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Achilles tendon disorders

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Figure:  Location of Symptoms:  A patient presenting with non-insertional Achilles tendonitis (seen at left) will often describe pain and tenderness 2-6 cm from the insertion of the tendon into the calcaneus. The patient will often describe an increase in activity level , such as starting a new training regimen or attempting to resume a normal activity level after an injury to another part of the foot or ankle.  Examination will usually reveal swelling and tenderness around the Achilles tendon. The location of the pain can help differentiate this from insertional tendinitis (seen at right) which presents with pain more distally.

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Achilles tendon rupture:  The most common acute injury to the Achilles tendon is a complete rupture.  This injury typically occurs in men in their 30s and 40s. The inciting event often is an athletic activity that requires a sudden acceleration or changes in direction (ex. basketball, tennis, soccer). Patients usually describe a sharp pain in their heel region almost as if they were struck in the back of the leg. Ruptures  Ruptures typically occur 2 to 5 cm proximal to insertion into the calcaneus. 

Achilles tendon ruptures usually occur when an athlete loads the Achilles immediately prior to pushing off. This can occur when suddenly changing directions, starting to run, or preparing to jump. A sudden change in direction requires the calf muscle to contract while still lengthening (eccentric loading).  This subjects the Achilles tendon to a large loading force which may not be adequately stretched and/or may be weaker in a middle-aged patient who only participates in sports occasionally (the so-called “weekend warrior”)can tear it. To be clear: the tendon tears because of the large internal forces generated by the eccentric contraction of the calf muscle and applied to the AchillesIf ANY patient , and not because of an external force. In such a sense, it may be said that the patient tore the tendon himself.

Although Achilles tendon tears are more common in middle aged men who exercise intensely but intermittantly (the so-called "weekend warrior"), the diagnosis must be considered in any patient who reports an acute mechanism of injury (or acute change in symptoms) implicating the heel or soft tissues above it, it is essential to ensure that the Achilles tendon is intact (i.e. that the problem is not in fact . In those patients, the examiner can exclude an Achilles tendon rupture) .  A rupture can be detected with the Thompson Test (described in the caption to the test. (see figure).  


The Thompson test, as shown, takes advantage of the fact that squeezing the patient's calf muscles with the knee flexed should induce plantar flexion of the ankle if and only if the Achilles is intact. 


Figure: The starting position for the Thompson test. The patient lays prone on the examining table. The affected leg is flexed 90, perpendicular to the table (blue lines). The examiner firmly squeezes the gastrocnemius (black arrows). The examiner examines the ankle for plantar flexion

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  1. The nomenclature of the Thompson test can be confusing: a "positive" Thompson test is the absence of motion (whereas "positive" using means something was affirmatively observed). It is therefore helpful to describe the results as "positive for rupture" or "negative for rupture".

  2. The Thompson test is necessary because testing active ankle plantar flexion  can can be misleading: an intact posterior tibialis and the flexors of the toe, which are both (weak) ankle flexors as well, might mask a torn Achilles. With these tendons intact, a patient with a ruptured Achilles may still be able to actively flex the ankle, especially without resistance.
     

A patient presenting with Achilles tendon rupture will often describe a sharp intense pain in the back of their heel at the time of the injury. Patients often initially report that they were “struck in the back of the heel” only to  realize realize that this was not the case, as there was no one around them.

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An MRI can give a detailed view of the soft tissue.  However, this test is NOT not routinely indicated in the initial assessment of Achilles tendonitis.  

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Ultrasound is usually less expensive than an MRI, but may not be available in all settings; examiner skill and experience is needed. Further, use of ultrasound may be limited by the examiner's lack of skill or experience.

Plain x-rays will be negative in patients who have suffered an Achilles tendon rupture unless the Achilles injury involved an avulsion (traumatic displacement of a bony fragment ) from the calcaneus). Avulsions are rare, except in older patients with weaker bone.

Achilles rupture can be seen on ultrasound or MRI. However, these studies are usually not needed as a good history and well-performed physicial physical exam should cinch the diagnosis. However, an MRI may be justified when the history or physical exam is ambiguous, or the quality of the tendon is in question (and whether it is amenable to repair) in the setting of chronic tendinopathy.  

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Figure: Achilles tendinopathy seen as seen on MRI. The tendon is shown in continuity, but continuity but is abnormally thickened. 

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Insertional Achilles tendonitis with its associated “terrible triad” of heel pain typically occurs in middle-aged individuals who are overweight. Another group of patients who suffer from , though this condition are is also seen in young, active runners.  The exact incidence of this bimodal distribution has not been recorded.

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There are four common causes for pain in region near the back part of the heel:

  1. non-insertional Achilles tendonitis, 
  2. insertional Achilles tendonitis (with or without bursitis)
  3. paratendonitis (inflammation of the sheath surrounding the Achilles tendon, rather than of the tendon itself), and 
  4. Achilles tendon rupture.  

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Because the forces applied to the Achilles tendon during activities are proportional to body weight, losing weight (even a small amount) can be very helpful (, though attaining enduring weight loss is difficult and maintaining it even harder.)

Surgical debridement, that is, the removal of the damaged tissue with meticulous repair of the remaining tendon, may be chosen if non-operative treatment fails.  One setting where surgery may be considered more readily is that of a high-level athlete with a Haglund’s deformity. Surgery usually involves removing the prominent excess bone and the thickened inflamed retrocalcaneal bursa, and bursa and debriding the Achilles tendon.

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Stiffness of the ankle, rupture of the tendon, and deep vein thrombosis are known potential complications. Infection is relatively uncommon , but if it occurs it is potentially a very serious problem due to the limited because loss of skin and soft-tissue coverage in this area is very hard to treat.

Achilles tendon rupture

Achilles tendon ruptures can be treated with either surgical repair or relative immobilization.  However, it is critical to realize that formal treatment, either operative or non-operative, is required.  If the ruptured tendon is ignored (or misdiagnosednot correctly diagnosed) the tendon ends will retracted retract, leading to failure of the calf muscle and a dysfunctional lower leg.

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Non-operative treatment consists of placing the foot in a downward position [equinus] initially, to encourage a position that encourages the torn ends to oppose; once contact each other. Once there is some healing, the foot can be advanced to a more neutral position. Early weight-bearing and controlled active plantar flexion has been shown to improve non-operative treatment.  However, care must be taken to avoid excessive dorsiflexion (extension), a position that encourages the torn ends to separate from each other.

It is very important that to monitor the status of the Achilles is monitored throughout non-operative treatment. This can be done by examination or via ultrasound. If there is evidence of gapping or non-healing, surgery may need to be considered. 

The primary advantage of non-operative treatment is avoiding an incision in an area, by dint of location and vascularity that is at higher risk for wound healing problems and infection.  The main disadvantage of non-operative treatment is that the recovery appears to be somewhat slower and the re-rupture rate appears to be higher.

Operative treatment of Achilles tendon ruptures involves opening the skin and identifying the torn tendon. This is then sutured together to create a stable construct.  By suturing the torn tendon ends together, they maintain continuity and and assuring continuity even if the ankle is not in full plantar flexion, the patient can be mobilized more quickly.

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Regular calf stretching, as shown in the figures, can help improve the Achilles tendon's mechanical compliance ("stretchability" in layman's terms) of the Achilles tendon. This and makes it more resilient to wear and tear due to the repetitive loading associated with standing and walking. 

 

 

Figure: A consistent calf stretching program is an important part of treatment and prevention of Achilles injuries. Leaning against the wall with one foot forward and the back heel kept on the ground will stretch the Achilles and posterior calf muscles.

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Figure: Controlled exercises where the Achilles tendon is being lengthened while the calf muscle contracts, such as the “Heel drop”shown here,  may help prevent (or amerliorate treat) Achilles tendonitis. In this exercise, patients stand on their toes while positioned on the edge of a ledge such as a stair. They then slowly lower their heels down below the ledge simultaneously stretching and strengthening the Achilles tendon. This can be done with both legs at a time (bilaterally) or for a more concentrated effort, one leg at a time. It can also be done with the knees straight (putting force on the gastrocnemius) or the knees bent (putting force on the soleus).

Patients should gradually work up to performing 5 sets of 10 repetitions. These exercises should be performed 5-6 days per week during the active treatment phase and then 3 times per week to minimize the chance of developing recurrent symptoms. It is critical that this exercise be is approached cautiously, as it has the potential to put excessive pressure on the Achilles. Patients should always warm up first (ex. get their blood flowing on an exercise bike for 5-10 minutes) before performing these exercises.

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In Greek mythology, Achilles was dipped into the River Styx by his mother Thetis, to coat his body with a shield of invulnerabilityprotection. Thetis held Achilles right above his  grasped Achilles by the heel (on the eponymous tendon) when she dipped him, leaving that one area not washed by the river unprotected; hence the , and in turn unprotected. From that comesthe term "Achilles heel", connoting a person's area ofvulnerabilityy

Key terms

Achilles tendonitis; insertional; non-insertional; Achilles tendon rupture; Haglund’s deformity; retrocalcaneal bursitis; Thompson test

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