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HeidiHaapasalo

Achilles Tendinopathy and Tendon Rupture

Essentials

  • Non-surgical treatment is recommended for acute Achilles tendon ruptures. Surgery can be considered in basically healthy young people, people doing heavy physical work and competing athletes.
  • Surgery is recommended for chronic ruptures.
  • When treating Achilles tendinopathy, rehabilitation with sufficient loading of the tendon is the primary form of treatment and should be started as soon as acute pain has subsided.
  • Local, repeated peritendinous glucocorticoid injections are not recommended.

Definition

  • Inflammation of the tissues surrounding the Achilles tendon is termed peritendinitis (tenosynovitis, inflammation of the tendon sheath).
  • Tendon pain was formerly termed tendinitis but tendinopathy is a more accurate term.
    • Tendon pain has not been found to be due to an underlying inflammatory disorder but rather to degeneration of the tendon.
  • Depending on the duration of symptoms, tendinopathy may be classified as being acute (< 2 weeks), subacute (2-6 weeks), subchronic (6 weeks - 6 months) or chronic (> 6 months).

Aetiology

  • Achilles tendinopathy is considered to result from microscopic tendon ruptures due to overuse.
    • In adults, tendon tissue is not regenerated, in practice, and its metabolism is extremely slow. Tendon injury is repaired by the formation of scar tissue, causing the typical clinical picture of a tendinopathic tendon, i.e., fusiform thickening of the tendon.
    • The mechanism behind the development of tendinopathic pain is unknown but it is considered to be associated with abnormal revascularization/reinnervation in the area of the tendon injury.
  • Achilles tendon rupture occurs typically in men aged 40-50 years during active exercise but Achilles tendon ruptures in the elderly, in particular, have increased.
    • A rupture may be partial or complete.
    • The ruptured tendon almost invariably shows degenerative changes, although most patients have had no preceding symptoms.
    • Use of fluoroquinolone antibiotics increases the risk of Achilles tendon rupture, particularly in patients aged over 60 years and when used concomitantly with a glucocorticoid .

Symptoms and diagnosis

Peritendinitis

  • Acute onset of pain (within a few days)
  • Peritendinous fusiform swelling and erythema
  • The tendon feels smooth on palpation while moving the ankle.
  • Crepitus can be felt in the tendon area when moving the ankle or walking.
  • May occur concomitantly with tendinopathy.
  • A primarily clinical diagnosis

Tendinopathy

  • Pain with gradual onset, fluctuating over weeks and months
  • Pain and swelling around the Achilles tendon
  • Pain during and after strain
  • Local tenderness to palpation of the Achilles tendon
  • Fusiform thickening of the Achilles tendon (moving with the tendon on palpation; cf. peritendinitis)

Tendon rupture

  • Tendon rupture causes acute pain when pushing off or landing down. Patients sometimes describe feeling as if they were kicked hard in the back of the lower leg.
  • Rupture of a tendinopathic tendon, in particular, may be completely painless.
  • Partial rupture of a tendinopathic tendon typically presents as aggravation of pain and the patient history nearly invariably still shows an acute triggering event (false step, slipping, starting off uphill).
  • In total rupture, the patient is unable to stand on his/her toes and a depression can be felt on the tendon on palpation (although this may be difficult due to swelling).
  • It should be noted that due to the action of other intact tendons crossing the ankle (long flexor tendons of the toes, posterior tibial tendon, peroneus longus), active plantar flexion is possible for nearly all patients with Achilles tendon rupture.
    • The most reliable clinical test is the Thompson test, where the patient lies prone with his/her foot over the end of the examination table. Squeezing the calf will not cause plantar flexion as it does on the unaffected side (Video The Thompson Test for Achilles Tendon Rupture).
  • An ultrasound examination may be helpful in uncertain cases but acute diagnosis is primarily clinical.
  • Magnetic resonance imaging gives clearly more information and helps to plan further treatment in cases where
    • A long time has elapsed between trauma and diagnosis
    • A chronic rupture is suspected, or
    • The diagnosis is otherwise uncertain.

Treatment

Conservative treatment of tendinopathy

  • Physical exercise or other strain triggering symptoms should be reduced
  • It should be noted that rest alone will not cure tendinopathy, but progressively increasing loading of the tendon towards normal requirements should be started immediately after the pain stage.
  • A short course of NSAIDs can be given first to alleviate the pain.
  • A heel insert may reduce the strain on the Achilles tendon effectively, particularly if symptoms occur at the insertion site.
  • Rehabilitation should be adjusted to the individual patient's level of requirements.
  • The efficacy of extracorporeal shock wave therapy (ESWT) in the treatment of Achilles tendinopathy does not differ from that of placebo 3.
  • Due to increased risk of rupture, local glucocorticoid injections are not recommended for the treatment of tendinopathy. They may be considered for the treatment of acute crepitating peritendinitis or isolated retrocalcaneal bursitis.
  • There are many forms of treatment for which there is no evidence available, such as nocturnal splinting, platelet-rich plasma (PRP) injections, kinesio taping and deep fascia massage.

Surgical treatment of tendinopathy

  • Symptoms of tendinopathy have a good natural healing tendency but in extremely painful cases or cases resistant to treatment, surgery can be considered.
  • Surgical techniques include open debridement and decompression, calf release (lengthening the Achilles tendon), percutaneous / minimally invasive procedures and flexor hallucis longus tendon transfer.
  • There is no convincing scientific evidence available for the usefulness of surgical treatment.

Tendon rupture

  • See Table T1.
  • Non-surgical treatment is recommended for acute Achilles tendon ruptures. An orthosis with a heel wedge or facilitating adjustment of the ankle angle can be used.
  • For young competing athletes or patients doing heavy physical work, surgical treatment can be considered if there are no factors increasing surgical risks.
    • The risk of recurring rupture is probably slightly lower in patients treated by surgery (risk difference 1.6%) 1 7 but the incidence of recurring ruptures is low in both groups (< 5%). The risk of other complications related to surgical treatment (wound problems, nerve injury, venous thrombosis) has been found to be notably higher (risk difference 3.3%) compared to conservative treatment.
    • Both forms of treatment have been found to leave calf strength reduced, conservative treatment possibly slightly more so. However, in long-term follow-up no difference was found on functional scales between various forms of treatment.
  • Patients must be informed of the benefits and risks of both forms of treatment. Treatment decisions should then be made together with the patient.
  • Situations where surgery should be considered as the primary form of treatment, unless there are contraindications
    • Recurring ruptures
    • Avulsions at the insertion site
    • Ruptures over 2 weeks old, in which the depression does not disappear when the foot is in equinus position (plantar flexion)
  • The primary form of surgical treatment is open or minimally invasive tendon suture.

Treatment protocol for Achilles tendon rupture.

Conservative treatmentOperative treatment
First aid
Equinus splint or orthosis
Touch down weight bearing, prohibition to push off from the ball of the foot
Surgery within the next few days
Surgical department
Equinus splint or orthosis
Touch down weight bearing, prohibition to push off from the ball of the foot
2-3 weeks
Fitting of Achilles orthosis (if not yet used)
Checking the scarring of the tendon
Removal of heel wedges / reduction of equinus angle once a week
Removal of stitches and wound inspection
3-6 weeks
Full weight bearing with orthosis
Progressive rehabilitation, daily physical exercise without weight bearing
No stretching of the tendon
6-8 weeks
End of orthosis treatment
Heel lift for 1-2 months
No eccentric exercises yet
3-6 months
Increasingly effective calf muscle exercises
Emphasis that even if the tendon is painless, it cannot tolerate maximum strain or exertion yet.
Jogging-level loading once walking is painless and fluent
6-9 months
Resumption of normal exercise when muscle strength and mobility are equivalent to the contralateral side

    References

    • Myhrvold SB, Brouwer EF, Andresen TKM, et al. Nonoperative or Surgical Treatment of Acute Achilles' Tendon Rupture. N Engl J Med 2022;386(15):1409-1420.
    • Leino O, Keskinen H, Laaksonen I, et al. Incidence and Treatment Trends of Achilles Tendon Ruptures in Finland: A Nationwide Study. Orthop J Sports Med 2022;10(11)23259671221131536. [PubMed]
    • van der Vlist AC, Winters M, Weir A, et al. Which treatment is most effective for patients with Achilles tendinopathy? A living systematic review with network meta-analysis of 29 randomised controlled trials. Br J Sports Med 2021;55(5)249-256. [PubMed]
    • Kearney RS, Ji C, Warwick J, et al. Effect of Platelet-Rich Plasma Injection vs Sham Injection on Tendon Dysfunction in Patients With Chronic Midportion Achilles Tendinopathy: A Randomized Clinical Trial. JAMA 2021;326(2)137-144. [PubMed]
    • Silbernagel KG, Hanlon S, Sprague A Current Clinical Concepts: Conservative Management of Achilles Tendinopathy. J Athl Train 2020;55(5)438-447. [PubMed]
    • Haapasalo H, Peltoniemi U, Laine HJ, et al. Treatment of acute Achilles tendon rupture with a standardised protocol. Arch Orthop Trauma Surg 2018;138(8)1089-1096. [PubMed]
    • Lantto I, Heikkinen J, Flinkkila T, et al. A Prospective Randomized Trial Comparing Surgical and Nonsurgical Treatments of Acute Achilles Tendon Ruptures. Am J Sports Med 2016;44(9)2406-14. [PubMed]
    • Kearney RS, Parsons N, Metcalfe D, et al. Injection therapies for Achilles tendinopathy. Cochrane Database Syst Rev 2015;(5)CD010960. [PubMed]
    • van der Linden PD, Sturkenboom MC, Herings RM, et al. Increased risk of achilles tendon rupture with quinolone antibacterial use, especially in elderly patients taking oral corticosteroids. Arch Intern Med 2003;163(15)1801-7. [PubMed]
    • Fahlström M, Jonsson P, Lorentzon R, et al. Chronic Achilles tendon pain treated with eccentric calf-muscle training. Knee Surg Sports Traumatol Arthrosc 2003;11(5)327-33. [PubMed]

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