Achilles Tendonitis and Rupture

Inflammation of the tendon, usually resulting from overuse associated with a change in playing surface, footwear or intensity of an activity.

Epidemiology

• Achilles tendonitis is often seen in sports that involve jumping.
• Other risk factors include participation in a new sporting activity or increasing the intensity of participation, or new or unsuitable footwear.
• Injury is observed more often in runners, gymnasts and cyclists.
• In cyclists, the problem may be a low saddle, which causes extra dorsiflexion of the ankle when pedalling.
• Quinolone antibiotics (e.g. ciprofloxacin, ofloxacin) can cause inflammation of tendons and predispose them to rupture.

Presentation

• The area of tenderness is from 2-5 cm above the calcaneus and nodules may be palpable
• There is often also crepitation and increased pain with passive ankle plantar flexion and dorsiflexion
• Sometimes it is associated with posterior heel pain

Investigations

Ultrasound or MRI may be necessary to differentiate tendonitis from a partial tendon rupture.

Management

• There is insufficient evidence from randomised controlled trials to determine which method of treatment is the most appropriate for the treatment of acute or chronic Achilles tendinitis.¹
• The patient should abstain from aggravating activities but with a minimum of rest in order to preserve overall fitness.
• Other beneficial interventions are physiotherapy and orthotic therapy with heel lifts, which are used on both sides to prevent a gait imbalance.
• Casting is an option for resistant Achilles tendonitis.
• Drugs: analgesics and non-steroidal anti-inflammatory drugs.
• Surgery is sometimes used for resistant Achilles tendonitis but usually as a last resort.

Achilles tendon rupture usually occurs at a point 4-5 cm above the calcaneus.

Epidemiology

Rupture can occur at any age but most often occurs in 30-50 year old recreational athletes and is commonly seen in football, running, basketball, diving, tennis, and other sports that require a forceful push off with the foot. Other risk factors include:

• Chronic recurrent Achilles tendonitis
• Systemic conditions, e.g. gout or hyperparathyroidism
• Previous steroid injections into or around the Achilles tendon
• Quinolone antibiotics

Presentation

• Acute onset of pain in tendon.
• There may also be a history of less intense pain for several days before rupture.
• There is usually obvious localised leg swelling with a palpable defect in the Achilles tendon.
• Active plantar flexion is weak or absent.
• The Thompson test is performed with the patient lying prone with the knee passively flexed. Absence of normal plantar flexion on squeezing the calf muscle is a positive test.

Differential Diagnosis

• Achilles tendonitis
• Partial Achilles tendon rupture
• Other ankle injuries
• Ankle osteoarthritis
• Ruptured Baker's cyst
• Deep vein thrombosis

Investigations

Imaging studies (x-ray, ultrasound, MRI) can be helpful in confirming the diagnosis.

Management

Urgent referral to an Orthopaedic Specialist for assessment.

• Surgery is recommended for competitive athletes and others with a high level of physical activity, or if there has been a delay in treatment or diagnosis, and for those with a recurrent rupture. It has lower rates of recurrence.²
• Conservative management may be indicated in older patients with minimally displaced ruptures.
• Conservative management consists of rest, pain control, serial casting (initially "equinus" position), and physiotherapy. Crutches are initially required in order to avoid weight bearing.

Complications

• Achilles tendon contracture and/or scarring may occur from excessive immobility
• Re-rupture occurs in 3.1% of patients undergoing surgery compared with 13% treated conservatively.²

Prognosis

• Achilles tendon injury has an excellent prognosis but the slight loss of function may be very significant for the competitive athlete.
• Open operative treatment of acute Achilles tendon ruptures significantly reduces the risk of rerupture compared to non-operative treatment, but produces a significantly higher risk of other complications, including wound infection.³
• Athletes should not expect to resume full activities for one year.