Achilles Rupture

Normal Anatomy Origin- the mid calf Insertion – posterior aspect of calcaneus Made up of soleus AND gastrocnemius Made from water (approximately 80%) collagen, ground substance and elastin Large amount of Type I Collagen in an organised structure Type 1 collagen provides good tensile strength (pulling force)

Pathology Tear of the Achilles tendon Degenerative Theory Tendon structure changes Increase in elastin Decreases tensile strength Mechanical Theory Violent muscle contraction Exceeds the limit of the tendon

Mechanism of Injury Traumatic Forced ankle dorsiflexion Eccentric contraction of Achilles tendon Push off phase of running with knee extended

Subjective Examination Sporting history with sudden starting and stopping (tennis, basketball, badminton) Traumatic dorsiflexion or eccentric contraction Traumatic push off phase of running Sensation of being kicking or shot in back of heel Popping sensation or sound Inability to weight bear Push off during walking absent Initially painful which may subside over a period of time

Objective Examination Weakness plantarflexion Visible defect of tendon with swelling Loss of resting plantarflexion Palpable gap

Special Test Thompsons Test

Further Investigation US Scan MRI

Management Conservative management considered in those less active or high risk factors for infection following surgery Ideally started ASAP following rupture Overall rehab programme approximately 7 – 8 months Rehab programmes for conservative and non-conservative management consultant led See (Thevendran, Sarraf et al. 2013) for more details

Conservative Reduce pain, inflammation and protect healing Equinius cast to allow healing of the tendon for approximately 4 weeks then removable brace for 2 weeks NSAID’s Ice Massage Restore Normal Range of Movement Knee, Hip (avoid stretching the calf) Joint mobilisations Joint manipulations stretches Restore Normal Muscle Activation Isometrics in pain free range Maintain strength of knee, hip, lumbopelvic spine Restore Dynamic Stability (once normal ROM achieved) Proprioceptive training Sport specific training

Plan B Surgical repair using a variety of different techniques and grafts

References Barfod, K. W. (2014). "Achilles tendon rupture; assessment of nonoperative treatment." Dan Med J 61(4): B4837. Freedman, B. R., J. A. Gordon and L. J. Soslowsky (2014). "The Achilles tendon: fundamental properties and mechanisms governing healing." Muscles Ligaments Tendons J 4(2): 245-255. Gulati, V., M. Jaggard, S. S. Al-Nammari, C. Uzoigwe, P. Gulati, N. Ismail, C. Gibbons and C. Gupte (2015). "Management of achilles tendon injury: A current concepts systematic review." World Journal of Orthopedics 6(4). Stavrou, M., A. Seraphim, N. Al-Hadithy and S. C. Mordecai (2013). "Review article: Treatment for Achilles tendon ruptures in athletes." J Orthop Surg (Hong Kong) 21(2): 232-235. Thevendran, G., K. M. Sarraf, N. K. Patel, A. Sadri and P. Rosenfeld (2013). "The ruptured Achilles tendon: a current overview from biology of rupture to treatment." Musculoskelet Surg 97(1): 9-20.