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)
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 injuryThompson 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 chairSqueeze the calf of the normal limb. You will notice the squeeze will cause the ankle to plantarflex appropriatelySqueeze 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 tearPerformance Characteristics (Garras 2012)X-RaysUsed to rule out other or concurrent pathologyMay 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 visualizedUltrasoundUltrasound 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)MRIGold-standard imaging modalityRarely, if ever, necessary in the EDUsed for equivocal physical exam/alternate imaging findings or for assessing the severity of the tear for possible operative managementFindingsA full-thickness tear often shows a tendinous gap filled with edema or bloodComplete rupture shows retraction of tendon endsProvide analgesiaTendon stabilization in an optimal healing positionFunctional bracing/splinting in resting equinus/talipus equinusAO 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-weightbearingAny weight-bearing can convert a partial tear to a complete tearMaintain 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-ruptureED Ortho consultation: patients with open wounds in the area of trauma, or with concomitant fracturesOperative 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 athletesThese cases will be determined during follow up with orthopedics and may warrant outpatient MRI to assess severity of tearFor 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 Orthobullets: Achilles Tendon Rupture
Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter/X: @srrezaie)
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