EBP: Achilles tendon ruptureJosh Meyer

Background

Anatomy: The largest and strongest tendon in the body, the Achilles tendon is a dense

band that runs from the posterior aspect of the calcaneus up to the triceps surae muscle

group.1 The triceps surae group consists of the soleus and both the medial and lateral heads of

the gastrocnemius.2 The tendon itself averages 15 cm in length and can range from anywhere

between 10-26 cm in an adult. It is at its thickest at its origin and gradually becomes thinner as

it travels down the leg to its insertion point on the calcaneus.3 The tendon and associated

muscles lie in the superficial posterior compartment of the leg which is innervated by the tibial

and sural nerves. Blood supply for the tendon comes mainly from the fibular and posterior

tibial arteries with most of that blood supply going to the proximal and distal sections.

Although some blood enters into the mid-shaft through its anterior surface, this definitely

leaves a hypovascular region where most Achilles problems occur.3

Mechanism of Injury (MOI): While an Achilles tendon is exposed to physical strain and

load everyday while walking and moving around, if the tension becomes too much, the tendon

fails resulting in rupture.4 A rupture of the Achilles tendon typically occurs with powerful

movements such as jumping, sprinting, or with activities that require a sudden change of

direction. Most often Achilles tendon ruptures are seen in athletes, specifically football players

that quickly try to change direction and make a play.5 However, continuous activity of smaller

forces, like with manual labor workers can also make the tendon vulnerable.6 The two main

theories behind why the tendon fails are due to chronic degeneration or failure of the inhibitory

mechanism when too much force is applied.4 Predisposing factors for Achilles tendon rupture

include individuals with chronic inflammation and microtears, degeneration due to age, those

who have had recent corticosteroid injection to the tendon, and those who are more sedentary

but perform periodic bouts of strenuous activity.2,4 It has even been shown that pathologic

tendons are more comprised of type III collagen instead of type I, possibly diminishing the

tendon’s tensile strength.3

Incidence/Prevalence: Achilles tendon rupture is more prevalent than you would think.

Annually there are anywhere from 600,000-1,800,000 cases in the world.7 This injury most

often occurs in males between the ages of 30-40.5 While women and children can be

susceptible too, Achilles tendon ruptures happen five times more in males.6 As in forceful

contractions, like sudden change of direction movements, Achilles tendon ruptures almost

always happen during concentric muscle contraction. Cases of rupture during eccentric

contraction are very rare. Another almost always is the location of the rupture. Ruptures

typically happen 2-6 cm above the insertion point on the calcaneus in the aforementioned

hypovascular region.4

Common Evaluation Findings

Signs & Symptoms: When an Achilles tendon rupture occurs, the most common thing

reported is that someone kicked them in the back of the leg. Injured individuals may also

report hearing a “pop” followed by immediate pain that quickly subsides.2 The patient will have

difficulty walking normally because of the inability to bear full weight on the injured leg.

Further visual inspection may reveal a palpable defect or knot in the tendon where the trauma

has occurred, although edema over the distal calf may preclude palpation.4,5 Other symptoms

include point tenderness over the tendon and lower calf musculature. A functional assessment

will reveal increased but painful dorsiflexion and weakness or complete loss of function in

active plantar flexion.2,4,8

Special Tests: After the initial evaluation special tests are the key to an accurate

diagnosis. The number one test used in evaluation of an Achilles tendon rupture is the

Thompson Test. In this test the patient lies prone on the table with heels placed over the

edge.9 The examiner then squeezes the calf and watches for slight plantar flexion. A positive

test occurs when there is no motion produced, indicating a rupture of the tendon.2,4,9 A second

but rarely used test is known as the Matles Test. In this test the patient lies prone with their

knees bent to 90°. The examiner then observes both feet for slight plantar flexion. A positive

test occurs when the foot on the injured leg falls into dorsiflexion.8 Accuracy of special tests are

measured in sensitivity and specificity. Sensitivity is the likelihood the test results are positive

in someone with the pathology whereas specificity is the likelihood the test results are negative

in someone without the pathology. The Thompson Test is widely known as the “gold standard”

test for Achilles rupture due to its 96% sensitivity and 93% specificity.10 The Matles Test has

shown an 88% sensitivity and 86% specificity.10

Differential Diagnosis: When evaluating for an Achilles tendon rupture there are other

pathologies you must differentiate between. Three of the most common differential diagnosis

include medial gastrocnemius tears, calcaneal avulsion fracture, and deep vein thrombosis

(DVT).5,8 A medial gastrocnemius tear can be confused for an Achilles tendon rupture because

it also typically occurs with jumping or quick starts/stops. The patient may even report getting

“kicked in the leg” along with presenting with point tenderness and strength loss. Palpating the

gastrocnemius’ muscle belly and feeling for a defect is a good way to discern between the two.

Someone with a calcaneal avulsion fracture will also present with swelling, pain, and inability to

bear weight. Onset of this injury is typically after landing from a jump and can be confused with

symptoms of Achilles injuries. X-rays and possible CT scans can rule out an avulsion fracture.2

DVT is a less common differential and is not necessarily due to physical activity. DVT is a blood

clot in the lower leg and presents with warm painful tightness of the calf. Homan’s sign,

another special test or diagnostic ultrasound can rule this out.4

Overview of Diagnostic Testing

Imaging: In most cases Achilles tendon ruptures are properly diagnosed after clinical

assessment but there are still as many as 25% that go undiagnosed due to vague symptoms or

inconclusive special tests.8 In that case, the next step is diagnostic imaging. The two options as

of now are magnetic resonance imaging (MRI) and diagnostic ultrasound. MRI images are very

detailed and leave no doubt to the amount of tear in the tendon. However, they are more time

consuming and more expensive. Ultrasound is faster, giving real time images but is certainly

less conclusive.11 Overall, ultrasound has an 80% sensitivity and a 49% specificity while MRI has

a 95% sensitivity and a 50% specificity.8 A definitive diagnosis is best made by an MRI.

Interpretation of Reports: When using ultrasound, they use a transducer to produce

images in the horizontal and transverse planes of both the injured and uninjured legs. They can

see either the complete absence of fibers or they can look for longitudinal tears that appear as

abnormal hypo-echoic gaps. They will then compare bilaterally to look for abnormalities.11

With MRI they look for any increase in signal intensity. T1 weighted scans look for fluid and can

show the site of hemorrhage. T2 weighted scans show the orientation of fibers and the size of

the gap between tendon ends. Ultrasound can be a useful tool, but in most cases should only

be a stepping stone to MRI in the diagnosis of Achilles tendon ruptures.8,11

Surgical Techniques

Description of Techniques: Currently there are two main surgical techniques to choose

from when it comes to fixing an Achilles tendon rupture. The first is the called the end to end

suture or more commonly known as the open technique.12 A medial incision is made over the

Achilles tendon to expose both ends of the tendon. The ends are then stretched back out until

they meet and two to four sutures are put in place to approximate the tendon ends. At this

time they will debride any degenerative tissue if tendonitis is present. If the rupture occurred

at the distal bony attachment, suture anchors are required to secure them to the calcaneus.5

The sutures are made of a strong nylon material. The second technique is called the Ma and

Griffith percutaneous technique or generally referred to as just the percutaneous method. In

this procedure the tendon ends are located first using diagnostic ultrasound. Two small

incisions are made at the proximal tendon end where the first set of sutures are knotted. Two

more incisions are made at the distal end. The sutures from the proximal end are then used to

pull the tendon together before the final set of sutures are knotted at the distal end.12 The two

techniques are essentially the same except for their invasiveness.

Conservative Treatment: For individuals that are against surgery, there is the option of

conservative methods. Conservative treatment consists of placing the tendon in total contact

while under the direction of ultra sound and then placing the patient in an upper leg plaster

cast.6 This method is rarely used as it relies solely on healing by formation of scar tissue. The

patient must be non-weight bearing for at least 4 weeks to allow that process to begin.

Another 4 weeks are followed with a smaller cast before finally the cast is removed and foot

walking position can be regained.6 Although conservative treatment reduces costs and surgical

complications, it requires more immobilization which leads to more leg atrophy. It also comes

with a higher rate of re-rupture and possible tendon extension leading to weakening of the

triceps surae muscle group.6 With all of these factors considered, individuals tend to choose

between the two surgical options.

Variables that Influence Options: The two biggest factors to consider when looking at

different surgical techniques are recovery time, or time to return to sport if that applies to you,

and cost. Taking a look at both the previous surgical options mentioned, recovery time was

very similar. Average recovery time for both the open and percutaneous techniques were

about 7-8 months.1 Return to sport varied from 6-12 months depending on the amount of

rehab, patient age/fitness, and what sport the patient was returning to.5 The second variable,

cost, is where you see a bigger difference between the two. Percutaneous repairs had a much

lower overall cost than open repairs. The surgery alone was priced at $1,500 for open yet only

$850 for the percutaneous. That doesn’t even take into account that open repairs had on

average a three month longer follow up period due to its invasiveness.13 Percutaneous repairs

are the more cost effective technique.

Interpretation of Operative Reports: Common complications include infection,

improper wound healing, sural nerve damage, and re-rupture. However, there were no

substantial differences between the two techniques. The overall complication rate was 14.3%

for open and 10.4% for percutaneous. Infection was 2.7% in open and 2.0% in percutaneous.

Wound deterioration was 2.8% in open and 0% in percutaneous. Nerve damage showed up at

5.6% open to 8.1% percutaneous. Re-rupture, possibly the most important post op statistic,

was 2.8% in open and 2.0% in percutaneous.13 Ultimately, final results of the techniques were

measured as either optimal or good in 90.9% of open repairs and 99.4% of percutaneous

repairs.12

Rehabilitation

Pre-Hab Phase: The first phase of rehab is the pre-hab phase. In the case of a ruptured

Achilles tendon, this phase begins at initial rupture and runs until surgery is performed. This

phase has not always been emphasized in a rehab program but studies show that patients that

engage in exercise prior to surgery return to a higher level of play, and return faster than those

who wait to begin rehab.14 Pre-hab revolves around maintaining fitness as much as possible

prior to surgery in order to be more effective post-surgery.2

Initially ice, compression, and immobilization in slight plantar flexion should occur along

with the use of crutches to avoid weight bearing.5 Modalities to use at this point include ice

bags and ice water immersion to decrease the swelling and regulate pain.15 Russian e-stim can

also be used on unaffected muscles such as the quads to help prevent disuse atrophy.5 Once

initial swelling has subsided exercise should include thigh, hip, and core strengthening as well as

cardiovascular exercises. Examples of pre-hab exercises include isometric quad sets, isometric

hip AB/ADduction, and using an upper extremity ergometer (UBE) bike.2 The only restrictions

for exercise prior to surgery would be anything that could potentially cause further harm to the

Achilles tendon.16

Like in any phase you want to set specific, measurable, attainable, realistic, and timely

(SMART) goals. Goals for this phase may include maintaining quad strength for the injured limb

equal to the opposite side by performing isometric quad sets twice a day and maintaining

cardiovascular fitness by using a UBE bike for 10 minutes twice a day. Another goal in this

phase would be to limit swelling by icing and elevating the limb for 30 minutes every two hours

and especially post exercise. Psychological response is also something you must think about in

rehab. Since the pre-hab phase would be considered under reaction to injury, the patient may

be experiencing fear or denial. At this time you need to provide as many details as possible

about the injury to the patient and lay out a plan for them so they can see how they will

recover.2

Inflammation Phase: The inflammation phase is characterized by redness, heat,

swelling, pain, and loss of function.15 Normally this phase starts immediately upon injury but in

a surgical situation the inflammation phase starts again post-surgery and may last as long as

four days.2 In this phase the main goal is to reduce swelling, pain, and secondary injury by using

rest, ice, compression, and elevation (RICE).

Modalities to use in the inflammation phase include ice, ice immersion, gentle ice

massage, light massage, Russian estim, and intermittent pneumatic compression (IPC).15,17

Using IPC as an adjunct to cryotherapy during the first two weeks has shown to increase levels

of glutamate and glucose helping to stimulate proliferation and promote angiogenesis and

tendon repair.17 During this roughly 4 day phase, no new exercises should begin. Continue to

strengthen thigh, hip, and core muscles while maintaining cardio as the limb is immobilized in

15° plantar flexion. No stretching or strengthening of affected tendon or surrounding

musculature is permitted at this point in the rehab program.5

Goals for the inflammation phase are very similar to the pre-hab phase and may include

decreasing swelling by icing and elevating for 30 minutes every two hours, controlling pain by

using light massage once a day, and aiding in the removal of edema by using IPC for 20 minutes

three times a day. During this phase the patient may be feeling depressed or have a sense of

hopelessness. It is important to again listen to all of your patients concerns and try to clarify

anything they don’t understand. If the patient is an athlete this is also a good time for coaches

and teammates to come by and provide emotional support.2

Repair Phase: The next phase in rehab is the repair phase. At this point swelling has

completely stopped and fibroblasts are laying down collagen to repair tissue. This phase starts

approximately on day four post-surgery and typically lasts 3-4 weeks. During this phase the

main goal is to begin regaining range of motion (ROM).2,15

Although swelling has subsided at this point, pain can still be a limiting factor in

progression. Modalities that can be used in the repair phase include ice, ice massage, massage

IFC e-stim, Russian e-stim, IPC, laser, and ultra sound (US).2,15,16,18 IFC can be used for pain

modulation in combination with ice.15 The addition of laser and US can be implemented to

increase blood flow to the wound site and speed up the healing process.15,18 A combination of

US and massage has proved helpful with myofascial release to prevent adhesions from forming

while the tendon heals.16 The repair phase is where you start to see advancement in rehab

exercises. According to evidence base practice (EBP), starting as soon as inflammation has

passed, partial weight bearing (PWB) should be initiated.16 With the use of an ambulatory

device, PWB should increase over the weeks and the patient should be full weight bearing

(FWB) at approximately 6-8 weeks.16 The repair phase is also the time when passive range of

motion (PROM) should begin within a pain free ROM. Active range of motion (AROM) in plantar

flexion and exercises involving the toes such as marble pickups and towel curls can also be

initiated within a pain free ROM.5 Early weight bearing and ROM has shown to decrease the

overall rehab time.16 Starting the third week, an additional 5° of dorsiflexion is gained in the

boot per week.5 In this phase you want to make sure to avoid any stretching of the tendon.

Stretching should not take place until week 4-5.5

Goals of the repair phase could include decrease pain to a 2/10 by week four, gain full

PROM plantar flexion by week three, and regain neuromuscular control over toes while doing

marble pickups in 1 week. At this point in time the patient has moved on from a psychological

response of reaction to injury into a reaction to rehab. This is a critical time to allow the patient

input on what specific exercises they would like to do. Allowing the patient to feel as if they

have input into their rehab program will make them more likely to stick with it. Also by making

small and attainable goals you can help the patient build confidence and feel successful.2

Maturation Phase: The last phase in the healing process is also the longest. The

maturation phase begins at the 3-4 week mark and can last for as long as a few years.2 This

may be the most important phase as the most change happens here. Collagen fibers are laid

down in a haphazard fashion and unless stressed properly and directed which way to arrange,

they can cause a loss of flexibility, loss of strength, or even predispose an individual to re-

rupture.2,15 The ultimate goal of this phase is to return to activity (RTA) or sport.

At this phase almost all modalities are safe for use. These modalities could include ice

(cryokinetics), hot packs, hot whirlpool, IPC, e-stim (Russian, IFC, Hivolt, TENS), laser, diathermy,

US, and massage.15 However, since this phase can range from 4 weeks to several years, make

sure to select modalities carefully and consider their precautions and contraindications before

use. Starting at 4-5 weeks post op, AROM dorsiflexion and passive stretching of the Achilles

tendon should occur.5 Passive stretching can be accomplished by either the clinician or by using

a slant board. Approximately by week 7, ROM should be unrestricted and there should be no

further need to wear a boot.16 Although the boot is gone and the patient is fully weight

bearing, they may still need to wear a small heel lift in their shoe. Tentatively, starting at week

8 the patient can begin progressive strengthening exercises such as the total gym (TG) working

up to double and single leg heel raises.2,5,19 Once a small base of strength has been built up the

patient should begin exercises such as double leg balancing and single leg balancing with

increasing difficulty to work on proprioception and balance.16 Although the patient is

progressing make sure to avoid any forceful motion for up to 12 weeks. Other rehab concerns

going forward include fully restoring Achilles tendon length and triceps surae strength.5

The eventual goal of the maturation phase would be to RTA. However, since this phase

can be such a lengthy one it is good to have some short term goals as well. These may include

being able to do a single leg heel raise with no assistance at 13 weeks, jogging straight ahead at

4 months, or for an athlete, return to partial practice at 7 months. Since the maturation phase

is the last phase of rehab, the patient or athlete can usually see the light at the end of the

tunnel. They may be ready to RTA physically but may not be ready emotionally or

psychologically.2 It is important for the patient to be progressed in small increments in order to

build up his/her confidence in the tendon. Another helpful thing is to teach the patient

progressive relaxation or breathing techniques to relax and focus the patient to avoid

overexcitement and possible re-injury.2

Return to Play Criteria: The final stage of the rehab process is the RTA or sometimes

called the return to play. This may involve a patient returning to their occupation but in most

cases involves an athlete returning to sport. Although the physician is ultimately responsible

for deciding when the patient is ready to return, it is important to already have set up

functional guidelines of what complete recovery is.2 This may include being able to perform a

certain task the patient is responsible for consistently performing. In addition strength,

proprioception, ROM, neuromuscular control, and cardiovascular endurance should be well

within normal limits if not equal to the opposing side.2 Sometimes, an Achilles tendon tape job

can help the patient RTA sooner. This taping helps the patient plantar-flex and avoid any

particularly painful ROM.20 Final progression to a RTA should always be guided by pain.

Although RTA for an athlete is typically 6-12 months, everyone is different and pain is the best

guide when deciding whether or not to progress the patient to the next level.5

Potential Medications

Medications can be very beneficial when aiding in the healing process. Immediate post-

injury the patient should take over the counter nonsteroidal anti-inflammatories (NSAIDS) such

as Ibuprofen or Aleve to try and lessen the inflammation, pain, and swelling that will form.5,19

NSAIDS inhibit prostaglandin synthesis and thus are very effective post-injury.2 Post-surgery,

narcotic pain relievers such as Oxycontin or Diluadid may be used to control severe pain but

typically pain is not too unbearable that over the counter pain relievers will do the trick.2

Key Points

“Gold standard” test for diagnosis is the Thompson Test (96% sens, 93% spec)

EBP has shown early PWB and ROM decrease overall rehab time

Stretching of the tendon should start at weeks 4-5 post op

Progressive resistance exercises should start at week 8 post op

Forceful motions should be avoided for the first 12 weeks

RTA timelines are 6-12 months depending on patient and activity returning to

References

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18. Jesus J, Spadacci-Morena D, Rabelo N, Pinfildi C, Fukuda T, Plapler H. Low-level laser therapy in IL-1β, COX-2, and PGE2 modulation in partially injured Achilles tendon. Lasers In Medical Science. 2015;30(1):153-158.

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