Achilles tendon ruptures

Achilles tendon rupturesHuman Evolution

Kathryn Newark4A Kinesiology

1

Evolutionary purpose?Evolved approximately 2 million years ago & designed to allow humans to run twice as fast.

Advantages:Strongest tendon in the bodyEnergy saving mechanism to allow fast locomotionAllows jumping and runningActs as a spring and shock absorber

Why is it that it is so prone to injury?

Injury to the achilles tendon is the 3rd most common major tendon disruption after rotator cuff tears and knee tendon injuries.75-85% of these tears associated with athletic activity.I will explore what current literature determines as predisposition to achilles ruptures, the relevant anatomy, surgical and rehabilitation procedures.2

Anatomical relevance

Achilles tendon extends from three posterior muscles of the leg including: the gastrocnemius, soleus & plantaris muscles which are all powerful flexors. These muscles combine at the achilles tendon and insert on the calcaneous tuberosity of the foot.Gastrocnemius making up the bulk of the calf it is vital in sports to propel us forward while walking, running and jumping.Soleus contains higher proportion of slow fibres and is very important posturally to help us prevent forward fall when were standing.This image shows us the function of the Achilles for our walking capabilities. When our calf muscles contract, our heel lifts via the achilles.This image shows the makeup of the Achilles tendon. It contains the Paratenon which replaces what would be a normal tendon sheath and is a soft tissue layer that surrounds the Achilles tendon allowing it glide during motion.3

Energy savingThe Achilles is an important elastic energy store.

The plantaris muscle and tendon return >90% of the energy store.Kinetic energy lost at one stage during gait is converted to elastic strain in the plantaris muscleReturned later as elastic recoil to the Achilles

This way, we save more than half of the metabolic energy otherwise needed for locomotion.

strengthThe Achilles is composed of collagen fibres that spiral downwards, with medial fibres passing posteriorlyResponsible for the tendons elastic propertiesAllows the tendon to act as a spring and shock absorber

Can be subjected to up to 3-12 times a persons body weight during a sprint or push-off

Means that as the tendon is stressed, the strain is taken up and a recoil effect is produced.5

When does a rupture occur?An Achilles tendon rupture typically occurs when a load is being applied while the tendon is stretched.It is believed that the main cause is most likely to be pre existing degeneration mainly Achilles tendonitis

6

pathologyAn evolutionary disadvantage to the Achilles tendon is its vascularityThis is a factor that generally causes tendinosis

Healthy tendons are composed of 95% Collagen 1 fibresCollagen 111 fibres (< tensile strength) replace torn collagen 1 fibresCauses an incomplete repair process that can have detrimental effects

In many cases, a concentric load is applied to the tendon followed quickly by an eccentric load (such as running backwards)

Around the mid section of the tendon, there is a decrease in the total area of blood vessels...detrimental effects to the elastic component of the Achilles.Eccentric = applying load while muscle is stretchedConcentric = applying load while muscle is shortened7

pathologyRibbans & Collins, 2013

Other contributing factors that are talked about in the many studies I read were things such as: calf flexibility, ankle ROM, fitness, proper warm up, and being between the age of 30-50. 8

pathologyOne study by Ribbans & Collins (2013) has highlighted that the incidence of acute and chronic Achilles tendon conditions may be due to genetic elements

The ABO blood group most likely to be a biochemical markerN-acetylgalactosamine transferase activityGene for the O blood group is in close proximity to genes whose protein products are directly involved in the biology and pathology of Achilles tendonitis

Major sports companies are increasingly involved in screening athletes for their relative risk of contracting an injury

Biochemical marker.the same study found a reduced incidence of rupture in patients with the A blood group.Transferase activity..is requireed for balanced composition of the matrix of connective tissue, bone & cartilage in our bodies. This activity is low in individuals with the O blood group9

diagnosisCan be misdiagnosed & neglect can be severe due to the insufficient repair system.

Swelling & pain (sometimes severe)Often hear a pop or have a feeling of something hitting the back of the legWeakness with walkingThompsons Test

-Stump necrosis of the tendon fibres may occur which can lead to muscle atrophy of the gastrocnemius-soleus complex.

Patient lies facedown on a table and the calf muscle is squeezed. If the tendon is still intact, the foot will flex.if the tendon has a complete tear, the foot will not move.10

Achilles tendon in athletesSeveral studies have attributed a larger Achilles tendon to those who frequently exercise.

Ying et al. compared the tendons thickness and cross sectional area between subjects who exercised frequently (at least 2 hrs exercise 3x a week) and those who didnt.

Significantly thicker Achilles tendonsSignificantly higher cross-sectional area in dominant foot

Yingthe exercise group had:

Suggests that there is a relationship between fast locomotion (to be a benefit to the hunter/gatherers OR athletes in our day and age) and the physical structure of the tendon.In contradiction.thicker tendons are more susceptible to injury and therefore athletes more prone than inactive subjects.11

Athletes

So I looked into a few professional athletes that have recently experienced achilles tears#1) Kobe Bryant he experienced a full rupture when landing while his achilles was fully stretched. He underwent open surgery which he posted to the world via Instagram and hes predicted to come back for the next line-up.#2) Erik Karlsson apparently a major NHL defensemen for the Ottawa Senators. His Achilles was sliced ~70% during this fluke accident from the other player stepping down on the back of his heel. Underwent surgery to accelerate healing although much faster than complete tear (also expects to be back in the game)#3) David Beckham complete tear, retired from the game on a professional level.12

Treatment optionsOperativePercutaneous SurgeryRe-approximation of Achilles tendon using suturesOpen Surgical RepairIncision is made and Achilles is sutured directlyNon-operativeCasting & splinting regimens to gradually heal the Achilles tendon

Percutaneous: 6 stab wounds are made where sutures are passed through by needle point. The distal and proximal ends of the ruptured tendon are approximated while the foot is held in full dorsiflexion. The sutures are tied and cut then pushed subcutaneously. Patients are placed in casts for up to 8 weeks post-surgery.Open: After palpation of the rupture gap, an incision is made through skin and subcutaneous fat to the paratenon. This is cut longitudinally to expose the ruptured tendon ends. The ends are reapproximated and sutured together. These may sometimes be augmented by a fascial graft OR woven tendon graft *MUST be careful not to overtighten as the length of the Achilles is optimized for human movement.Non-operative: Usually a short leg cast is applied while the ankle is in slight plantar flexion. Theoretically the achilles tendon ends are better apposed for healing purposes. This is worn for ~4-6 weeks. After removal, a 2-cm heel lift in the shoe is worn for 2-4 months and a rehabilitation program is initialized.13

Treatment optionsShort-leg CastRigid Orthosis

Treatment optionsTreatment TypeAdvantagesDisadvantagesPercutaneous SurgeryMinimal rate of infection~80% of people can return to pre-rupture activitiesHigh rates of sural nerve entrapmentSome studies suggest higher rates of re-rupture than open surgeryCostly

Open SurgicalLowest re-rupture rates (1.7-5.6%)Increased post-operative muscle strength, power & enduranceMost advantageous for young, athletic individualsDeep infectionsDeep vein thrombosisFistulae & drainage problemsNecrosis of the skin/tendonCostlyNon-operativeLow costNo wound complicationsSome research reports re-rupture rates as high as 40%More difficult for surgical repair after re-ruptureTendon edges may heal in an elongated position resulting in decreased ROM of the ankle as well as power & endurance

There is controversy in the literature about whether a rupture should be treated surgically on the first rupture or upon re-rupture of the Achilles.15

Rehabilitation Following surgery:Following immobilization, patients begin active or active-assisted ROMIn most cases, patients can progress to pre-injury activity levels in 4-6 monthsNon-operative rehabilitation:Following cast removal, 2-cm heel lift is worn 2-4 months and rehabilitation program is initiated

Exercises include: Time FrameExercise2-4 weeks (post op.)Pain-free active ankle ROM, hip & core strengthening4-8 weeks (post op.)Frontal & sagittal plane stepping drills, gentle stretching, static balance exercises, ankle strengthening with resistive tubing, active ankle ROM8 weeks (post op.)Multi-plane proprioceptive exercises, single leg stand, functional movements (ie. Squat & lunges)4 months (post op.)Impact control exercises, movement control exercises, progression into sport/work related proprioceptive exercises, stretching to avoid muscle imbalances

(UW Health Sorts Medicine Centre, 2011)

All cases first involve immobilization of the ankle joint via casting or splinting to allow the tendon to heal. One study mentioned that the relative tendon pain before surgery was a factor for how quickly the tendon healed post surgery (this wasnt replicated in any other studies).

Exercises (after cast removal are generally similar for both groups and include)16

Preventative measuresStretch & StrengthenFeel a noticeable pull, but not painDo NOT bounce in the stretchAlternate High Impact SportsSwitch between high and low intensities Increase Training Intensities SlowlyAbruptly increasing intensity commonly causes Achilles injuriesChoose Running Surfaces CarefullyAvoid slippery surfaces

Calf strengthening will allow the muscle to absorb more force through the tendon.Such as running with lower intensity such as biking, walking or swimming..also avoid such activities as hill running which can place excessive force on the achilles.17

Future research optionsStrength analysis of the calf muscles during rehabilitation are often not comparable between studies due to differences in data collection. Studies should be performed with standardized testing and larger sample sizes to give the health field a better idea (less controversy) over which treatment option is best for each individual.

Newer studies should be performed on those who opt for the non-operative treatment due to the inconsistent findings of re-rupture rates (some ranging from 5-40%) in many studies. Larger sample sizes would also be more useful in representing probability.

Studies pertaining to the results of patients who undergo surgery upon the first rupture of the achilles tendon versus those who undergo surgery upon re-rupture should be performed. There is controversy in many studies about which would be most beneficial when taking risks and benefits into account.

What do you think?One study focused on the genetic factors that can be traced in athletes that are suggested to be at higher risk of incurring an Achilles rupture. Blood tests are being used increasingly more by major sports companies to Profile athletes based on these studies. Do you think this should be a deciding factor for athletes looking to make it big? Is it ethical?

Achilles ruptures can be very detrimental to the physical activity levels of athletes; if the original resting length of the tendon changes during the healing process, the force-tension relationship decreases functional strength of the muscles. Knowing this, do you think chances of re-rupture would be greater for those who choose the non-operative option?

Think about trying to return to previous sport/activity & decreased power/endurance. Maybe more psychological? Age factor? Maybe learn to use different techniques? How the muscle is trained?19

ReferencesJacobs, B., Lin, D., & Schwartz, E. (October, 2012 10). Achilles tendon rupture treatment & management. Retrieved from http://emedicine.medscape.com/article/85024-treatment

Poinier, A., & Bardana, D. (January, 2011 03). Surgery for an achilles tendon ruptur . Retrieved from http://www.webmd.com/a-to-z-guides/surgery-for-an-achilles rupture

UW Health Sorts Medicine Centre. (2011). Rehabilitation guidelines for achilles tendon repair. Retrieved from http://www.uwhealth.org/files/uwhealth/docs/sportsmed/SM- 27399_AchillesTendonProtocol.pdf

http://www.mayoclinic.com/health/medical/IM04167