Achilles tendon rupture is when the tear of the achilles is torn. Achilles are the most commonly injured tendons. Breaks can occur when performing actions that require explosive acceleration, such as pushing or jumping. Male and female ratios for Achilles tendon rupture vary between 7: 1 and 4: 1 in various studies.
Video Achilles tendon rupture
Cause
The Achilles tendon is most often injured by a sudden plantarflexion or dorsiflexion of the ankle, or with ankle dorsiflexion beyond the normal range of motion.
Another mechanism by which Achilles may tear involves sudden onset of trauma to the tendon, or sudden activation of Achilles after atrophy from a prolonged period of inactivity. Some other common tears can occur from excessive use while participating in intense sports. Movement twisting or jerking can also cause injury.
Antibiotics fluorokuinolon, the famous ciprofloxacin, is known to increase the risk of tendon rupture, especially Achilles.
People who are often victimized by rips or ruptures of Achilles include recreational athletes, parents, individuals with previous or broken Achilles tendon tears, previous tendon injection or quinolone use, extreme changes in training intensity or activity level, and participation in new activities..
Most cases of Achilles tendon rupture are a traumatic exercise injury. The median age of the patients was 29-40 years with a male-female ratio of nearly 20: 1. Antibiotics fluorokuinolone, such as ciprofloxacin, and glucocorticoids have been associated with an increased risk of Achilles tendon rupture. For Fluoroquinolone antibiotics, the risk of tendon rupture is 1: 1231 and 1:66 for Achilles tendinitis. Direct steroid injections into the tendon have also been associated with rupture.
The use of quinolones has been associated with Achilles tendonitis and Achilles tendon rupture for some time. Quinolone is an antibacterial agent that acts at the level of DNA by inhibiting DNA girase. DNA gyrase is an enzyme used to release double-stranded DNA that is essential for DNA replication. Quinolone specializes in the fact that it can attack bacterial DNA and prevent them from replicating with this process, and is often prescribed for the elderly. About 2% to 6% of all elderly people over the age of 60 who have had an Achilles rupture may be associated with the use of quinolones.
Maps Achilles tendon rupture
Anatomy
The Achilles tendon is the strongest and thickest tendon in the body, connecting the gastrocnemius, soleus and plantaris to the calcaneus. The length is about 15 cm (5.9 inches) and begins near the center of the calf. Contraction of plantar gastrosoleus flexs the legs, allowing activities such as walking, jumping, and running. The Achilles tendon receives its blood supply from the musculotendinous joint with triceps surae and its innervation from the sural nerve and to the lower level of the tibial nerve.
Diagnosis
Diagnosis is made based on clinical history; usually people say it feels like being kicked or shot behind the ankle. After the inspection the gap may be felt just above the heel unless the swelling has filled the gap and the Simmonds test (aka Thompson test) will be positive; squeezing the calf muscles from the affected side while the patient is lying on his stomach, facing down, with his legs hanging slack without motion (no passive plantarflexion) of the foot, while the movement is expected with the Achilles tendon intact and should be observed after the manipulation of the uninvolved calf. Walking will usually be very disturbed, because patients will not be able to get off the ground using an injured foot. The patient also will not be able to stand at the end of the foot, and pointing the foot down (plantarflexion) will be disrupted. Pain can be severe, and swelling is common.
Sometimes ultrasound scans may be needed to clarify or confirm the diagnosis and recommended on MRI. MRI is generally not necessary.
Imaging
Musculoskeletal ultrasonography can be used to determine tendon thickness, character, and the presence of tears. It works by sending very high sound frequencies throughout the body. Some of these sounds are reflected back from the space between interstitial fluid and soft tissue or bone. These reflected images can be analyzed and counted into an image. These images are captured in real time and can be very helpful in detecting tendon movement and visualizing the possibility of injury or tearing. This device makes it very easy to find structural damage to the soft tissues, and a consistent method to detect this type of injury. This imaging modality is not expensive, does not involve ionizing radiation and, in the hands of ultrasound experts, may be highly reliable.
MRI can be used to see imperfect rupture of Achilles tendon degeneration, and MRI can also distinguish between paratenonitis, tendinosis, and bursitis. This technique uses a strong uniform magnetic field to align the millions of protons that flow through the body. These protons are then bombarded with radio waves that make some of them misaligned. When these protons return they emit their own unique radio waves that can be analyzed by the computer in 3D to create a sharp-sectional image of the desired area. MRI can provide unparalleled contrast in soft tissue for exceptionally high photo quality making it easier for technicians to see tears and other injuries.
Radiography can also be used to identify Achilles tears indirectly. Radiography uses X-rays to analyze the point of injury. This is very ineffective in identifying soft tissue injury. X-rays are created when high-energy electrons hit the metal source. X-ray images are obtained by utilizing different attenuation characteristics of solids (eg calcium in bone) and less dense (eg muscle) tissue when these rays pass through tissue and are captured on film. X-rays are generally exposed to optimize the visualization of dense objects such as bone while soft tissues remain relatively undifferentiated in the background. Radiography has little role in assessment of Achilles tendon injury and is more useful to rule out other injuries such as calcaneal fractures.
Treatment
Treatment options for Achilles tendon rupture include surgical and non-surgical approaches. Among the opinions of the medical profession are divided what is preferred.
Non-surgical management is traditionally selected for small ruptures, less-active patients, and those with medical conditions that prevent them from undergoing surgery. It traditionally consists of restrictions in the cast for six to eight weeks with the feet pointed down (to counter the broken end of the tendon). But recent research has yielded superior results with much faster rehabilitation on fixed or hinged boots.
Some surgeons feel the initial surgical repair of the tendon is beneficial. Surgical options are considered long to offer much less risk than rupture again compared to traditional non-operating management (5% vs. 15%). Of course, surgery imposes a higher relative risk of perioperative mortality and morbidity, such as infections including MRSA, bleeding, deep vein thrombosis and prolonged anesthetic effects.
However, three recent studies have scientifically tested the efficacy of surgery, using the patient's random stream into surgical and non-surgical protocols, and employing an almost identical (and aggressive) rehabilitation protocol for both types of patients. None of the three studies found statistically significant benefits from surgery, apart from other confounding variables. They all yielded comparable results in the rate of rupture again (with each study adding a careful note about the small sample size, one study showed a 12% re-rupture in non-surgical treatment versus 4% rupture back in surgical treatment, which insignificant statistics), strength, and range of motion, while most have reaffirmed the greater rate of complications of surgery. Although this study meets the sample size determined by the a priori power calculation, differences in the rerupture rate may be considered clinically important by some people. Two studies showed small, but statistically significant differences in plantarflexion strength: Surgical groups had significantly better outcomes in increased heel work, high rise heels, concentric strength, and hopping tests on 6 month evaluation than non-surgical groups. However, at the 12-month evaluation, there were significant group differences in just one test, the heel work test increased.
The relative benefits of surgical and non-surgical treatments remain a matter of debate; Study authors are cautious about preferred treatment. It should be noted that in centers with no initial range of available movement rehabilitation, surgical improvement is preferred to reduce the rate of re-rupture.
Surgery
There are two different types of surgery; open surgery and percutaneous surgery.
During open surgery, an incision is made on the back of the leg and the Achilles tendon is sewn together. In complete or serious ruptures the plantar tendon or other vestigial muscle is taken and wrapped around the Achilles tendon, increasing the strength of the improved tendon. If network quality is bad, e.g. injuries have been neglected, surgeons may use amplifying mesh (collagen, Artelon or other degraded materials).
In percutaneous surgery, the surgeon makes several small incisions, rather than one large incision, and stitches the tendon back together through an incision. Surgery may be delayed for about a week after the rupture to allow the swelling to fall. For patients who are not sedentary and those with vasculopathy or risk for poor cure, percutaneous surgical repair may be a better treatment option than open repair surgery.
Rehabilitation
Non-surgical treatments are used to involve very long periods in a series of cast, and take longer to complete than surgical treatments. But both surgical and non-surgical rehabilitation protocols have recently become faster, shorter, more aggressive, and more successful. In the past, patients undergoing surgery will wear a cast for about 4 to 8 weeks after surgery and are only allowed to move the ankle gently out of the cast. Recent studies have shown that patients have a faster and more successful recovery when they are allowed to move and lightly stretch their ankles immediately after surgery. To keep the ankle safe, these patients use removable boot while walking and performing daily activities. Modern studies including non-surgical patients generally limit non-weight-bearing (NWB) up to two weeks, and use modern boots, either fixed or hinged, not molded. Physiotherapy often begins as early as two weeks after the start of both treatments.
There are three things to keep in mind when rehabilitating a broken Achilles: range of motion, functional strength, and sometimes orthotic support. The range of motion is important because it notices the tightness of the improved tendon. When initiating rehabilitation, a patient should perform light stretches and increase intensity over time and allow pain. Putting linear stress on the tendon is important because it stimulates the repair of connective tissue, which can be achieved while performing "stretching runners," (put your toes a few inches up the wall when your heels are on the ground). Stretching to gain functional strength is also important as it improves healing of the tendons, which in turn will lead to quicker return of activity. This stretch should be more intense and should involve a kind of load bearing, which helps reorient and strengthen collagen fibers in the injured ankle. The popular stretch used for this rehabilitation phase is the elevation of toes on high surfaces. The patient should push to the toes and lower himself as far as possible and repeat several times. Another part of the rehabilitation process is orthotic support. It has nothing to do with stretching or strengthening the tendon, but rather in a place to keep the patient comfortable. These are specially made inserts that fit the patient's shoes and help with proper foot pronation, which is a problem that can cause problems with Achilles.
To summarize the steps to rehabilitate the broken Achilles tendon, you should start with a range of stretched movements. This will allow the ankle to get used to moving again and get ready for heavy load activity. Then there is the functional strength, this is where the load bearing should begin to start strengthening the tendon and make it ready to perform daily activities and finally in an athletic situation.
References
External links
- A sequence of images showing Achilles tendinosis and Achilles tendon rupture
Source of the article : Wikipedia
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