Achilles Tendon Rupture – Diagnosis, Treatment and Pilate’s for Rehabilitation

The Achilles tendon is the confluence of the independent tendons of the gastrocnemius and soleus, which fuse to achilles_backandsideviewbecome the Achilles tendon
approximately 5 to 6 cm proximal to its insertion on the posterior surface of the calcaneus.
The gastrocnemius and soleus muscles, via the Achilles tendon, function as the chief plantarflexors of the ankle joint. This musculotendinous unit provides the primary propulsive force for walking, running, and jumping. The normal Achilles tendon can withstand repetitive loads near its ultimate tensile strength, which approach 6 to 8 times body weight [1].

Complete Achilles tendon ruptures occur most commonly at the mid-substance, but also distally at the insertion site or proximally at the myotendinous junction. These can be traumatic and devastating injuries, resulting in significant pain, disability, and healthcare cost. As many as 2.5 million individuals sustain Achilles tendon ruptures each year and the incidence is rising [2]. This trend is due, in part, to an increase in athletic participation across individuals of all ages.

Achilles tendon rupture is when the achilles tendon breaks. The achilles is the most commonly injured tendon. achilles_tendon_ruptureRupture can occur while performing actions requiring explosive acceleration, such as pushing off or jumping. For a 150 lb person the amount of muscle force that would have to be generated to rupture the Achilles (excluding external trauma forces) would be 900 – 1200 lbs. The male to female ratio for Achilles tendon rupture varies between 7:1 and 4:1 across various studies.

The Achilles tendon is most commonly injured by sudden plantarflexion or dorsiflexion of the ankle, or by forced  dorsiflexion of the ankle outside its normal range of motion. Other mechanisms by which the Achilles can be torn involve sudden direct trauma to the tendon.  Some other common tears can occur from overuse while participating in intense sports. Twisting or jerking motions can also contribute to injury.

Most cases of Achilles tendon rupture are traumatic sports injuries. The average age of patients is 29–49 years with a male-to-female ratio of nearly 20:1.

Diagnosis is made by clinical history; typically people say it feels like being kicked or shot behind the ankle. Upon examination a gap may be felt just above the heel unless swelling has filled the gap. Walking will usually be severely impaired, as the patient will be unable to step off the ground using the injured leg. The patient will also be unable to stand up on the toes of that leg, and pointing the foot downward (plantarflexion) will be impaired. Pain may be severe, and swelling is common.  Sometimes an ultrasound scan may be required to clarify or confirm the diagnosis. MRI can also be used to confirm the diagnosis.

Treatment options for an Achilles tendon rupture include surgical and non-surgical approaches. Among the medical profession opinions are divided what is to be preferred.

Non-surgical management traditionally consisted of restriction in a plaster cast for six to eight weeks with the foot pointed downwards (to oppose the ends of the ruptured tendon). But recent studies have produced superior results with much more rapid rehabilitation in fixed or hinged boots. Some surgeons feel an early surgical repair of the tendon is beneficial. The surgical option was long thought to offer a significantly smaller risk of re-rupture compared to traditional non-operative management (5% vs 15%).[3]

Non-surgical treatment used to involve very long periods in a series of casts, and took longer to complete than surgical treatment. But both surgical and non-surgical rehabilitation protocols have recently become quicker, shorter, more aggressive, and more successful. It used to be that patients who underwent surgery would wear a cast for approximately 4 to 8 weeks after surgery and were only allowed to gently move the ankle once out of the cast. Recent studies have shown that patients have quicker and more successful recoveries when they are allowed to move and lightly stretch their ankle immediately after surgery. To keep their ankle safe these patients use a removable boot while walking and doing daily activities. Modern studies including non-surgical patients generally limit non-weight-bearing (NWB) to two weeks, and use modern removable boots, either fixed or hinged, rather than casts. Physiotherapy is often begun as early as two weeks following the start of either kind of treatment.

The relative benefits of surgical and nonsurgical treatments remain a subject of debate; authors of studies are cautious about the preferred treatment.[4]  It should be noted that in centers that do not have early range of motion rehabilitation available, surgical repair is preferred to decrease re-rupture rates.[5]

Rehabilitation: There are three things that need to be kept in mind while rehabilitating a ruptured Achilles: range of motion, functional strength, and sometimes orthotic support. Range of motion is important because it takes into mind the tightness of the repaired tendon. When beginning rehab a patient should perform stretches lightly and increase the intensity as time and pain permits. Putting linear stress on the tendon is important because it stimulates connective tissue repair.  Doing stretches to gain functional strength are also important because it improves healing in the tendon, which will in turn lead to a quicker return to activities. These stretches should be more intense and should involve some sort of weight bearing, which helps reorient and strengthen the collagen fibers in the injured ankle. Such as the toe raise on an elevated surface; the patient pushes up onto the toes and lowers his or her self as far down as possible or better yet, foot work on the Pilate’s reformer.

The other part of the rehab process is proper alignment of the foot.  This can be achieved with orthotic support or with Pilate’s reformer footwork training. This doesn’t have anything to do with stretching or strengthening the tendon, rather it is to keep the patient comfortable and place them in as proper alignment as possible. Custom made shoe inserts can be made to help maintain proper pronation of the foot.  If ankle and foot alignment are compromised, it can lead to further problems with the Achilles.

To briefly summarize the steps of rehabilitating a ruptured Achilles tendon, you should begin with range of motion type stretching. This will allow the ankle to get used to moving again and get ready for weight bearing activities. Then there is functional strength, this is where weight bearing should begin in order to start strengthening the tendon in proper alignment and getting it ready to perform daily activities and eventually in athletic situations.[6] [7]

 

Original articles adapted from Soslowsky Laboratory projects, Perelman School of Medicine and
Wikipedia, the free encyclopedia

 

References:

[1] Allenmark, C. (1992). “Partial Achilles tendon tears.” Clinics in sports medicine 11(4): 759-769.
[2] Suchak, A. A., G. Bostick, et al. (2005). “The incidence of Achilles tendon ruptures in Edmonton, Canada.”Foot & ankle international / American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society26(11): 932-936.
[3] Richter J, Josten C, Dàvid A, Clasbrummel B, Muhr G (1994). “[Sports fitness after functional conservative versus surgical treatment of acute Achilles tendon ruptures]”. Zentralbl Chir (in German) 119 (8): 538–44.

[4] Nilsson-Helander K, Silbernagel KG, Thomeé R, et al. (November 2010). “Acute achilles tendon rupture: a randomized, controlled study comparing surgical and nonsurgical treatments using validated outcome measures”. The American Journal of Sports Medicine 38 (11): 2186–3.

[5] Jump Up Soroceanu A, Sidhwa F, Aarabi S, Kaufman A, Glazebrook M (December 2012). “Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials”The Journal of Bone and Joint Surgery. American Volume 94 (23): 2136–43.doi:10.2106/JBJS.K.00917.

[6] Cluett, J. (2007, April 29). Achilles Tendon Rupture: What is an Achilles Tendon Rupture. Retrieved May 6, 2010, fromhttp://orthopedics.about.com/cs/ankleproblems/a/achilles_3.htm

[7] Jump Up Christensen, K.D. (2008). Rehab of the Achilles Tendon. Retrieved May 6, 2010, from http://www.ccptr.org/articles/rehab-of-the-achilles-tendon/.htm

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s