Achilles Tendonitis and Rupture

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

The Achilles tendon is surrounded by a connective tissue sheath (paratenon or paratendon), rather than a true synovial sheath. The paratenon stretches with movement, allowing maximum gliding action. Near the insertion of the tendon are 2 bursae, the subcutaneous calcaneal and the retrocalcaneal bursae.¹

Epidemiology and causes¹

• Achilles tendonitis occurs in sports such as running, jumping, dancing and tennis.
• Other risk factors include participation in a new sporting activity or increasing the intensity of participation.
• Poor running technique, excessive pronation of the foot and poorly fitting footwear may contribute.
• 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.

Presentation¹

• Gradual onset of pain and stiffness over the tendon, which may improve with heat or walking and worsen with strenuous activity.
• Tenderness of the tendon on palpation. There may also be crepitus and swelling.
• Pain on active movement of the ankle joint.
• Rupture of the tendon should be looked for (always do a Thompson test - below).

Investigations

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

Management¹

• 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 tendonitis.²
• The patient should abstain from aggravating activities, but with a minimum of rest in order to preserve overall fitness.
• Possible treatments are: NSAIDs, ice, rest, increased warm-up/stretching exercises, physiotherapy and heel lifts (orthotic devices - used on both sides to prevent a gait imbalance).
• Other treatments evaluated in a Cochrane review were: heparin, steroid injections, glycosaminoglycan sulfate, Actovegin, and topical laser treatment. There was no clear evidence of benefit from these.²
• 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.
• Other recently reported treatments include: continuing sports activity in conjunction with rehabilitation,³ low-energy shock wave therapy⁴ and topical glyceril trinitrate (GTN).⁵

Prognosis

Recovery usually takes weeks to months.¹

Epidemiology

• Rupture can occur at any age, but most often occurs in 30-50 year old recreational athletes. It is commonly seen in football, running, basketball, diving, tennis, and other sports that require a forceful push off with the foot.
• Other causes are:
  • Injury such as a fall, where there is forced dorsiflexion of the foot (producing a sudden stretch on the tendon)
  • Deep lacerations over the site of the tendon

Risk factors include:¹

• Increasing age
• Chronic/recurrent Achilles tendonitis
• Steroids:
  • Systemic corticosteroids (prolonged or high doses) or Cushing's syndrome
  • Previous steroid injections into or around the Achilles tendon
• Systemic conditions, e.g. gout, rheumatoid arthritis, SLE
• Quinolone antibiotics (mainly if over 60 and/or also taking steroids)⁶

Presentation

The diagnosis may not be obvious initially, and can be missed.¹ It is important to actively look for features of tendon rupture, to do a Thompson test (below) and to refer if rupture is suspected (because early treatment is beneficial).

History

• Acute onset of pain in tendon, felt as a sudden, sharp pain initially. Sometimes a 'snap' is heard as the tendon ruptures. The pain then settles into a dull ache.
• There may also be a history of less intense pain for several days before rupture.
• Patients may notice inability to stand on tiptoe, and altered gait (unable to 'push off' with the affected foot).

Examination

Differential diagnosis

• Achilles tendonitis
• Retrocalcaneal bursitis
• Other ankle injuries
• Ankle osteoarthritis
• Ruptured Baker's cyst
• Deep vein thrombosis

Investigations

Ultrasound or MRI may help if the diagnosis is unclear (for example, to distinguish partial rupture from tendonitis).

Management

• Non-weightbearing as soon as rupture is suspected.
• Urgent referral to an orthopaedic specialist for assessment.
• Treatment options:
  • Surgery may be recommended for: competitive athletes and others with a high level of physical activity; if there has been a delay in treatment or diagnosis; and for those with a recurrent rupture. It has lower rates of recurrence.⁷ A splint or cast is required after surgery.
  • Conservative management is an option, especially for older or less athletic patients. This consists of rest, pain control, serial casting or splinting (initially "equinus" position), and physiotherapy. Crutches are initially required in order to avoid weight bearing.
  • There are different approaches to rehabilitation. With both surgery and conservative treatment, a period of non-weightbearing and a brace (orthosis) or cast will be required. The use of a brace rather than a cast may reduce complications.⁸ There seems to be a trend towards earlier weightbearing,⁹ or early mobilisation using a removable orthosis,¹⁰ with some good results.

Complications

• Achilles tendon contracture and/or scarring may occur from excessive immobility.
• Re-rupture can occur. Traditionally, it was found that re-rupture rates were lower with surgery rather than conservative treatment.^7,8,11 However, one study found similar rates for both, when patients were also given 'early mobilisation' treatment.¹⁰

Prognosis

• Achilles tendon injury has a good prognosis, but the slight loss of function may be very significant for the competitive athlete.
• Surgical treatment of acute Achilles tendon ruptures significantly reduces the risk of re-rupture compared to non-operative treatment, but has a higher risk of other complications, including wound infection.^8,11
• Athletes may be unable to resume full activities for one year.