A collaborative approach to Achilles tendon rupture

Physiotherapist Greg Turpin and Dr Mareeni Raymond discuss a multidisciplinary approach to managing Achilles tendon rupture.

Unexpected forces cause injury (SPL)
Unexpected forces cause injury (SPL)

The Achilles tendon, the thickest in the body, attaches the gastrocnemius and soleus muscles to the calcaneus and is capable of transmitting huge forces, but it is relatively common to injure it.

Although the aetiology is not completely understood, a combination of degenerative change and mechanical stress is the cause of rupture.1

The injury becomes more prevalent in people aged 30-50 years. This is likely to be due to the onset of degenerative changes, coupled with the continuing participation of this age group in athletic activities. The casual athlete in their 30s is most likely to sustain this injury.

The mechanism of injury is through sharp, unexpected dorsiflexion force, with the calf muscles contracted or by pushing off with the knee extended and by a violent dorsiflexion force.1

Key points
  • Achilles tendon rupture is most common in people aged 30-50.
  • Patients may describe the injury as feeling or hearing a snap or bang, or as feeling they have been shot in the back of the leg.
  • On examination, patients will have reduced plantarflexion and a positive Thompson test.
  • Surgery is associated with a lower risk of re-rupture and a greater likelihood of returning to sporting activity.
  • Conservative management reduces the chance of complications.
  • Educating the patient about the advantages and disadvantages of the different treatment options, according to their desired level of activity, will enable them to make the best decision about their treatment.

GP's perspective

History
Patients may report feeling and hearing a snap or bang. Some describe a feeling as if they have been shot in the back of the leg. They will usually describe a painful event, may present with considerable pain around the calf and may be non-weight bearing on the affected leg.

Examination
A diagnosis can be made clinically, but an MRI or ultrasound scan can confirm it. On examination, the patient will present with reduced plantarflexion strength, a positive Thompson test and potentially, a palpable gap in the Achilles.2

The whole length of the tendon should be examined to check for injuries that can occur at the insertion and the musculotendinous junction.

Management
Referral to a surgeon for open or percutaneous repair of the tendon is often necessary, followed by an immobilisation period. Functional bracing and early mobilisation are becoming more widely used postoperatively.3 There is no definitive protocol for this and it may differ, depending on the surgeon.

Operative treatment has a reduced chance of re-rupture compared with conservative treatment (3.5% versus 12.6%) and a higher percentage of patients returning to the same level of sporting activity (57% versus 29%).4 The patient's desired functional outcome and comorbidities that affect healing will be factors in the decision to operate.

There is no definitive protocol for conservative management. Traditionally, conservative treatment involved immobilisation in a cast or boot, with initial non-weight bearing. Recently, good results have been achieved with functional bracing and early mobilisation, and it is common to be immediately weight-bearing in an orthotic.3

Conservative management reduces the chance of complications, such as infection. There is a risk the tendon can heal too long and more slowly.4

Physiotherapist's perspective

A physiotherapist will generally see patients with Achilles tendon rupture early in the process of recovery. With both conservative and surgical management, the emphasis will be on early non-weight bearing exercises for the lower limb, management of swelling, education on using the Aircast boot and crutches, and maintaining normal gait as far as possible.

Further into rehabilitation, once the patient is fully weight bearing, more aggressive stretching can begin. The position of the foot in the Aircast boot will be altered to gradually allow more dorsiflexion.

Lower limb exercises that isolate weak muscle groups and low-load functional exercises can be commenced. Once sufficient strength has been restored to the lower limb, plyometric, acceleration and deceleration exercises can start. These can be integrated with sport or functionally specific drills.

Referral
It is important to check with the patient that they have been referred from A&E or an orthopaedic surgeon for physiotherapy. They should be seen within two weeks after the injury or operation.

Patients who are struggling to regain full strength or range of movement and who have developed functional deficits may benefit from being re-referred to a physiotherapist if they developed these deficits following discharge.

Working together
GPs and physiotherapists working at the same site may wish to liaise on presentation of acute injury to confirm a diagnosis before sending the patient to an orthopaedic surgeon.

Educating the patient about the nature of the injury, rehabilitation and treatment is fundamental. Gauging their level of desired activity and taking into account their health helps present the advantages and disadvantages of treatment options.

Presenting a neutral version of the options allows the patient to make an informed decision. Education about rehabilitation and prognosis helps patients to plan their work and leisure time according to their weightbearing status and functional ability.

  • Mr Turpin is a senior physiotherapist, Royal Bournemouth and Christchurch NHS Foundation Trust; Dr Raymond is a GP in east London

References
1. Sun C, Zhuo Q, Chai W et al. Conservative interventions for treating Achilles tendon ruptures (Protocol). Cochrane Database Syst Rev 2013, Issue 10. Art No: CD010765. DOI: 10.1002/14651858.CD010765
2. Soroceanu A, Sidhwa F, Aarabi S et al. Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials. J Bone Joint Surg Am 2012; 94: 2136-43.
3. Kearney RS, Costa ML. Current concepts in the rehabilitation of an acute rupture of the tendo Achillis. J Bone Joint Surg Br 2012; 94-B: 28-31.
4. Khan RJ, Carey Smith RL. Surgical interventions for treating acute Achilles tendon ruptures. Cochrane Database Syst Rev 2010, Issue 9. Art No: CD003674. DOI: 10.1002/14651858.CD003674.pub4References

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