REBEL Core Cast 116.0 – Achilles Tendon Rupture

REBEL EM – Emergency Medicine Blog

Take Home Points

• Achilles tendon rupture is a clinical diagnosis. The Thompson Test should be applied in all suspected cases.
• Remember to brace or splint a rupture, even if suspected, in the resting equinus position for optimal healing and prevention of further injury.
• Schedule follow up with orthopedics within 1 week for discussion of operative management vs early rehab protocols.

REBEL Core Cast 116.0 – Achilles Tendon Rupture

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Achilles Tendon Rupture Exam (www.lfaclinic.co.uk)

Physical Exam

• May have palpable gap or deformity in region of tendon.
• Weakness with plantar flexion.
• Increased resting ankle dorsiflexion on affected side in prone position with knees bent .
• Usually in absence of bony tenderness unless accompanied by other injury
• Thompson Test (video)
  • Place the patient in the prone position, with feet hanging over the end of a stretcher or table. If patient is not able to lay down/there are no stretchers, the patient can kneel on a stool or chair
  • Squeeze the calf of the normal limb. You will notice the squeeze will cause the ankle to plantarflex appropriately
  • Squeeze the calf of the limb with the suspected Achilles tendon rupture. You will notice the squeeze will cause no motion if there is a full rupture/tear, and diminished motion if there is a partial tear
  • Performance Characteristics (Garras 2012)

Sensitivity	Specificity	(+) LR	(-) LR
96-100%	93-100%	13.7	0.04

Imaging

• X-Rays
  • Used to rule out other or concurrent pathology
  • May show soft tissue swelling and destruction of pre-Achilles fat pad (Kager’s Fat Pad)
  • Findings are non-specific as tear of tendon unable to be visualized

• Ultrasound
  • Ultrasound is helpful if obvious findings present and to distinguish between partial vs complete tears, however only around 50% sensitive for detecting only partial tears (Kayser 2005)
• MRI
  • Gold-standard imaging modality
  • Rarely, if ever, necessary in the ED
  • Used for equivocal physical exam/alternate imaging findings or for assessing the severity of the tear for possible operative management
  • Findings
    • A full-thickness tear often shows a tendinous gap filled with edema or blood
    • Complete rupture shows retraction of tendon ends

ED Management

• • Provide analgesia
  • Tendon stabilization in an optimal healing position
    • Functional bracing/splinting in resting equinus/talipus equinus
    • AO splint/brace in 20 degrees of plantar flexion for 4-6 weeks (may use tall CAM boot with 20 degrees wedge inserts)
    • All patients should be non-weightbearing
      • Any weight-bearing can convert a partial tear to a complete tear
      • Maintain non-weightbearing status until see orthopedics (within 1 week)
      • After evaluation by orthopedics, early weight-bearing and early ROM exercises yield better outcomes (can be as early as 2 weeks)
• Referral to rehab warranted to improve plantar flexion and decrease risk of re-rupture
  • ED Ortho consultation: patients with open wounds in the area of trauma, or with concomitant fractures
  • Operative Management is usually reserved for acute ruptures (approximately <6 weeks) of full thickness with large tendon gaps, failed conservative treatment of partial thickness tears, or high performance athletes
    • These cases will be determined during follow up with orthopedics and may warrant outpatient MRI to assess severity of tear

Prognosis

• • For conservative management, there is no significant difference in plantar flexion strength (Willits, 2010)
  • Some increased risk of re-rupture compared to operative management, although review of evidence shows that this may not be significant if patients used structured, accelerated rehab protocol.
    • Protocol includes initially non-weightbearing cast with the foot in equinus position as described above, then transitioned to a pneumatic walker with elevated heels (elevation gradually reduced biweekly), and physical therapy to improve gait, strength, and mobility. (Wallace 2011)
  • If addressed early and appropriately, most patients have good self-reported long-term outcomes regardless of the treatment modality

Links

Orthobullets: Achilles Tendon Rupture

Resources:

• Sheth U et al. The epidemiology and trends in management of acute Achilles tendon ruptures in Ontario, Canada: a population-based study of 27,607 patients. Bone Joint J. 2017; 99-B(1): 78-86. PMID: 28053261
• Chiodo CP, Wilson MG. Current Concepts Review: Acute Ruptures of the Achilles Tendon. Foot Ankle Int 2006; 27(4): 305-13. PMID: 16624224
• Leppilahti J, Orava S. Total Achilles tendon rupture. A review. Sports Med. 1998; 25(2): 79-100. PMID: 9519398
• Kayser R et al. Partial rupture of the proximal Achilles tendon: a differential diagnostic problem in ultrasound imaging. Br J Sports Med. 2005; 39(11): 838-42. PMID: 16244194
• Margetic P et al. Comparison of ultrasonographic and intraoperative findings in Achilles tendon rupture. Coll Antropol. 2007; 31:279-284. PMID: 17598414
• Garras DN et al. MRI is Unnecessary for Diagnosing Acute Achilles Tendon Ruptures: Clinical Diagnostic Criteria. Clin Orthop Relat Res 2012; 470(8): 2268-2273. PMID: 22538958
• Willits K et al. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation .J Bone Joint Surg Am. 2010; 92(17): 2767-75. PMID: 21037028
• Wallace RG et al. The non-operative functional management of patients with a rupture of the tendo Achillis leads to low rates of re-rupture. J Bone Joint Surg Br 2011; 93(10):1362-6. PMID: 21969435
• Erickson BJ. Is Operative Treatment of Achilles Tendon Ruptures Superior to Nonoperative Treatment? Orthop J Sports Med. 2015; 3(4): PMID: 26665055

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter/X: @srrezaie)

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