INTRODUCTION

This Wiki Page provides an overview of the elements associated with Achilles Tendon Rupture. It is intended to be a quick resource that can be utilized in a clinical setting.
Problems that affect the Achilles tendon are common among active, middle-aged people. These problems cause pain at the back of the calf. Severe cases may result in a rupture of the Achilles tendon.


Biomechanics/Anatomy

The Achilles tendon, or tendon calcaneus, is a large rope-like band of fibrous tissue in the back of the ankle that connects the powerful calf muscles to the heel bone (calcaneus). Sometimes called the heel cord, it is the largest tendon in the human body. When the muscles of the calf contract, the Achilles tendon is tightened, pulling the heel. This allows you to point your foot and stand on tiptoe (plantarflexion of the ankle). It is vital to such activities as walking, running, and jumping. A complete tear through the tendon, which usually occurs about 2 inches above the heel bone, is called an Achilles tendon rupture.
Picture of the metatarsal (foot) and calcaneus (heel) bones, the plantar fascia ligament, and the Achilles tendon of the lower leg and foot
Picture of the metatarsal (foot) and calcaneus (heel) bones, the plantar fascia ligament, and the Achilles tendon of the lower leg and foot



Mechanism of Injury

external image mcdc7_achillesrupture.jpg
  • sudden acceleration
  • fast contraction of the muscles

  • more suceptible with
    • overuse
    • significantly increasing workout routine
    • not beginning exercise with stretching
    • frquently wearing high heels
    • men over 30
    • athletes especially sprinters and divers


SIGNS and SYMPTOMS


Practical Presentation

Most people who have an Achilles tendon rupture will experience a combination of the following symptoms:
  • Snapping or popping sound at the time of injury
  • Pain and swelling around the injured heel
  • Inability to bend the injured foot downward; this will also affect the terminal stance phase of the gait cycle
  • Inability to perform a heel raise on the injured foot
  • Positive Thompson test


external image achilles-tendon-rupture.jpg



One man's progress detailed in his blog.
http://achillesblog.com/tomtom/exercise/

TREATMENT APPROACH/INTERVENTION

Achilles tendon ruptures are best managed acutely to decrease the likelihood of more permanent deficits. A neglected injury to the calcaneal tendon eliminates conservative treatment as an option for all but the poorest surgical candidates. Surgery, meanwhile has not been shown to return all strength and ROM to the ankle joint. One study described the deficits of patients 10 years after they received the surgical intervention and subsequent 6-week immobilization and found that the gastrocnemius and soleus were less active on EMG for plantarflexion activities and more active during dorsiflexion. Power metrics as well as ROM were also decreased in the surgical ankle compared to the non-surgical ankle. Evidence exists that individuals receiving the surgical intervention are three or four times less likely to rerupture the tendon, though complications of the surgery have been shown to increase the risk of contracture, infection, and nerve damage. Strength and endurance gains have been shown to occur earlier after surgery versus conservative treatment, but these differences were no longer seen at 12 months after injury.



Duration-how long would you typically see this patient?

2-3x per week for 8-12 weeks after cast has been removed. Taper to once per week and eventually every other week. HEP should be performed for up to a year.

Protocols

Achilles Tendon Rupture / Repair Protocol

PHASE I: (0-2 WEEKS)
  • NWB with assistive device x 2 weeks
  • Immobilization in splint
PHASE II: (2-6 weeks)
  • 50 % WB with ROM walker boot
  • Active dorsiflexion, passive plantarflexion, ankle ROM
PHASE III: 6-12 weeks
  • FWB at 6 weeks if incision healed
  • Begin PT at 6 weeks for strengthening
PHASE IV: 12-16 weeks
  • ROM/stretching Achilles as needed, other LE muscles
  • Gait: Ensure good gait pattern: heel-toe gait, good heel strike and push-off, stance time equal left to right
  • SLB activities (eyes open/closed, head nods, arm movement)
  • Progress to multiple planes
  • Ankle theraband
  • Begin functional strengthening exercises
  • Leg press - bilateral
  • Leg press toes raises (bilateral, progress to unilateral)
  • Progress to WB bilateral toe raises
  • Proprioception activities – i.e. BAPS, balance board
  • Hip and knee PRE’s
  • Soft tissue and joint mobs as needed
  • Stairmaster, bike for cardio
  • Ice as needed
  • Criteria to progress: Good gait mechanics
  • ROM equal to opposite side
  • Controlled inflammation
  • No pain
  • Plantarflexor strength 4/5 (perform 10 partial to full toes raises)
PHASE V: 16-20 weeks
  • Progress previous exercises: hip and knee PRE’s
  • Progress to WB unilateral heel raises
  • Stairmaster
  • Isokinetics for ankle (inv/ev, dors/pltf) – optional
  • Begin jumping progression: leg press, min-tramp, ground)
  • Functional rehab
  • Forward dips multiple plane for balance
  • Begin light plyos
  • Criteria to progress: ROM equal to opposite side
  • Perform 20 unilateral toes raises (full range, pain-free)
  • Perform bilateral jumping in place 30 seconds each F/B, L/R with good technique
PHASE VI: 5-6 months post-op
  • Progress previous exercises
  • Progress jumping to hopping
  • Begin jogging/running when hopping is performed with good technique
  • Sport specific drills for appropriate patients
  • Criteria to discharge non-athletes:
  • Good gait pattern
  • ADL’s without difficulty
  • Gastroc/soleus 4+ - 5/5 strength
  • Criteria to discharge athletes:
  • Good gait pattern
  • Patient performs the following tests within 80% of the uninvolved leg:
  • Hop for distance
  • Single leg balance reach
  • Isokinetic strength test
  • Maintenance program should stress continued strength and endurance work at least 2-3 times per week.

For a more accelerated treatment approach to Achilles Tendon Rupture Protocol visit:
http://www.muhealth.org/documents/Ortho/Sports/Marberry/1Achilles_Tendon_Repair_Rehab.pdf

Exercises

  • ROM- ABC’s, ROM all planes
  • Calf/ Achilles stretching
    • progression
  • Scar massage
  • Isometrics
  • Walking
  • TB all planes
  • Leg press
  • Toe raises
  • BAPS board
  • Balance work
  • Jump/ plyometric work
  • Running
external image proStretch_one_leg.jpg external image Towel_stretch.gifexternal image Stretch_the_calf_muscle.gif


  • Many of these exercises can also be performed through aquatic therapy





Modalities

  • In clinically suspected acute Achilles tendon rupture, ultrasound is a useful imaging modality which may confirm the diagnosis and distinguish between complete ruptures and partial tears. Ultrasound may help determine whether surgical or conservative treatment is most appropriate, and, where surgery is contemplated, allow optimal surgical planning.
  • Ice, whirlpool, and massage may be used to decrease pain and inflammation while massage and ultrasound can help promote healing and strengthening.


  • 3 days - 2 weeks
    • E-stim/biofeedback as needed
    • Soft tissue treatments
    • Cryotherapy
  • 2 weeks - 8 weeks
    • Proprioception exercises
    • Intrinsic muscle strengthening
    • Proprioceptive Neuromuscular Facilitation (PNF) - (not to Achilles Tendon)
    • Continue soft tissue treatment

Adjunct Treatment and/or Alternative Treatment

  • Conservative/alternative treatment
    • One study has shown using an articulated dynamic ankle brace, as opposed to a rigid brace or surgical intervention, for eight weeks after the injury resulted in good functional outcomes. The dynamic brace allowed varying degrees of plantar flexion, which was changed according to how many weeks the patient was into the treatment protocol. The patients also participated in physical therapy, starting two weeks after the injury and continuing for up to three months.
  • Prevention
    • The following tips can be used to help reduce your chance of suffering an Achilles tendon rupture:
      • Carefully choose running surfaces
        • Avoid/limit running on hard or slippery surfaces
      • Strengthen and stretch calf muscles
        • Strengthening exercises can help the tendon and muscle absorb more force, helping to prevent injury
      • Vary your exercises
        • High-impact sports should be alternated with low-impact sports
      • Slowly increased training intensity
        • Since injuries to the Achilles tendon often occur when training intensity is abruptly increased, intensity should be increased by no greater than 10% each week.

Overview Video:



References:

Anderson, K., (2004). Achilles Tendon Rupture / Repair Protocol. William Beaumont Hospital.
Horstmann T, Lukas C, Merk J, Brauner T, Mundermann A. Deficits 10-Years after Achilles Tendon Repair. Int J Sports Med. Apr 12 2012.
Bevilacqua NJ. Treatment of the neglected achilles tendon rupture. Clin Podiatr Med Surg. Apr 2012;29(2):291-299.
Donaldson PR. Surgical versus nonsurgical treatment of acute Achilles tendon rupture. Clin J Sport Med. Mar 2012;22(2):169-170.
(2011, Sep 23). Achilles tendon rupture. Retrieved from
http://www.mayoclinic.com/health/achilles-tendon-rupture/DS00160/DSECTION=symptoms
Neumayer F, Mouhsine E, Arlettaz Y, Gremion G, Wettstein M, Crevoisier X. A new conservative-dynamic treatment for the acute ruptured Achilles tendon. Arch Orthop Trauma Surg. Mar 2010;130(3):363-368.
(2012). "What is an Achilles Tendon Rupture." Achilles Tendon Rupture. Retrieved from: Web. 16 Apr. 2012. <http://www.achillestendonrupture.org/>.
Nannini, C. C. (2012). Achilles Tendon Rupture: Overview. Retrieved from http://www.emedicinehealth.com/achilles_tendon_rupture/article_em.htm#Achilles Tendon Rupture Overview
Spann, S., et al. (2012). Achilles Tendon Repair Rehabilitation Protocol. Westlake Orthopaedics Spine & Sports.
Achilles Tendon Repair Rehabilitation Protocol Missouri Sports Medicine University of Missouri-Columbia
Elias, D., & McKinnon, E. (2012). The role of ultrasound imaging in acute rupture of the Achilles tendon. Royal Society of Medicine Press Ltd. 19-2 (70-75).