TENDON RUPTURE

OF ACHILLES
MR. TAPIA
ANATOMY
the musclessoleus and gastrocnemius converge to form the tendon
of Achilles,
The contraction of these muscles, along with the actions of the tibialis.
posterior and of the long and short peroneus, causes the foot to flex from
plantar form that inserts posteriorly into the calcaneus.
Tendon ruptures occur when the blood supply from the
gastrocnemius-soleus muscle complex is poorer, from 2 to 6 cm
above the insertion point.
EPIDEMIOLOGY
The incidence of Achilles tendon rupture in the general population is
from approximately 5 to 10 per 100,000.
Approximately the10 percent of patients who suffer a rupture
The Achilles tendon had preexisting problems.
Tendon rupture occurs in 8.3 percent of athletes.
competitive
The maximum age for the breakup is30 to 40 years for men and
women; The breakup is four to five times more common in men than
in women.6:1
Fluoroquinolone antibiotics are rarely associated with tendinopathy.
of Achilles or the rupture of the tendon. 12/100,000.
Theage over 60 years and concomitant use of glucocorticoids
systemic further increases the risk of Achilles problems
MECHANISM OF INJURY
The sharp pain of the Achilles tendon generally develops
when athletes abruptly increase their activity (e.g.,
Runners who start training for a marathon
Recurrent microtrauma causes tendon degeneration.
Achilles. The relative hypovascularity of the tendon 2 to 6 cm from its
The insertion point can impede proper healing.
The break occurs whenapply a sudden tension of
cut (e.g., cut during a basketball game) to a tendon already
debilitated or degenerative.
Lift the foot off the ground (knee extended) or sudden dorsal flexion or
much pain in plantar flexion.
DIFFERENTIAL DIAGNOSIS
The ankle sprainit is the most common misdiagnosis when the
tendon rupture is the real cause of the pain
Do not assume that the rupture is absent because the patient may
perform plantar flexion of your ankle or walk. The posterior tibial and the
wide peroneus provides significant force in flexion
they plant and partially compensate for the rupture of the Achilles tendon
Calcaneal bursitis
Calcaneal apophysitis: Sever's disease
CLINICAL PRESENTATION
When sudden forces are applied to the Achilles tendon
during exhausting physical activities that involve twisting
sudden in a foot or a rapid acceleration.
Many patients feel as if they have been violently beaten.
at the back of the ankle. Some hear a 'pop' and
They experience severe acute pain, although the absence of pain does not
discard the break.
PHYSICAL EXAMINATION

The examination of the Achilles tendon is usually simple because the tendon
it is easily identified and felt.
It is worth noting that a considerable minority of patients with rupture
complete tendon can wander.
Patients must be examinedlying face down with feet hanging
from the edge of the examination table. Inspect the tendon region of
Achilles to see if there are bruises, swelling, and misalignment of the
pies.
Palpate the Achilles tendondue to sensitivity, thickening or a defect,
recognizing that an edema or a hematoma can mask such
defect. sensitivity 73, specificity 89 percent to detect a
partial tearing of the tendon and comparing with the unaffected side is useful.
the calf compression or Thompson testprovides a
a precise means to detect the complete rupture of the Achilles tendon. The
the doctor presses the abdomen of the gastrocnemius muscle while he observes the
plantar flexion. The absence of flexion = positive test indicative of
break
In a series of 174 patients with a clinical diagnosis of tear of the
complete unilateral Achilles tendon and 28 patients with rupture of the
unilateral Achilles tendon, but suspected but not real, the test
of Thompson had a sensitivity of 96 percent and a specificity
of 93 percent, using magnetic resonance imaging (MRI) or
ultrasound as the gold standard. A negative test may omit
up to 10 percent of breakups.
The Matles testit is another means
to assess the tendon rupture of
Achilles. To carry out the test, the
the patient lies inclined with the knees
bent at 90 degrees.
Observe if the affected foot hasflexion
dorsal or it is neutral.

sensibilidad 88 y especificidad 85.

IMAGING DIAGNOSTICS
TheSimple X-rays are generally not useful in the evaluation.
of Achilles tendon pathology, but they can reveal a
spur on the heel or a bony protrusion (called deformity of
Haglund or 'pump bump'.
The images byUltrasound is increasingly used to evaluate the
the aspect and function of the tendon. Ultrasound can reveal tendon
normal, thickening of the tendon or signs of tendon pathology
more significant, such as neovessels, hypoechogenicity, fibers
disordered, gaps in the tissues and fluid.
The rupture of the Achilles tendonit can be diagnosed solely through a
clinical examination, but the ultrasound allows for a quick confirmation of the
diagnosis in bed. Although the published data is limited, in the hands
experienced, ultrasound seems to be a precise tool for
diagnose the tear of the Achilles tendon and distinguish between tears
complete and partial. sensitivity of 100 percent, a specificity of 83
one hundred percent and a 92 percent accuracy to distinguish between tears of the
partial and complete thickness Achilles tendon, using the findings
surgical as the gold standard.
Magnetic resonance imaging (MRI)) se usa a menudo para evaluar las quejas
musculoskeletal and is the test of choice when a rupture is suspected
tendon and high-quality diagnostic ultrasound is not available. The MRI
provides greater anatomical detail and greater accuracy in detection
partial tears of the Achilles tendon. With tendinopathy, the MRI can
show an increase in the weighted signal in T2 in the tendon or an increase in the
tendon diameter.
TREATMENT
Initial care - The initial management of Achilles tendon rupture consists of ice.
applied to the area, pain relievers, no weight bearing and use of crutches and splint in plantar flexion.
Complete rupture of the tendon:
Surgical repairit reduced the risk of repeated tendon rupture compared to
the non-surgical treatment (12/240 [5 percent] versus 30/249 [12 percent]; index of
risk [RR] 0.41; 95% CI: 0.21 to 0.77.
The combined results indicate that complications other than rupture
they reported more frequently in the surgically treated group, although this was not
statistically significant
Although the disparate outcome measures prevented the authors from grouping the data,
all studies except one found no significant differences in the percentage of
patients treated surgically or non-operatively who were able to return to their level of
sports activity prior to the injury.
•●Four studies included in the review reported that surgical repair
percutaneous reduced postoperative wound infections compared to the
open repair (0/68 versus 12/66; RR 9.32; 95% CI: 1.77-49.16), without affecting the rates
of reappearance. There was no significant difference in the rates of other complications.
A subsequent meta-analysis of seven randomized trials reported similar results. The recovery rate among the
Surgical patients in this review were 3.6 compared to 8.8 percent among the treated patients.
no operation (OR 0.425; 95% CI: 0.222 to 0.815). Several randomized trials published after both
meta-analyses report consistent findings. In addition, a small randomized trial reported a higher
muscle strength of the calf in patients treated surgically.
Despite the lower break rates among surgical patients reported in these reviews
systematic reviews, the authors of several studies have questioned the preference for surgical repair when
they manage broken Achilles tendons:
In a controlled trial,144 patients with acute Achilles tendon rupture were assigned.
randomly to surgical or non-surgical treatment, and both groups also underwent a
accelerated rehabilitation that included initial weight-bearing exercises and range of motion
early. Although the re-rupture rates were comparable (2/72 patients in the surgical group
versus 3/72 in the non-operative group), soft tissue complications (e.g., infection) occurred
more frequently among surgically treated patients (13/72 [18 percent] versus 6/72 [8 percent]
one hundred]). Other important clinical outcomes, including strength, movement, and overall function, were
similar in both groups in the one and two year follow-up.
In a similar essay,42 patients with acute rupture of the Achilles tendon were randomly assigned to
surgery or no surgery, while the treatment for both groups included early movement
controlled in a removable orthosis, progressing to full load at eight weeks. No reports were made
differences in complications and a similarly low number of re-ruptures was reported for both groups.
In a long-term observational study that was not considered in any of the systematic reviews, 945
Consecutive patients with acute and late rupture of the Achilles tendon were treated with a non-surgical approach.
using a structured functional rehabilitation protocol. Patients were initially placed in a
model without load with the foot in equine position (plantar flexion), then transferred to a pneumatic walker
with elevated heels (the elevation gradually reduced every two weeks), and eventually received physical therapy
to improve walking, strength, and mobility. Among the patients treated with this protocol, it was reported that the
reappearance rates were low (2.8 percent in the acute tendon rupture group; 2.7 percent in the
late break group) regardless of the activities they resumed.
The findings of these studiesthey suggest that a non-surgical protocol that uses
accelerated functional rehabilitation can prevent the main complications of
surgical treatment without increasing the risk of recurrence. If the randomized trials
additional findings reproduce the results of these studies, it will be necessary to reconsider the role
appropriate for surgical and non-surgical treatment.
For patients treated with surgery, it usually takes two to three months
absence from work that require walking. Athletes usually return to
sports from three to six months, once they have regained strength and mobility
suitable. However, additional time is often required to achieve the function
complete. According to a systematic review of 10 studies with 570 patients, the
combination of early ankle mobility exercises and early weight loading is
association with better functional outcomes without differences in major complications in
comparison with the conventional approach to postoperative immobilization.
Non-athletes and older patients may forgo surgery and choose to be
treaties with immobilization using a plantar flexion in the short leg or a
functional brace with a heel lift for six to eight weeks. These
patients should be informed of the increased risk of repeated rupture. Ideally, the
The launch must take place within 48 hours of the injury.
For patients who ruptured the Achilles tendon many weeks or months before the
diagnosis, immobilization with an orthopedic device followed by physical therapy is a
reasonable management approach.
Partial tendon rupture: the clinical diagnosis of tear or rupture
the partial Achilles tendon is imperfect, and studies are lacking to
determine optimal management. The increasing use of ultrasound and
magnetic resonance imaging (MRI) can improve this situation. It is unclear whether
surgery or conservative treatment lead to better outcomes.
We treat most cases of partial Achilles tear without surgery,
how we would do it with chronic tendinopathy.
Partial tears can be [Link] reduce the discomfort,
the initial treatment may include immobilization in a boot with
controlled ankle movement (CAM). Physical therapy or exercises in the
homes are necessary to prevent loss of movement and strength that
it can result from immobilization.
FOLLOW-UP CARE: approximately 80 percent of athletes
they return to play after the rupture of their Achilles tendon. Prevention
The new injury is essential for follow-up care. The ten.
One hundred of the ruptures of the Achilles tendon occur in previously injured tendons.
injured. The prevention of Achilles tendon injury is described in
continuation.
Although no study demonstrates the benefit of eccentric exercise in the
prevention of acute Achilles tendon injury, we suggest that patients
continue doing these exercises once it has been completed
rehabilitation and the symptoms have been resolved.
Some patients treated for chronic Achilles tendinopathy have
persistent symptoms, but it is not clear if this is true in patients who
they complete a properly designed rehabilitation program that emphasizes
high resistance exercise. Patients who do not fully recover
they can experience a new injury.
PREVENTION
General measures: various interventions can reduce the risk of developing a
new or recurrent Achilles tendonopathy and other lower limb injuries.
Before doing any vigorous exercise, it is important to do adynamic warm-up
appropriate. Although few studies have specifically evaluated the Achilles tendon at this
regarding the findings of a prospective and observational study of infantry recruits
they suggest that performing a warm-up of this type and avoiding training in cold weather reduces
the risk of Achilles tendinopathy.
Clinical studies are lacking that evaluate the impact of stretching specifically on the
Achilles tendinopathy. However, many clinicians believe that imbalances in strength
muscular or flexibility predispose some athletes to injury. Typical techniques include
stretch the gastrocnemius and soleus muscles while leaning against a wall.
stretches are done both with the knee bent and straight. The stretch can be
performing while standing on the edge of a step and letting the heel descend gradually, or
flexing the foot with an elastic band.
Although a high body mass index (BMI) is associated with tendon problems, none
The study clearly shows that weight loss prevents such problems.
• Measures for patients with fluoroquinolones: the risk of tendon-related problems associated with fluoroquinolones is low. However, for athletes or patients
highly active individuals who require treatment with fluoroquinolones, it is reasonable to take precautions to reduce the risk of Achilles tendinopathy or tendon rupture. It
lacks high-quality evidence to determine which measures are most effective, but the following steps are reasonable:
• Starting with the first dose of fluoroquinolone, athletes should reduce their training volume and intensity and maintain these reductions throughout the course of
antibiotics. High-intensity training or ballistic activities are not allowed (e.g., sprinting, jumping, full-speed training or
competition) up to two or four weeks after completing therapy with fluoroquinolone.
• Runners should reduce their total mileage to 60 percent of normal training volume during the first seven days of therapy, and they should avoid
interval training of ascent and speed. Runners who remain symptom-free two weeks after completing therapy can increase the
mileage by 10 percent per week, but they should not implement speed or hill training for an additional two weeks. If they decide to compete
During this time, they should be informed of the relatively high risk of Achilles rupture.
• The athletes participating in field sports (for example, soccer, football) or other multidirectional activities (for example, tennis) that increase the risk of
Achilles injury may choose to resume normal activity and competition between two and four weeks after completing fluoroquinolone therapy. However,
it is better to gradually increase activity, and athletes who resume full activity before four weeks should be informed of the greater relative risk of
Achilles rupture.
• Athletes who do not have symptoms during therapy and complete the full course of antibiotics can begin a gradual return to full activity as...
as described earlier, but they must be closely monitored for any musculoskeletal symptoms in or around the Achilles tendon. They must interrupt all
sports activity if symptoms develop during this period and must be evaluated by an expert doctor. Assuming there are no injuries, they can resume a
gradual return to full activity once the symptoms are resolved.
• Athletes who develop symptoms or sensitivity around the Achilles while taking a fluoroquinolone antibiotic or in the first three to six months after
starting this treatment deserves an objective evaluation, preferably with musculoskeletal ultrasound to assess the findings of tendinopathy or other injury. The
Individuals with findings suggesting tendinopathy generally require a rehabilitation program with eccentric exercises and possibly therapy.
complementary. Their return to the game depends on the clinical response and averages 6 to 12 weeks.
AB BackgroundThere is a lack of consensus on the best management of acute tendon rupture.
of Achilles. Treatment can be broadly classified as surgical (open or percutaneous) and non
surgical (immobilization by molding or functional bracing). Objectives Evaluate the relative effects
surgical treatment versus non-surgical treatment, or different surgical interventions, for the tendon
Achilles tendon ruptures in adults. Search strategy Searches were conducted in the Registry
Specialized in the Cochrane Group of Bone, Joint, and Muscle Trauma (July 2009), the Registry
Central Cochrane of Controlled Trials (The Cochrane Library 2009, Number 3), MEDLINE (1966 to 20 of
July 2009), EMBASE (1966 to 2009 week 29), CINAHL (1983 to July 2007) and reference lists of
Articles. Selection criteria All randomized and quasi-randomized trials that compare treatments
surgical versus non-surgical or different surgical methods for acute Achilles tendon ruptures
in adults. Data collection and analysis Two authors of the review independently selected
the potentially eligible trials; then the quality of the trials was assessed using a scale of 10
items. When possible, the data were grouped. Main results Twelve trials were included with
844 participants. A trial tested two comparisons. Authors' conclusions The treatment
open surgical treatment of acute Achilles tendon ruptures significantly reduces the risk of
reappearance compared to non-surgical treatment, but it poses significantly risks.
greater complications, including wound infection. The latter can be reduced by the
performance of percutaneous surgery.
Treatment for Achilles tendon rupture varies from management
conservative with the foot in a plantar flexed position for 8 to 12
weeks to open the administration with primary repair and preservation of the
tenosynovitis and includes percutaneous repair through small incisions and
open repair with or without increase. A meta-analysis of 12 random trials
a higher incidence of re-rupture was observed with non-surgical treatment
(13% compared to 3.1%). However, the complications, particularly the
infection, were greater in the surgical group, with a percutaneous repair
which provided less risk of infection than the open treatment. The
nervous injuries have been reported more frequently with techniques
percutaneous. Better results have been observed with functional treatment
early after the repair. In the final analysis, a good one can be obtained
result with closed treatment, assuming that a new one does not occur
rupture (7% in a series). Careful rehabilitation can minimize the risk
of a new rupture. Surgical treatment offers a lower possibility of
reappearance but at the cost of complications like an infection.
The surgical technique must include an incision in the posteromedial [Link] of one in
the midline, which could be associated with problems of shoe wear, as well as
skin detachments. The paratenon should be preserved and repaired, if possible, to
avoid adhesions between the skin and the tendon repair. The ends of the tendons
they come closer again with appropriate suturing techniques in the manner of Bunnell or
Kessler. The loose ends of the tendon can be sutured in bundles before going back.
connect. The plantar tendon can be used to enhance primary repair if not
It seems strong enough. An alternative technique is based on a suture placed
percutaneously through the ends of the tendons, which are not exposed in a
effort to avoid skin complications (a problem with repairs
open). After primary repair or augmentation, options include the
immobilization of the short leg for 6 to 8 weeks, followed by the use of a
heel lift to protect the repair for 6 weeks
additional. An early range of motion protocol can also be used, with
an early recovery possibility for the athletic population.
Late repairs of neglected Achilles tendon ruptures can
increased with a rejection of the gastrocnemius fascia, a strip of fascia lata, the tendon
plant or the long flexor of the big toe.
 Pearls and Considerations
••
Patients experiencing Achilles tendon ruptures may present with or without pain.
and they can still maintain their ability to wander or flex their ankles. If there is pain, then
General occurs 2 to 6 cm proximal to the insertion of the Achilles tendon in the calcaneus.
••
When evaluating Achilles tendinopathy, palpate the course of the Achilles tendon carefully.
pay special attention to any edema, bruising, or palpable sinking or discontinuity of the tendon.
••
A positive Thompson test is an accurate means to assess tendon ruptures.
Achilles.
••
Acute ruptures of the Achilles tendon must be treated within 14 days.
it has been demonstrated that surgical intervention reduces rupture rates compared to
non-surgical treatment options.
Thank you..