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Achilles tendon rupture is increasingly reported in patients treated with corticosteroid and fluoroquinolones. We report about a patient who sustained a spontaneous non-traumatic Achilles tendon rupture while he was taking oral corticosteroid for the treatment of microscopic polyangiitis (MPA). This patient’s tendon rupture was treated with a non-surgical approach because of his age, immunocompromised state and delay in presentation. The rupture healed gradually and his corticosteroid dose was weaned as the MPA improved.
Press release: Achilles tendon injuries more likely in male 'Weekend Warriors' than others
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Los Angeles, CA (April 23, 2013) -- Male athletes are the group most likely to tear their Achilles tendon, according to a new study published in the April 2013 issue of Foot & Ankle International (FAI), A SAGE journal. The activity most likely to cause the injury was basketball, and NBA players such as Kobe Bryant have been in the news lately for this exact injury.
Drs. Steven Raikin, David Garras and Philip Krapchev reviewed 406 records from patients at one clinic diagnosed with Achilles tendon injuries from August 2000 and December 2010. The average age was 46 years old, 83% of the patients were males, and sports were responsible for 68% of the ruptures.
The most common sports involved were basketball (32% of all ruptures), tennis (9%), and football (8%). Among patients younger than 55 years of age, 77% of ruptures occurred during sports, compared to 42% of the patients 55 or older.
Older patients, and those whose BMI (body-mass index) was greater than 30, were more likely to have non-sports related causes and were more likely to not have been diagnosed correctly at the time of injury. Greater than one-third of the tendon ruptures not caused by sports occurred at work. When the diagnosis was missed, it was usually because the initial diagnosis was an ankle sprain.
"Delayed diagnosis and treatment have been shown to result in poorer outcomes," says Steven Raikin, MD, of the Rothman Institute in Philadelphia, PA, and American Orthopaedic Foot & Ankle Society (AOFAS) member. "Older individuals, and those with a higher BMI, should be evaluated carefully if they have lower leg pain or swelling in the Achilles tendon region."
Re-rupture of the same tendon occurred in 5% of the group, and 6% of the study's population had previously ruptured the other leg's tendon. The study supported previous findings that an Achilles tendon rupture on one leg increases the likelihood of a rupture on the other leg. When the same tendon was re-ruptured, 85% of those injuries had not been treated surgically earlier.
Incidence of Symptomatic Deep Venous Thrombosis after Achilles Tendon Rupture
Asim M. Makhdom, MD, MSc (C), Adam Cota, MD, Neil Saran, MD, MHSc (Clin Epi) FRCSC, Ruth Chaytor, MD, FRCSC Journal of Foot and Ankle Surgery; Article in Press
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Deep venous thrombosis (DVT) is a significant source of morbidity and mortality and is associated with many orthopedic procedures. Previous studies have reported highly variable DVT rates in patients with Achilles tendon rupture undergoing operative and nonoperative treatment. We performed a retrospective chart review for all patients who underwent Achilles tendon repair at our institution from January 2006 to February 2012. Patient data were collected from the electronic medical record system. A total of 115 patients were eligible for the present study. Of these patients, 27 (23.47%) with a surgically treated Achilles tendon rupture developed a symptomatic DVT either while waiting for, or after, surgical intervention, with approximately one third of these diagnosed before surgical intervention. Of the 27 patients with DVT, 3 had a proximal DVT and 24 had a distal DVT. One patient developed a pulmonary embolism. The DVT incidence was greater in the 2 older age groups (40 to 59 and 60 to 79 years) compared individually with the younger age group (20 to 39 years; p < .0026 and p < .0014, respectively). We have shown a high incidence of DVT after Achilles tendon rupture. We recommend a high level of suspicion for the signs and symptoms of DVT during the follow-up period. In addition, patient education and early mobilization should be advocated, especially for patients older than 40 years. Additional randomized controlled trials investigating any benefits to pharmaceutical DVT prophylaxis in this population are needed to establish evidence-based recommendations.
Purpose
The purpose of this study was to establish a relationship between the lengthening of the Achilles tendon post-rupture and surgical repair to muscle activation patterns during walking in order to serve as a reference for post-surgical assessment.
Method
The Achilles tendon lengths were collected from 4 patients with an Achilles tendon rupture 6 and 12 months post-surgery along with 5 healthy controls via ultrasound. EMG was collected from the triceps surae muscles and tibialis anterior during overground walking.
Results
Achilles lengths at 6 and 12 months post-surgery were significantly longer (p < 0.05) on the involved side compared to the uninvolved side, but there were no side-to-side differences in the healthy controls. The integrated EMG (iEMG) of the involved side was significantly higher than the uninvolved side in the lateral gastrocnemius at 6 months and for the medial gastrocnemius at 12 months in the patients with Achilles tendon rupture; no side-to-side difference was found in the healthy controls. The triceps surae muscles’ activations were fair to moderately correlated to the Achilles lengths (0.38 < r < 0.52).
Conclusions
The increased Achilles tendon length and iEMG from the triceps surae muscles indicate that loss of function is primarily caused by anatomical changes in the tendon and the appearance of muscle weakness is due to a lack of force transmission capability. This study indicates that when aiming for full return of function and strength, an important treatment goal appears to be to minimize tendon elongation.
Operative Treatment of Chronic Irreparable Achilles Tendon Ruptures With Large Flexor Hallucis Longus Tendon Transfers. Rahm S, Spross C, Gerber F, Farshad M, Buck FM, Espinosa N. Foot Ankle Int. 2013 Apr 26.
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BACKGROUND:
Transfer of the flexor hallucis longus (FHL) tendon aims to restore function and relieve pain in chronic Achilles tendon (AT) disease. The goal of the present study was to investigate the clinical and radiographic outcomes of FHL transfer to the AT and to compare the transtendinous technique to the transosseous technique. We hypothesized that the type of technique would have a notable impact on outcome.
METHODS:
Forty patients (42 ankles) were retrospectively reviewed and divided into group 1 (transtendinous technique, 22 patients/24 ankles) and group 2 (transosseous technique, 18 patients/18 ankles). Outcome parameters included the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, Victorian Institute of Sports Assessment-Achilles (VISA-A) score, Foot Function Index (FFI), and Short Form-36 (SF-36) scores. Magnetic resonance imaging of the lower leg was performed preoperatively to assess muscle quality and fatty infiltration. Postoperatively, isokinetic plantar flexion strength was assessed using a Con-Trex dynamometer.
RESULTS:
In group 1 (follow-up, 73 months; age, 52 years), the AOFAS score improved from 66 points to 89 points (P < .001) with average values for the VISA-A of 76 points, FFI-D pain 15%, and FFI-D function 22%. In group 2 (follow-up, 35 months; age, 56 years), the AOFAS score increased from 59 points to 85 points (P < .001) with mean values for the VISA-A 76 points, FFI-D pain 25%, and FFI-D function 24%. At follow-up, the average SF-36 score in group 1 was 66% and in group 2 was 77%. Isokinetic testing at 30 deg/s in group 1 revealed notable weakness in the operated ankle averaging 54.7 N·m (75% of normal), and in group 2 the average was 58.2 N·m (77% of normal). No statistically significant differences were found between the groups.
CONCLUSION:
The hypothesis was disproved. Both techniques for FHL transfer to AT, intratendinous and transosseous, provided good to excellent clinical and functional outcome in the treatment of irreparable AT disease.
PURPOSE. To survey the practice of orthopaedic consultants in the Greater London area for treating Achilles tendon ruptures.
METHODS. 221 orthopaedic consultants working in 28 hospitals within the Greater London area were identified. A questionnaire regarding conservative treatment for acute Achilles tendon ruptures was sent. The choice of immobilisation, the period of immobilisation, the time to weight bearing, the use of heel raises, and the use of diagnostic ultrasonography were enquired about.
RESULTS. 62 of 86 respondents treated Achilles tendon ruptures conservatively by below-knee casts (n=51), above-knee casts (n=5), or functional braces (n=6). The most common immobilisation regimen (n=7) was to keep the foot in a sequence of an equinus position, a semi-equinus position, and a neutral position (3 weeks in each position). After cast removal, 45 of respondents preferred to use a heel raise for a median duration of 4 (range, 2-36) weeks. Respectively for foot and ankle specialists (n=24) and other orthopaedic specialists (n=38), the median immobilisation period prescribed was 8 (range, 3-13) and 9 (range, 6-36) weeks, respectively (p=0.625), whereas the median time to weight bearing prescribed was 6 (range, 0-9) and 6 (range, 0-12) weeks, respectively (p=0.402).
CONCLUSION. Functional bracing was not as widely used as below-knee cast immobilisation. There was no consensus on the optimal immobilisation regimen.
Modification of Side-locking Loop Suture Technique Using an Antislip Knot for Repair of Achilles Tendon Rupture
Shinji Imade, MD, PhD, Ryuji Mori, MD, PhD, Yuji Uchio, MD, PhD Journal of Foot and Ankle Surgery; Article in Press
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The 2-strand side-locking loop suture technique provides high tensile strength and stiffness immediately after surgery, and good clinical results have been reported in the treatment of Achilles tendon rupture. However, it is assumed that major differences exist among surgeons with regard to the optimal tension of the side-locking loop suture. We report a detailed technique to ensure application of a standard tension with the use of the side-locking loop suture in the clinical setting.
Healing of human Achilles tendon ruptures: Radiodensity reflects mechanical properties
Schepull, Thorsten & Aspenberg, Per Thesis; 2013
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Purpose: We investigated if radiodensity from computed tomography can be used to quantitatively evaluate the healing of ruptured Achilles tendons.
Methods: We measured the radiodensity of the healing tendons in 65 patients who were treated for Achilles tendon rupture, and tested the hypothesis that density would correlate with an estimate for e-modulus, derived from strain, measured by Roentgen Stereophotogrammetric Analysis (RSA), with different mechanical loadings.
Results: Radiodensity 7 weeks after injury was decreased to 67 % of the contralateral, uninjured tendon. There was no improvement in radiodensity from 7 to 19 weeks, whereas at one year it had increased to 106 %. Only 2 of 52 measured values at one year were lower than the highest value at 19 weeks, i.e. there was minimal overlap. The variation in radiodensity could explain 80 % of the variation in e-modulus, but radiodensity correlated only weakly with e-modulus at each time point separately. At one year, both radiodensity and e-modulus correlated with functional results, although weakly.
Conclusions: From 19 weeks onwards, radiodensity appears to reflect mechanical properties of the tendon and might to some extent predict the final outcome. Radiodensity at 7 weeks is difficult to interpret, probably because it reflects both callus and damaged tissues.
Rerupture Rate after Early Weightbearing in Operative Versus Conservative Treatment of Achilles Tendon Ruptures: A Meta-Analysis
Dorien M. van der Eng, MD, Tim Schepers, MD, PhD, Niels W.L. Schep, MD, PhD, MSc, J. Carel Goslings, MD, PhD Journal of Foot and Ankle Surgery; Article in Press
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Whether Achilles tendon rupture benefits from surgery or conservative treatment remains controversial. Moreover, the outcome can be influenced by the rehabilitation protocol. The goal of the present meta-analysis was to compare the rerupture rate after surgical repair of the Achilles tendon followed by weightbearing within 4 weeks versus conservative treatment with weightbearing within 4 weeks. In addition, a secondary analysis was performed to compare the rerupture rates in patients who started weightbearing after 4 weeks. Seven randomized controlled trials published from 2001 to 2012, with 576 adult patients, were included. The primary outcome measure was the rerupture rate. The secondary outcomes were minor and major complications other than rerupture. In the early weightbearing group, 7 of 182 operatively treated patients (4%) experienced rerupture versus 21 of 176 of the conservatively treated patients (12%). A secondary analysis of the patients treated with late weightbearing showed a rerupture rate of 6% (7 of 108) for operatively treated patients versus 10% (11 of 110) for conservatively treated patients. The differences concerning the rerupture rate in both groups were not statistically significant. No differences were found in the occurrence of minor or major complications after early weightbearing in both patient groups. In conclusion, we found no difference in the rerupture rate between the surgically and nonsurgically treated patients followed by early weightbearing. Weightbearing after 4 weeks also resulted in no differences in the rupture rate in the surgical versus conservatively treated patients. However, surgical treatment was associated with a twofold greater complication rate than conservative treatment.
Biomechanical Properties of the Plantar Flexor Muscle–Tendon Complex 6 Months Post-Rupture of the Achilles Tendon
Peter McNair et al Journal of Orthopaedic Research (early view)
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We compared the effects of a non-weight bearing protocol (NWB) and a weight bearing (WB) protocol on energy stored, stiffness, and shock absorption in the plantar flexor muscle–tendon unit of patients managed non-operatively following an Achilles tendon rupture. Thirty-eight subjects were randomized to a WB cast fitted with a Bohler iron or a traditional non-weight-bearing cast. At a 6-month follow-up, a biomechanical assessment utilizing an isokinetic dynamometer allowed measurement of peak passive torque, energy stored, shock absorption, and stiffness. The WB group had greater peak passive torque (∼20%). Irrespective of group, peak passive torque in unaffected legs was greater (∼26%) than affected legs. Across the groups, energy stored in the NWB group was 74% of the WB group. The energy stored in affected legs was 80% of that in unaffected legs. Shock absorption was not significantly different across legs or groups. Irrespective of group, affected legs had significantly less stiffness (20–40%). While the augmentation of plaster with a Bohler iron to allow increased weight bearing had positive effects, deficits in affected compared to unaffected legs irrespective of group were notable, and should be addressed prior to participation in vigorous physical activities.
Purpose
The purpose of this study is to analyze the progress of muscle rehabilitation for patients with acute Achilles tendon rupture, who underwent Achilles tendon repair, checking capable time of single heel raise and isokinetic plantar flexion power.
Materials and Methods
From March 2006 to June 2011, 42 of 81 patients were excluded and the other 39 patients, who underwent surgery due to acute Achilles tendon rupture in our institute, were enrolled in this study. The operation and rehabilitation were constantly performed according to the author's method. Isokinetic plantar flexion power was measured at three months post-operation, capable time of single heel raise was assessed, and clinical results of the last follow up were measured and analyzed.
Results
Single heel raise was possible at an average of 14 weeks and three days, and repetitive single heel raise more than 10 times was possible at an average of 20 weeks. The peak torque of 30°/s plantar flexion was mean 69 Nm. The peak torque of 120°/s was 41 Nm. Assessment at three months post-operation showed 69% power, compared to the contralateral leg. The group of patients who were able to perform single heel raise within three months, showed better Achilles tendon total rupture score and foot and ankle outcome score at last follow up, and showed better plantar flexion power at three months post-operation.
Conclusion
At the last follow up, we can expect better clinical results and muscle power in patients who are able to perform single heel raise early treatment of acute Achilles tendon rupture.
Early Weightbearing Using Achilles Suture Bridge Technique for Insertional Achilles Tendinosis: A Review of 43 Patients
Ryan B. Rigby, DPM, AACFAS, James M. Cottom, DPM, FACFAS, Anand Vora, MD Journal of Foot and Ankle Surgery; Article in Press
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Posterior heel pain caused by insertional Achilles tendinosis can necessitate surgical intervention when recalcitrant to conservative care. Surgical treatment can necessitate near complete detachment of the Achilles tendon to fully eradicate the offending pathologic features and, consequently, result in long periods of non-weightbearing. A suture bridge technique using bone anchors is available for reattachment of the Achilles tendon. This provides restoration of the Achilles footprint on the calcaneus, including not only contact, but also actual pressure between the tendon and bone. We performed a review of 43 patients who underwent surgical treatment of insertional Achilles tendinosis with reattachment of the Achilles tendon using the suture bridge technique. The mean age was 53 (range 29 to 87) years. The mean follow-up period was 24 (range 13 to 52) months. The mean postoperative American Orthopaedic Foot and Ankle Society score was 90 (range 65 to 100). The mean preoperative visual analog scale pain score was 6.8 (range 2 to 10) and the mean postoperative visual analog scale pain score was 1.3 (range 0 to 6). The mean interval to weightbearing was 10 (range 0 to 28) days. No postoperative ruptures occurred. Of the 43 patients, 42 (97.6%) successfully performed the single heel rise test at the final postoperative visit. Concomitant procedures were performed in 35 patients, including 33 (77%) requiring open gastrocnemius recession and 2 (5%) requiring flexor hallucis longus tendon transfer. A total of 42 patients (97.6%) returned to regular shoe gear, and 42 (97.6%) returned to their activities of daily living, including running for 20 athletic patients (100%). Complications included postoperative wound dehiscense requiring surgical debridement in 2 patients (5%) and soft tissue infection requiring antibiotics and surgical debridement in 1 (2%) patient. Our findings support using the Achilles tendon suture bridge for reattachment of the Achilles tendon in the surgical treatment of insertional Achilles tendinosis.
INTRODUCTION:
Rupture of Achilles tendon is the most common among those taking place in the lower extremities, being twice as common in men than in women between 30-50 years old and usually caused while doing sport. There are some risk factors such as age or chronic treatments based on corticosteroids or antibiotics when belonging to Quinolones group. Spontaneous bilateral rupture of the Achilles tendon is much more infrequent, being almost exceptional in young and healthy patients without known pathological conditions.
METHOD:
In relation to a specific clinical case, a medical history review was developed: personal history, diagnosis, treatment and progress.
RESULT:
Asthmatic 45 year old male occasionally undergoing medical treatment with inhaled corticosteroids. Previously asymptomatic. Training athletics in the morning and handball in the afternoon. After the first 10 min of the match notices a bilateral acute pain when starting to run, showing ruptures of both Achilles tendons confirmed by MRI scan. Treatment: surgical open-to-end suture reinforced with inverted taenia (see figure 1 below). Development: 3 weeks immobilisation without setting foot, 3 weeks Walker boot, partial setting foot and rehabilitation, medical discharge after 6 months without complications.
DISCUSSION:
Simultaneous and spontaneous rupture of bilateral Achilles tendons in patients without pathological factors is really unusual. 25% of the healthy population above 30 years of age has degenerative structural changes in the Achilles tendon that increase the risk of rupture depending on the patient's activity level. Both percutaneous and open surgical treatments on young and active patients provide an appropriate alternative. The open surgical treatment allows the possibility of tendon reinforcement techniques and a more complete visualisation of the damage. The postsurgical rehabilitation management is an important factor for biomechanic tendon recovery alsoallowing the restart of patient's activities as soon as possible. Figure 1Appearance of Achilles tendon before (left) and after (right) surgical repair.
Conservative treatment for acute Achilles tendon rupture: survey of current practice
Donald Osarumwense, Jonathan Wright, Kikachukwu Gardner, Laurence James Journal of Orthopaedic Surgery 2013;21(1):44-6
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PURPOSE. To survey the practice of orthopaedic consultants in the Greater London area for treating Achilles tendon ruptures.
METHODS. 221 orthopaedic consultants working in 28 hospitals within the Greater London area were identified. A questionnaire regarding conservative treatment for acute Achilles tendon ruptures was sent. The choice of immobilisation, the period of immobilisation, the time to weight bearing, the use of heel raises, and the use of diagnostic ultrasonography were enquired about.
RESULTS. 62 of 86 respondents treated Achilles tendon ruptures conservatively by below-knee casts (n=51), above-knee casts (n=5), or functional braces (n=6). The most common immobilisation regimen (n=7) was to keep the foot in a sequence of an equinus position, a semi-equinus position, and a neutral position (3 weeks in each position). After cast removal, 45 of respondents preferred to use a heel raise for a median duration of 4 (range, 2–36) weeks. Respectively for foot and ankle specialists (n=24) and other orthopaedic specialists (n=38), the median immobilisation period prescribed was 8 (range, 3–13) and 9 (range, 6–36) weeks, respectively (p=0.625), whereas the median time to weight bearing prescribed was 6 (range, 0–9) and 6 (range, 0–12) weeks, respectively (p=0.402).
CONCLUSION. Functional bracing was not as widely used as below-knee cast immobilisation. There was no consensus on the optimal immobilisation regimen.
Re: Achilles tendon rupture
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