Diseases, Disorders information

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Achilles tendon rupture is a weekend warrior injury; the recreational athlete that perhaps at the start of his or her recreational season, they are out to perform their activities, they haven’t sufficiently warmed up and it’s been a long winter and they haven’t really been doing much activity, they tear their Achilles tendon, and the mechanism here is an eccentric contracture, meaning, as they are trying to contract their Achilles tendon or put the foot into the ankle into plantar flexion, the ankle is actually is actually dorsiflexing from the stress applying to it, so you have that large force to pull the Achilles tendon apart. That patient may hear or feel a pop behind the ankle, they may say, I thought the ball hit me in the back of the ankle or somebody stepped on my at the back of the ankle, that is what they may complain to you, but it really was the Achilles tendon completely rupturing. In some case, the patient is not going to be completely incapacitated by this injury, they are going to be able to walk afterwards. Sometimes, in 20 to 30% of the cases, the diagnosis can be delayed in Achilles tendon rupture. We sort of suspect this injury perhaps in the man or woman in their late teens up to maybe their mid 40s or 50s, I have seen patient’s that are older than that in their 70s or whatever, that actually have an Achilles tendon rupture, they didn’t quite have this resounding pop, but they did feel something back there, they were able to walk around, despite the fact that the Achilles tendon is ruptured, and I would tell you perhaps it’s more anecdote than evidence-based, but I would say the older you are and less active you are, you are the one, if you have an Achilles tendon injury, the diagnosis may be delayed in making this, so always have a high suspicion. Here is how to make the diagnosis, there is pain and swelling over the point of disruption, there is a positive gap sign, meaning you run your finger up here, you feel the muscle belly, you feel the Achilles tendon and then you feel mush. There is a space there, there is an indentation where the tendon is not in continuity. The Thompson’s test can be done here if the patient is kneeling over a chair, they can be done on an examination table, they are squeezing the calf muscles, you’re squeezing the muscle bed of the gastrocnemius and soleus, you are shortening the tendon and if the ankle doesn’t plantar flex here because there is a disc continuity, that means you have an Achilles tendon rupture. So compare this to the other side, to make sure you are not being fooled, but if the ankle doesn’t plantar flex when you squeeze the calf, there is a discontinuity in the Achilles tendon, and suddenly, they are going to have limited plantar flexion if you are going to test that as well.
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So how to treat this, well, operative versus nonoperative, in a nutshell, the benefits of operative treatment are that there is a lower rate of rerupture associated with Achilles tendons as opposed to nonoperative management, if you are trying to anatomically restore the Achilles tendon to it’s length and bring those ends together, so the less scar tissue that intervenes the form between those two torn ends of the Achilles tendon, the likelier it is that it’s going to be a stronger repair, so that’s why operative treatment seems to be associated with less of a rerupture rate than nonoperative, but your patient certainly has to accept the associated risks of operative treatment to get the benefits, you have to consider what the patient’s expectations are. The young active male or female who has a very active lifestyle and recreation sports are quite important to them, their expectations might lead you to say that operative treatment is the best management versus someone who is older, has other medical problems, perhaps diabetes of peripheral vascular disease or something else that would increase their risk of having surgical treatment, they may need nonoperative management, it may be the best thing for them. Here is a demonstration of an Achilles tendon that basically is looking like spaghetti that needs to be put back together.
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