midsole or outsole breaks down or cushioning is lost
  • Ensure proper running mechanics
  • Redress imbalances in muscle strength or flexibility

The findings of a prospective, observational study of infantry recruits suggest that performing a proper warmup before exercise and avoiding cold weather training and hard or slippery running surfaces reduces the risk of Achilles tendinopathy [7].

A systematic review found that running injuries are reduced when training intensity is increased gradually [38]. Training should progress in a stepwise fashion, with distance, frequency, and duration increasing by no more than 10 percent per week. We recommend that runners take one 24 to 48 hour break in any weekly training schedule. Longer breaks are needed when embarking on a new training endeavor. Replacing running with low impact activities, such as swimming, on some training days may reduce tendon stress.

Some experts suggest that runners replace their shoes every 500 to 650 kilometers (300 to 400 miles) but no evidence exists to support this recommendation. It seems reasonable to replace running shoes before the tread becomes worn or cushioning is lost. Excessive supination is associated with tendon pain. Although running shoes cannot correct supination, proper footwear can reduce the stresses placed upon the cavus foot. Coaches, athletic trainers, or sports medicine specialists can recommend appropriate shoes. Orthotics have not been shown to prevent injury [17].

It makes sense to have injured or recovering runners evaluated by knowledgeable specialists to ensure proper running mechanics.

Stretching is commonly practiced to prevent injury and reduce post-exercise pain. However, systematic reviews of limited studies have found no clear evidence that stretching prevents muscle soreness following exercise or injury during exercise [38,51-54]. Clinical studies evaluating the impact of stretching specifically upon Achilles tendinopathy are lacking.

Despite these findings, many clinicians believe imbalances in muscle strength or flexibility predispose some athletes to injury. We believe it is reasonable to include stretching following exercise or a warmup as part of an Achilles injury prevention regimen. Typical techniques include stretching the gastrocnemius and soleus muscles while pushing against a wall or dorsiflexion of the foot using a stretch band. It may be helpful for patients to undergo assessment by an athletic trainer, physical therapist, or sports medicine specialist to identify imbalances in flexibility or strength and to receive instruction in appropriate training techniques.

Although a high body mass index (BMI) is associated with tendon problems, no studies clearly show that weight loss prevents such problems. Nevertheless, common sense suggests that obese patients should try to lose weight in order to reduce strain on the lower extremity, among many other health benefits. (See “Overview of therapy for obesity in adults” and “Health hazards associated with obesity in adults”.)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

  • Basics topic (see “Patient information: Achilles tendinopathy (The Basics)”)

SUMMARY AND RECOMMENDATIONS

Presentation and diagnosis

  • Acute tendon pain generally develops when athletes abruptly increase their training intensity. Chronic tendon pain (>3 months) may result from sustained stress, poor running mechanics, or improper footwear. Rupture occurs when a sudden shear stress is applied to an already weakened or degenerative tendon. (See ‘Epidemiology and risk factors’ above and ‘Mechanism of injury and pathophysiology’ above.)
  • Pain arising from the region between the posterior calcaneus and the gastrocnemius-soleus muscle complex may be caused by a number of conditions (table 2). Ankle sprain is the most common misdiagnosis when tendon rupture is the actual cause of pain. Do not assume rupture is absent because the patient can plantar flex or walk. (See ‘Differential diagnosis’ above.)
  • Patients with Achilles tendinopathy typically experience pain or stiffness 2 to 6 cm above the posterior calcaneus. They are likely to be casual or competitive athletes who have recently increased their training intensity. Pain increases with activity and diminishes with a period of rest. Tendon rupture occurs when sudden forces are exerted upon the Achilles during strenuous activities that involve sudden pivoting on a foot or rapid acceleration. Patients may hear a “pop” and experience severe acute pain, although the absence of pain does not rule out rupture. (See ‘Clinical presentation’ above.)
  • Examination should include palpation of the Achilles tendon for tenderness, thickening, or a defect. Note that edema or a hematoma may mask a defect in the tendon. Patients with tendinopathy typically have localized tenderness 2 to 6 cm above the insertion point of the Achilles tendon. Pain at the insertion point suggests calcaneal bursitis or possibly enthesopathy. (See ‘Physical examination’ above.)
  • The calf squeeze (ie, Thompson compression) test provides an accurate means for detecting complete Achilles tendon rupture (picture 2). A sizable minority of patients with complete tendon rupture are able to ambulate. (See ‘Physical examination’ above.)
  • Achilles tendinopathy (without rupture) is a clinical diagnosis. Imaging is not generally necessary. Plain radiographs are generally unhelpful. Magnetic resonance imaging (MRI) is often used to assess musculoskeletal complaints and is the study of choice when tendon rupture is suspected. (See ‘Radiographic findings’ above.)

Treatment and prevention

  • All complete tendon ruptures merit surgical referral. Partial tendon tears and chronic tendinopathy that fail to improve with three to six months of conservative treatment may benefit from consultation with a specialized runners’ clinic, sports medicine specialist, physical therapist, or orthopedic surgeon. (See ‘Indications for referral’ above.)
  • Acute Achilles tendinopathy is treated in standard fashion with rest, ice, and tendon support. For chronic midportion tendinopathy (>3 months symptoms), we suggest rehabilitative treatment with eccentric exercise using heavy loads (table 1) (Grade 2B). Eccentric exercise and other possible interventions for chronic Achilles tendinopathy are discussed in the text. (See ‘Acute tendinopathy’ above and ‘Chronic tendinopathy’ above.)
  • We suggest that tendon rupture be treated with surgical repair (Grade 2A). This suggestion applies to active patients who place a high value on regaining preinjury levels of activity and are willing to accept a higher rate of treatment complications. Inactive patients and those unwilling to accept higher complication rates may opt for nonoperative management. Percutaneous surgical repair may reduce postoperative wound infection rates compared with open repair. Postoperatively, early mobilization improves quality of life without impairing healing. (See ‘Tendon rupture’ above.)
  • Several interventions may reduce the risk of developing Achilles tendinopathy. We suggest the following (Grade 2C):
  • Perform a proper warmup before training
  • Avoid cold weather training or wear appropriate training attire
  • Avoid running on hard surfaces
  • Increase training in gradual increments
  • Replace running shoes before midsole and outsole cushioning is lost
  • Ensure proper running mechanics
  • Redress imbalances in muscle strength or flexibility
SEE MORE:  Center for Medical Technology Innovation
Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES

  1. Alfredson H, Lorentzon R. Chronic Achilles tendinosis: recommendations for treatment and prevention. Sports Med 2000; 29:135.
  2. Leppilahti J, Puranen J, Orava S. Incidence of Achilles tendon rupture. Acta Orthop Scand 1996; 67:277.
  3. Suchak AA, Bostick G, Reid D, et al. The incidence of Achilles tendon ruptures in Edmonton, Canada. Foot Ankle Int 2005; 26:932.
  4. Leppilahti J, Orava S. Total Achilles tendon rupture. A review. Sports Med 1998; 25:79.
  5. Kujala UM, Sarna S, Kaprio J. Cumulative incidence of achilles tendon rupture and tendinopathy in male former elite athletes. Clin J Sport Med 2005; 15:133.
  6. Fahlström M, Jonsson P, Lorentzon R, Alfredson H. Chronic Achilles tendon pain treated with eccentric calf-muscle training. Knee Surg Sports Traumatol Arthrosc 2003; 11:327.
  7. Milgrom C, Finestone A, Zin D, et al. Cold weather training: a risk factor for Achilles paratendinitis among recruits. Foot Ankle Int 2003; 24:398.
  8. Järvinen TA, Kannus P, Paavola M, et al. Achilles tendon injuries. Curr Opin Rheumatol 2001; 13:150.
  9. Leppilahti J, Korpelainen R, Karpakka J, et al. Ruptures of the Achilles tendon: relationship to inequality in length of legs and to patterns in the foot and ankle. Foot Ankle Int 1998; 19:683.
  10. Holmes GB, Lin J. Etiologic factors associated with symptomatic achilles tendinopathy. Foot Ankle Int 2006; 27:952.
  11. Józsa L, Kvist M, Bálint BJ, et al. The role of recreational sport activity in Achilles tendon rupture. A clinical, pathoanatomical, and sociological study of 292 cases. Am J Sports Med 1989; 17:338.
  12. Sode J, Obel N, Hallas J, Lassen A. Use of fluroquinolone and risk of Achilles tendon rupture: a population-based cohort study. Eur J Clin Pharmacol 2007; 63:499.
  13. Corrao G, Zambon A, Bertù L, et al. Evidence of tendinitis provoked by fluoroquinolone treatment: a case-control study. Drug Saf 2006; 29:889.
  14. van der Linden PD, Sturkenboom MC, Herings RM, et al. Fluoroquinolones and risk of Achilles tendon disorders: case-control study. BMJ 2002; 324:1306.
  15. Butler MW, Griffin JF, Quinlan WR, McDonnell TJ. Quinolone-associated tendonitis: a potential problem in COPD? Ir J Med Sci 2001; 170:198.
  16. Kleinman M, Gross AE. Achilles tendon rupture following steroid injection. Report of three cases. J Bone Joint Surg Am 1983; 65:1345.
  17. Borman P, Koparal S, Babaoğlu S, Bodur H. Ultrasound detection of entheseal insertions in the foot of patients with spondyloarthropathy. Clin Rheumatol 2006; 25:373.
  18. Aldridge T. Diagnosing heel pain in adults. Am Fam Physician 2004; 70:332.
  19. Kaufman KR, Brodine SK, Shaffer RA, et al. The effect of foot structure and range of motion on musculoskeletal overuse injuries. Am J Sports Med 1999; 27:585.
  20. Kader D, Saxena A, Movin T, Maffulli N. Achilles tendinopathy: some aspects of basic science and clinical management. Br J Sports Med 2002; 36:239.
  21. Gravlee JR, Hatch RL, Galea AM. Achilles tendon rupture: a challenging diagnosis. J Am Board Fam Pract 2000; 13:371.
  22. Maffulli N. The clinical diagnosis of subcutaneous tear of the Achilles tendon. A prospective study in 174 patients. Am J Sports Med 1998; 26:266.
  23. Johnston CA, Taunton JE, Lloyd-Smith DR, McKenzie DC. Preventing running injuries. Practical approach for family doctors. Can Fam Physician 2003; 49:1101.
  24. Archambault JM, Wiley JP, Bray RC, et al. Can sonography predict the outcome in patients with achillodynia? J Clin Ultrasound 1998; 26:335.
  25. Aström M, Gentz CF, Nilsson P, et al. Imaging in chronic achilles tendinopathy: a comparison of ultrasonography, magnetic resonance imaging and surgical findings in 27 histologically verified cases. Skeletal Radiol 1996; 25:615.
  26. Khan KM, Forster BB, Robinson J, et al. Are ultrasound and magnetic resonance imaging of value in assessment of Achilles tendon disorders? A two year prospective study. Br J Sports Med 2003; 37:149.
  27. Kayser R, Mahlfeld K, Heyde CE. Partial rupture of the proximal Achilles tendon: a differential diagnostic problem in ultrasound imaging. Br J Sports Med 2005; 39:838.
  28. Maffulli N, Sharma P, Luscombe KL. Achilles tendinopathy: aetiology and management. J R Soc Med 2004; 97:472.
  29. McLauchlan GJ, Handoll HH. Interventions for treating acute and chronic Achilles tendinitis. Cochrane Database Syst Rev 2001; :CD000232.
  30. Dreiser RL, Ditisheim A, Charlot J, Lopez A. A double blind, placebo controlled study of niflumic acid gel in the treatment of acute tendinitis. Eur J Rheumatol Inflamm 1991; 11:38.
  31. DaCruz DJ, Geeson M, Allen MJ, Phair I. Achilles paratendonitis: an evaluation of steroid injection. Br J Sports Med 1988; 22:64.
  32. Mayer F, Hirschmüller A, Müller S, et al. Effects of short-term treatment strategies over 4 weeks in Achilles tendinopathy. Br J Sports Med 2007; 41:e6.
  33. Roos EM, Engström M, Lagerquist A, Söderberg B. Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathy — a randomized trial with 1-year follow-up. Scand J Med Sci Sports 2004; 14:286.
  34. Mafi N, Lorentzon R, Alfredson H. Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis. Knee Surg Sports Traumatol Arthrosc 2001; 9:42.
  35. Silbernagel KG, Thomeé R, Thomeé P, Karlsson J. Eccentric overload training for patients with chronic Achilles tendon pain–a randomised controlled study with reliability testing of the evaluation methods. Scand J Med Sci Sports 2001; 11:197.
  36. Magnussen RA, Dunn WR, Thomson AB. Nonoperative treatment of midportion Achilles tendinopathy: a systematic review. Clin J Sport Med 2009; 19:54.
  37. Petersen W, Welp R, Rosenbaum D. Chronic Achilles tendinopathy: a prospective randomized study comparing the therapeutic effect of eccentric training, the AirHeel brace, and a combination of both. Am J Sports Med 2007; 35:1659.
  38. Yeung EW, Yeung SS. Interventions for preventing lower limb soft-tissue injuries in runners. Cochrane Database Syst Rev 2001; :CD001256.
  39. de Vos RJ, Weir A, Visser RJ, et al. The additional value of a night splint to eccentric exercises in chronic midportion Achilles tendinopathy: a randomised controlled trial. Br J Sports Med 2007; 41:e5.
  40. Stergioulas A, Stergioula M, Aarskog R, et al. Effects of low-level laser therapy and eccentric exercises in the treatment of recreational athletes with chronic achilles tendinopathy. Am J Sports Med 2008; 36:881.
  41. de Vos RJ, Weir A, van Schie HT, et al. Platelet-rich plasma injection for chronic Achilles tendinopathy: a randomized controlled trial. JAMA 2010; 303:144.
  42. Glaser T, Poddar S, Tweed B, Webb CW. Clinical inquiries. What’s the best way to treat Achilles tendonopathy? J Fam Pract 2008; 57:261.
  43. Rompe JD, Furia J, Maffulli N. Eccentric loading compared with shock wave treatment for chronic insertional achilles tendinopathy. A randomized, controlled trial. J Bone Joint Surg Am 2008; 90:52.
  44. Rompe JD, Furia J, Maffulli N. Eccentric loading versus eccentric loading plus shock-wave treatment for midportion achilles tendinopathy: a randomized controlled trial. Am J Sports Med 2009; 37:463.
  45. Khan RJ, Carey Smith RL. Surgical interventions for treating acute Achilles tendon ruptures. Cochrane Database Syst Rev 2010; :CD003674.
  46. Cetti R, Christensen SE, Ejsted R, et al. Operative versus nonoperative treatment of Achilles tendon rupture. A prospective randomized study and review of the literature. Am J Sports Med 1993; 21:791.
  47. Metz R, Verleisdonk EJ, van der Heijden GJ, et al. Acute Achilles tendon rupture: minimally invasive surgery versus nonoperative treatment with immediate full weightbearing–a randomized controlled trial. Am J Sports Med 2008; 36:1688.
  48. Suchak AA, Bostick GP, Beaupré LA, et al. The influence of early weight-bearing compared with non-weight-bearing after surgical repair of the Achilles tendon. J Bone Joint Surg Am 2008; 90:1876.
  49. . Management of partial tears of the gastro-soleus complex. Clin Sports Med 2008; 27:219.
  50. Morberg P, Jerre R, Swärd L, Karlsson J. Long-term results after surgical management of partial Achilles tendon ruptures. Scand J Med Sci Sports 1997; 7:299.
  51. Herbert RD, de Noronha M. Stretching to prevent or reduce muscle soreness after exercise. Cochrane Database Syst Rev 2007; :CD004577.
  52. Small K, Mc Naughton L, Matthews M. A systematic review into the efficacy of static stretching as part of a warm-up for the prevention of exercise-related injury. Res Sports Med 2008; 16:213.
  53. Park DY, Chou L. Stretching for prevention of Achilles tendon injuries: a review of the literature. Foot Ankle Int 2006; 27:1086.
  54. Thacker SB, Gilchrist J, Stroup DF, Kimsey CD Jr. The impact of stretching on sports injury risk: a systematic review of the literature. Med Sci Sports Exerc 2004; 36:371.


Shein.com INT

June 2016
M T W T F S S
« May   Sep »
 12345
6789101112
13141516171819
20212223242526
27282930  


tittygram INT


Aviasales.ru