Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

Featured on Channel NewsAsia

Achilles Tendon Rupture

SYMPTOMS

A sharp sudden pain in the Achilles tendon during activity, often recognised by the patient and people around as a loud snap, followed by the inability to continue. Often the patient believes somebody has hit them over the calf. It is most common in middle-aged recreational athletes in impact sports such as badminton or soccer.

AETIOLOGY

This is a complete rupture of the Achilles tendon, two to six centimetres proximal to the distal insertion. In most cases the tendon is not healthy before the rupture but suffers from tendinosis changes (see Achilles tendinosis).

CLINICAL FINDINGS

There is local tenderness on palpation over the tendon, swelling/bruising, a palpable gap in the tendon and a positive squeeze test often referred to as Thomson’s or Simmond’s test. The patient lies prone with the ankle outside the stretcher. Squeeze the calf muscle; normally, the ankle should plantar flex but if the tendon is ruptured nothing will happen. To confirm the diagnosis, add resistance to an active plantar flexion. The injured patient will not be able to apply any force. Compare to the other side. Note that an active plantar flexion can be achieved by plantaris longus, despite a complete Achilles tendon rupture. However, on adding an active toe raise, the diagnosis is clear since the injured athlete is unable to stand up on their toes, due to weakness.

INVESTIGATIONS

Ultrasound or MRI will show the bleeding and rupture but often underestimate the extent of the injury. With the history and signs above this is always a complete rupture even though some fibres may look intact.

TREATMENT

In the acute phase RICE is advocated. Surgery with anatomical reconstruction is recommended for sporting people, due to lower morbidity and an earlier return to sport. Surgery is followed by a few weeks’ partial immobilisation and rehabilitation before resuming sport. Early weightbearing is allowed, if protected by an ankle brace.

Non-surgical treatment, with eight to twelve weeks cast or brace treatment, can be sufficient for less active people or others with ailments contraindicating surgery. The risk of re-rupture is higher for non-operated cases.

REFERRALS

Refer to Dr Kevin Yip, orthopaedic surgeon for consideration of surgery. Refer to physiotherapist for planning of a three to six months’ gradual return programme.

EXERCISE PRESCRIPTION

Cycling and swimming (when the wound is healed) are good alternatives to keep up general fitness.

EVALUATION OF TREATMENT OUTCOMES

Monitor clinical symptoms and signs. The tendon will remain thicker than normal after complete healing. Calf muscle strength should be similar to the other side. Objective tests with resisted toe raises are strongly suggested before resuming sport.

DIFFERENTIAL DIAGNOSES

With the typical history and clinical findings above, the diagnosis should be clear. Despite this, many of these injuries are missed in clinical practice.

PROGNOSIS

Excellent-Good. Fewer than 3-4 per cent of injured athletes complain of persistent symptoms or re-rupture after surgery but in the non-operated group this figure is higher.

Leave a Reply

You can use these HTML tags

<a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <s> <strike> <strong>