Achilles Tendon Rupture 13.

e3

PHYSICAL FINDINGS • Matles test (knee flexion test): The test is

BASIC INFORMATION A palpable delve in the posterior distal third of an additional physical examination finding
the Achilles tendon may be appreciated with utilized to assess Achilles tendon ruptures.
DEFINITION increased dorsiflexion of the ankle. Depending The patient is placed in the prone position
Achilles tendon rupture is a disruption of the on the severity of the rupture pain, ecchymosis with the knees flexed at 90 degrees. If the
continuity of the Achilles tendon that most often and diffuse edema may be noted. The patient injured foot falls in a neutral or dorsiflexed
results from the combination of mechanical may present with an antalgic gait and the position instead of a plantar flexed position
stress and intratendinous degeneration. inability to perform a single heel raise on the when compared to the contralateral limb, the
injured limb secondary to weakened plantar test of the injured limb is positive for Achilles
flexion power. tendon rupture.
ICD-10CM CODES
S86.0 Unspecified injury of Achilles ETIOLOGY/MECHANISM OF IMAGING STUDIES
tendon INJURY • Ultrasound imaging may be used to assess
S86.012 Achilles tendon rupture left Indirect trauma is most often associated with Achilles tendinopathy and is considered
S86.011 Achilles tendon rupture right Achilles tendon ruptures, which typically fall by some the first-line imaging modality.
M66.871 Non traumatic Achilles tendon under three categories: mechanical, vascular, Ultrasound provides clinicians with a practi-
rupture right and poor tissue quality. cal means of evaluating Achilles tendinopa-
M66.872 Non traumatic Achilles tendon • Mechanical: Involves variations of a rapid thy and ruptures at the bedside.
rupture left loading process on an already tensed tendon • MRI (Fig. E2) is often utilized to further evalu-
such as a sudden dorsiflexion of the ankle ate Achilles tendinopathy, especially rup-
EPIDEMIOLOGY & with the knee extended while an eccentric tures. Discontinuity of the Achilles tendon
DEMOGRAPHICS load is applied. can be seen on T2-weighted images, where
• Vascular: Located 2 to 6 cm proximal to the the signal in the tendon is increased at the
INCIDENCE: In the general population, Achilles
Achilles tendon insertion is a known area of area of rupture and the tendon diameter is
tendon ruptures occur in 7 per 100,000 indi-
hypovascularity. increased. MRI provides greater anatomic
viduals and are the most common large tendon
• Poor tissue quality: Tendonitis, which is detail as well as greater accuracy in detect-
ruptures, accounting for 20%-35% of all large
inflammation that occurs within the tendon ing partial Achilles tendon tears. MRI has
tendon injuries in the human body.
after an acute injury, and tendonosis, which proved to be superior to ultrasound in defin-
PEAK INCIDENCE: 30- to 40-yr age group.
is a degeneration process from repetitive ing ruptures histologically.
PREDOMINANT AGE: 30- to 55-yr age group.
tears related to chronic injuries, are known to
RISK FACTORS: General risk factors include
weaken the tendon before it is ruptured. This
recreational athletes, stop-and-go sports
often occurs in the form of repetitive micro-
TREATMENT
(e.g., basketball, tennis, and soccer), preexist-
trauma from improper training techniques. Initial treatment should consist of the PRICE
ing Achilles tendinopathy, increase in dura-
tion or intensity of running, advanced age, protocol (protection of the injured limb, rest,
male gender, and poor running mechanics. DIAGNOSIS ice, compression to reduce swelling, and eleva-
Fluoroquinolone antibiotics have been associ- tion). Adequate analgesics for at-home use
ated with Achilles tendon ruptures, with an DIFFERENTIAL DIAGNOSIS can include acetaminophen and/or nonsteroidal
incidence of 12 per 100,000. This is more likely • Achilles tendinopathy (tendinosis vs. antiinflammatory drugs.
to occur in first-time users of fluoroquinolones tendonitis) The typical course of immobilization of the
and usually occurs within the first 90 days of • Retrocalcaneal bursitis injured limb ranges from a minimum of 8 to 12
therapy. Other risk factors can be categorized • Ankle sprain weeks. Over the past few yrs there has been a
into intrinsic and extrinsic. • Calcaneal avulsion fracture trend in nonoperative management of Achilles
Intrinsic risk factors include Achilles tendi- • Partial rupture of gastrocnemius tendon ruptures that include accelerated pro-
nopathy and biomechanics, such as overprona- • Plantaris rupture tocol to rehabilitation. These accelerated pro-
tion or underpronation, pes planus, pes cavus, • Partial rupture of gastrocnemius tocols have been shown to improve outcomes
limb length discrepancy, and foot misalign- • Os trigonum syndrome of nonoperative Achilles tendon management.
ment. Rheumatologic disorders such as sys- • Calcaneal apophysitis These protocols have the patient non–weight
temic lupus erythematosus, rheumatoid arthri- bearing in a posterior splint or equinus short
tis, and gout can cause collagen degeneration, WORKUP leg cast with crutches for 2 weeks. A controlled
inflammation, crystallization, and calcification A thorough history and physical examination, ankle motion walker with special sequential
of tendons, which causes them to weaken and along with a high clinical suspicion, is key to heel wedges then follows this for the next 4
predisposes them to rupture. distinguishing Achilles tendon ruptures from weeks of non–weight bearing with crutches.
other Achilles tendinopathies. The clinical his- After 4 to 6 weeks the patient may return to
CLINICAL PRESENTATION tory in most presentations is very specific, and regular shoe gear, with a heel wedge modifi-
A classic presentation for acute Achilles tendon the physical examination is usually diagnostic. cation for an additional 2 months. During this
rupture is a middle-aged male who participates The following is a list of specific clinical tests period it is recommended that patients start
in strenuous activities involving sudden pivoting and imaging modalities. resistance exercises, proprioception and gait
on a foot or rapid accelerating as in recreational • Simmonds-Thompson’s test (Fig. E1): Also retraining, and sport retraining.
sports. A snapping/popping sensation of the known as the “calf squeeze test,” it is an
tendon may be described by some patients, accurate means of detecting Achilles tendon SURGICAL TREATMENT
followed by an acute onset of severe pain in ruptures. The patient is placed in a prone If surgical intervention is warranted, it should
the posterior ankle. Patients who also attempt position with the affected limb hanging off be done within 7 to 14 days of the injury.
new strenuous activities without proper training the examination table with the knee flexed. Proper timing of surgical repair is imperative to
and stretching or who typically lead a sedentary While squeezing the gastrocnemius, the clini- postsurgical recovery. The inflammatory phase
lifestyle are more likely to experience some kind cian evaluates for the presence or absence of of wound healing occurs within the first 7-14
of Achilles tendinopathy, including ruptures. It ankle plantar flexion. If ankle plantar flexion days following an acute Achilles tendon rupture.
is important to note that pain is not always an is absent, the test is said to be positive and During this phase, vascularity to the injured ten-
initial presenting symptom. indicative of Achilles tendon rupture. don increases, aiding in postoperative healing.

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 Achilles Tendon Rupture 13.e4

NORMAL RUPTURED
ACHILLES TENDON

Palpation of tendon

No palpable gap Palpable gap

Calf squeeze test

Ankle plantarflexes No movement

Knee flexion test (Matles test)

Ankle >90° Ankle <90°

FIG. E1 Tests for rupture of the Achilles tendon.1All tests are performed with the patient lying prone with
his or her feet extending over the end of the examination table. The patient’s asymptomatic side serves as a control
(for each test, a patient with an intact Achilles tendon is depicted on the left, compared with a patient with a rup-
tured Achilles tendon on the right). (1) Palpable gap in tendon (top): The clinician gently palpates the course of the
tendon, searching for gaps, which if present usually lie between 2 and 6 cm from the calcaneus.2 (2) Calf squeeze
test (Simmonds–Thompson test, middle): The clinician gently squeezes the patient’s calf in its middle third and just
below the place of widest girth, observing the ankle for movement. If the tendon is intact, the ankle should plantarflex.
Absence of movement or minimal movement is a positive response. The normal plantar flexion of the ankle results
from compression of the soleus muscle, which bows the Achilles tendon posteriorly.3 (3) Knee flexion test (Matles test,
bottom): The clinician observes the position of the patient’s ankles as the patient flexes both knees to 90 degrees (the
knees may be flexed individually or simultaneously). The ankle remains slightly plantar flexed if the tendon is intact;
slight dorsiflexion or a neutral position of the ankle is the positive response. Thompson described the calf squeeze
test in 1962,2 pointing out that the test could be performed with the patient prone or kneeling on a chair. Simmonds
described the identical test in 1957.4 Matles described the knee flexion test in 1975.5 (From McGee S. Evidence-
based physical diagnosis, ed 4, Philadelphia, 2017, Elsevier. [1] Maffulli N: The clinical diagnosis of subcutaneous tear
of the Achilles tendon: a prospective study in 174 patients, Am J Sports Med 26[2]:266–270, 1998; [2] Thompson
TC, Doherty JH: Spontaneous rupture of tendon of Achilles: a new clinical diagnostic test, J Trauma 2:126–129, 1962;
[3] Scott BW, Chalabi AA: How the Simmonds–Thompson test works, J Bone Joint Surg Br 74B[2]:314–315, 1992;
[4] Simmonds FA: The diagnosis of the ruptured Achilles tendon, Practitioner 179[1069]:56–58, 1957; [5] Matles AL:
Rupture of the tendon Achilles, Bull Hosp Jt Dis 36[1]:48–51, 1975.)

The primary goal of surgical treatment of decreased operative times and decreased REFERRAL
Achilles tendon rupture is to reestablish ankle postoperative deep infections. Other open Acute and/or complete Achilles tendon rup-
plantar flexion. This is usually achieved when surgical procedures can involve lengthen- tures warrant surgical intervention. Acute
there is an end-to-end apposition of the dam- ing and flap-down methods to bridge the complete Achilles tendon ruptures are more
aged Achilles tendon. Several surgical tech- gap in the tendon. Multiple biologic grafts likely to have better postoperative outcomes
niques exist to repair the ruptured Achilles are available to augment and reinforce the if addressed within 14 days of initial injury.
tendon, which include percutaneous repair rupture site. After surgery, 10 to 12 weeks of Newer studies suggest that acute Achilles
and open operative techniques. Percutaneous immobilization followed by rehabilitation is tendon ruptures surgically managed within
repair has shown to be advantageous, with recommended. 48 hours of injuries tend to have less adverse
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Achilles Tendon Rupture 13.e5

A B C D
FIG. E2 Complete Achilles tendon rupture, managed nonoperatively with 6 weeks of ankle
casting in plantar flexion. A, Transverse T1-weighted magnetic resonance image (MRI). Shown is
severe Achilles tendinopathy (arrow). B, Sagittal short tau inversion recovery (STIR) MRI reveals tendon
fiber discontinuity with fluid-filled gap (arrows). Transverse T1-weighted (C) and sagittal STIR (D) MRIs
obtained in follow-up 18 months after casting show thinning and attenuation of the tendon but reestab-
lished tendon fiber continuity (arrow in C).

events postoperatively than those Achilles ten- continued on a regular basis following Achilles RELATED CONTENT
don ruptures that are surgically repaired after tendon ruptures and particularly before engag- Achilles Tendon Rupture (Patient Information)
3 days of initial injury. Orthopedic or podiatric ing in any vigorous exercise.
surgical consultation should be obtained for • The patient should reduce his or her train- AUTHOR: COURTNY JOHNSON, D.P.M., M.S.H.S.
symptomatic acute or chronic Achilles tendi- ing intensity during fluoroquinolone use and
nopathy or ruptures. anabolic steroid use.

PEARLS &
CONSIDERATIONS SUGGESTED READINGS
Dakin SG, et al.: Chronic inflammation is a feature
• Patients who experience Achilles tendon rup- of Achilles tendinopathy and rupture, Br J Sports
tures may present with or without pain and Med 52(6):359–367, 2017.
may still maintain their ability to ambulate or Deng S, et al.: Surgical treatment versus conserva-
flex their ankles. If pain is present, it usually tive management for acute Achilles tendon rup-
occurs 2 to 6 cm proximal to the Achilles ture: a systematic review and meta-analysis of
tendon insertion on the calcaneus. randomized controlled trials, J Foot Ankle Surg
• When evaluating Achilles tendinopathy, palpate 56:1236–1243, 2017.
the course of the Achilles tendon with particular Lantto I: A prospective randomized trial comparing
attention to any edema, ecchymosis, or pal- surgical and nonsurgical treatments of acute
pable delve or discontinuity of the tendon. Achilles tendon ruptures, Am J Sports Med
• A positive Thompson’s test is an accurate 44:2406–2414, 2016.
means for assessing Achilles tendon ruptures. Lim CS, et al.: Functional outcome of acute Achilles
• Acute Achilles tendon ruptures should be tendon rupture with and without operative treat-
treated within 14 days. Surgical interven- ment using identical functional bracing protocol,
tion has been shown to decrease re-rupture Foot and Ankle Int 1:1–6, 2017.
rates as well as restore calf muscle strength Magnan B, et al.: The pathogenesis of Achilles ten-
sooner when compared to nonsurgical treat- dinopathy: a systematic review, Foot Ankle Surg
ment options. 20:154–159, 2014.
Suzuki T, et al.: Retrocalcaneal bursitis precedes or
accompanies Achilles tendon enthesitis in early
PREVENTION
phase of rheumatoid arthritis, Clin Med Insights
• Previous tendinopathy or previous Achilles ten- Arthritis Musculoskelet Disord 11:1–4, 2018.
don ruptures are known risk factors and are Willits K, et al.: Operative versus nonoperative
associated with up to 10% of re-rupture rates. treatment of acute Achilles tendon ruptures:
• Physical therapy as well as physical rehabilita- a multicenter randomized trial using acceler-
tion protocol should be maintained following ated functional rehabilitation, J Bone Surg Am
both operative and nonoperative therapies. 92:2767–2775, 2010.
Eccentric and concentric exercise should be

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