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Achilles Tendon Ruptures

The Achilles tendon is the single strongest tendon in the human body. The primary function of the Achilles tendon is to transmit the power of the calf to the foot resulting in the ability to move us forward, allow us to jump, dance; you name it. If it has to do with motion, the Achilles tendon is a part of that activity. Occasionally the Achilles tendon looses the ability to keep up with us and the tendon becomes inflamed resulting in Achilles tendonitis. This article discusses the onset, symptoms and treatment of Achilles tendonitis. Achilles tendon ruptures are also discussed.

 

Acute Achilles tendonitis

Acute Achilles tendonitis (also known as Albert's Disease) typically has a abrupt onset with moderate pain 2-3 cm proximal to the tendons' insertion on the back of the heel. Most individuals with acute Achilles tendonitis can describe an injury or single event that initiated the pain. Symptoms of acute Achilles tendonitis occur at the beginning of an activity and are typically described as a sharp pain. As the activity progresses, the pain decreases for a period of time. With excessive use, the tendon again becomes painful at the end of activity. For example, runners with Achilles tendonitis experience pain as they begin their run. The pain subsides during their run only to recur near the end of their normal running distance.

Chronic Achilles tendonitis

Chronic Achilles tendonitis exhibits the same type of pain as acute Achilles tendonitis but the location of the pain is usually at the insertion of the Achilles tendon into the heel. Chronic Achilles tendonitis can also cause hypertrophy (enlargement) of the posterior heel and in limited cases, enlargement of the tendon. This bony enlargement of the back of the heel goes by many names including retrocalcaneal bursitis, pump bump or Haglund's Deformity.

In cases of chronic Achilles tendonitis it's important to differentiate between pain strictly due to the Achilles tendon or from the enlargement of the heel rubbing against the shoe. The difference between Achilles tendonitis and a pump bump can easily be understood by evaluating the pain while barefoot (suggestive of Achilles tendonitis) compared to pain while wearing shoes with an enclosed heel (pump bump). It's not unusual to find both conditions simultaneously.

This picture shows the back of a right heel, the outside of the ankle and a few of the small toes. The red dotted line outlines the Achilles tendon. This is the area within the tendon where we are most likely to find an acute tear of the Achilles tendon or tendonitis. The red circle shows the area where the Achilles tendon inserts into the calcaneus and is the location of chronic Achilles tendonitis. This are will often become hypertrophied (enlarged) as the result of spurring that forms on the posterior heel at the insertion of the tendon. The red circle is also the area where we would find pain associated with retrocalcaneal bursitis. The blue area is on the outside, or lateral aspect of the heel. The blue area is where we would find the symptoms of Haglund's Deformity or a pump bump.

Treatment of acute and chronic Achilles tendonitis

Knowing that the single greatest contributor to acute and chronic Achilles tendonitis is equinus (see the biomechanics section below for more information on equinus), we know that we need to weaken the calf muscle to allow the Achilles tendon an opportunity to heal. This can be done by elevating the heel with heel lifts or by high heel shoes. Inflammation of the tendon can be calmed by ice, both before and after activities. Anti-inflammatory medications, casting or ultrasound treatment can also be used. Steroid injections are typically not used to treat Achilles tendonitis since injecting the tendon has a tendency to weaken the tendon resulting in a possible rupture.

Manipulation techniques are also helpful to increase the range of motion of the ankle. One new technique involves manipulation of the fibula (smaller outer bone of the ankle and leg) to allow greater excursion of the talus (foot bone of the ankle). This technique must be performed by someone other than the patient and is performed as follows;

1. The patient is placed in a sitting position with the hip and knee flexed. Standing on the side of the chair opposite to the leg that will be manipulated, place the index and middle fingers of both hands over the head of the fibula (That's just below the knee on the outside of the leg). Using a firm and rapid motion, manipulate the head of the fibula anteriorly (towards the front of the leg). A slight shift or pop may or may not be noted.

2. Next, with the patient sitting and the hip and knee extended (straight) place traction on the foot with the ankle slightly plantar flexed (toes pointing down and away from the leg). Continue traction for 30-45 seconds. Then dorsiflex the ankle (move the foot/toes towards the shin). Complete a series of range of motion of the ankle with the patient.

3. Repeat as needed.

In cases of chronic Achilles tendonitis, patients who do not respond to heel lifts, manipulation and anti-inflammatory medications require a lengthening procedure of the Achilles tendon with or without a partial resection of the posterior heel. In cases with minimal hypertrophy of the heel, lengthening of the tendon will suffice. Lengthening of the Achilles tendon may be performed through three 0.5cm incisions but does require a period of casting. Full recovery may take 6-18 months.

Achilles Tendon Ruptures

Chronic Achilles tendonitis is not a symptom to be ignored based upon the knowledge that Achilles tendonitis is often a precursor to an Achilles tendon rupture. A rupture of the Achilles tendon can be a debilitating injury. The actual rupture of the tendon is described by most patients as feeling as if they were hit in the back of the leg. An audible pop is often described. Most ruptures occur 2-4cm proximal to the insertion of the tendon into the calcaneus (heel bone).

The repair of Achilles tendon ruptures may be conservative or surgical. Orthopedic and podiatric literature abounds with articles that compare the merits of conservative vs surgical care of Achilles tendon ruptures. Re-rupture of the tendon is not uncommon regardless of the method of correction although, statistically, re-rupture does seem to occur less in those patients that undergo surgical repair. These findings may also reflect the nature of patient that would be a surgical candidate. Typically we would assume that those patients that were in poor health (eg elderly, diabetic, immune compromised) would not become surgical candidates and therefore may contribute to the increased rate of re-rupture seen in those treated with conservative care.

Recent articles have advocated a surgical approach for repair of ruptured Achilles tendons that employs both an open and percutaneus technique of repair. The most popular method was described by M. Kakiuchi of The Osaka Police Hospital in 1995. This technique involves the use of an open procedure at the site of rupture to enable debridement of the ruptured tendon. Kakiuchi also employs a closed technique to suture the tendon to allow for proper healing.

 

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