Talk:Achilles tendon rupture

This article was the subject of a Wiki Education Foundation-supported course assignment, between 3 January 2022 and 31 May 2022. Further details are available on the course page. Student editor(s): BryceH2331 (article contribs).

A request for practical edits adding warnings for patients

On the basis of woeful personal experience, I suggest that somebody with the requisite expertise edit the achilles tendon rupture page to include the warning that, if there is any possibility of tendon rupture, the patient should see a specialist as soon after the injury as possible. Apparently, after a month or so, the development of scar tissue precludes surgery and the patient is doomed to have a floppy foot for the rest of his or her life. God knows, I would love to learn otherwise. nickthompson@clarku.edu

• How on earth did you manage to function for a month after rupturing your Achilles? When I did mine last November I could barely walk. After visiting a Dr the next morning I was basically sent straight to hospital for a cast. Even now I'm not really 100 per cent. Lisiate 02:28, 13 June 2007 (UTC)

Risk factors for Achilles Tendon Rupture

Please feel free to improve this section and add cites to prepare it for inclusion in the main article.

Risk Factors for Achilles Tendon Rupture

A number of factors predispose the Achilles tendon to either partially break or snap (partial rupture) or to rupture completely or almost completely. These include:

1. Steroid use, especially if injected into the tendon, (as has been done in the past, ironically, to treat Achilles tendons already stressed from overuse);
2. Sports. When you engage in sports that require the tendon to absorb landing force while delivering force to jump again, especially if the tendon is stretched (toes back toward knee) when the force is required. Can happen at any age.
3. Being older. As you move beyond your 20s, your risk of Achilles rupture increases;
4. Overuse may predispose by causing slight injuries that are not allowed ample time to heal;
5. Being unconditioned may predispose – Like other body parts, tendons react to training by getting stronger. The Achilles has a poor blood supply, but in most people does slowly respond to training by getting stronger. Whatever isn't used, though, tends to get resorbed by the body and become weaker. Muscles respond visibly and relatively quickly to exercise by increasing in size and strength, while tendons and bones respond much more slowly to exercise.
6. Cold; The tendon being cold when stressed may be a factor;
7. Stretching before exercise MAY INCREASE rupture risks. Surprisingly, the conventional wisdom that stretching is protective lacks sound scientific underpinning. A Medline search reveals a number of recent reviews showing that older science provided only scant support for stretching, per se, after the benefits of heat-generating warm-ups was separated out. Instead, most of the recent and better-designed studies report that the stretching groups actually ran a slightly higher risk of Achilles rupture than the no-stretching groups. The conventional idea had been that stretching might make the tendon stronger or more supple, but actually a longer, recently stretched tendon seems to have given up some of its “give” making it more prone to injury. The slightly better strategy now seems to be to warm up the body through aerobic exercise, without stretching the Achilles, before engaging in activities explosively stressing the Achilles.

Reducing Risk of Achilles Rupture

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1. Avoid risk factors, e.g. steroids in general, and steroid injections into the Achilles in particular;
2. After your 20s, or if you have other risk factors, consider changing to a sport that requires less explosive power from the Achilles.
3. Increase body warmth before stressing the Achilles. Science does support a protective role for warming up the body temperature before jumping, zigg-zagging, or making other demands on the Achilles for explosive power.
4. Warming the Achilles directly. Notice that ballet dancers often wear warmers over their ankles? Might help and unlikely to hurt.
5. Strengthening the Achilles gradually, via exercise without over-stretching it, e.g., by lifting the body by coming up on tip-toe. Be aware that the muscles of the leg will strengthen first and the Achilles only later, so that the risk of rupture from muscles being strong enough to snap the Achilles may increase until the Achilles catches up;
6. Rest an overused Achilles, don't make further demands on it until it has had the chance to heal up the micro-tears (Full healing can eventually makes an Achilles stronger, but until then the micro-tears increase the risks of rupture).
7. (Probably) AVOID stretching the Achilles right before asking it to provide and absorb explosive power, as in jumping and landing, zigging and zagging, sprinting, etc.

Recognizing and dealing with a ruptured (snapped) Achilles tendon

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1. If you are bleeding – call an ambulance. If you are seriously cut or lacerated through your Achilles or any body part, get to an emergency room where you can get antibiotics and immediate cleaning of the wound and any needed surgery. You have a risk of getting drug-resistant germs established and losing the leg, or worse. The Achilles and surrounding tissue are poorly supplied with blood, and hence more vulnerable to allowing an infection to be established. Minutes count. Call an ambulance. Advise the emergency room to expect a serious emergency that requires immediate assessment and probably surgery by an orthopedic surgeon (they'll need to call in their “on call” orthopedic surgeon if he/she is not there). Ask the ambulance dispatch, the emergency room doctor, or other source of medical advice what first aid to provide. Apply first aid until the ambulance arrives, moving the foot only as necessary to field-clean and disinfect any visible dirt or debris in the wound.
2. Whether or not you're not cut, try to keep the affected leg very still and relaxed. You risk damaging yourself and making a semi-serious injury very serious if you try to use a partially ruptured Achilles. Don't try to even walk, let alone run, jump, or play, nor to do anything else that could pull your toes up level with your heel, let alone up toward your knee. To get up and hop off the field get help. Move by hopping on the good leg with an arm over someone on each side, or failing that hop or hop or crawl off the field yourself, without using the injured leg. Either trying to use the muscles to move the foot or letting any forces move it out of its natural slightly pointing position would stretch and stress a partially ruptured Achilles and risk completely snapping it in two, which would diminish your option of possibly avoiding surgery with an outcome acceptable to you. Don't curiously try to use your muscles to point your foot, but make sure the foot is allowed to stay slightly pointed, usually just from it's own weight, with no exceptions – no “real quick” weight bearing or using the muscles to point, not even once.
3. Is it snapped (“ruptured”)? You have a classic presentation if you are over 30, start to play sports in the cold, jump and land on your toe or zigg back and tried to zagg forward in a lunge you (try to) power with the foot of the ill-fated Achilles, then feel a kick on the back of your ankle right above your heel, (maybe) hear a pop, fall down, lay there looking for the person or meteorite that hit your ankle, maybe try to move the foot but notice it feels wrong, broken, weak, or limp. Or, maybe you land on the toe area (“ball”) of one foot after a huge ballet leap, try to launch right into another leap but hear a pop and fall down, probably with plenty of pain.
4. If it's snapped, is it a partial or complete rupture? If you notice a big notch right above your heel where your Achilles tendon used to be, you likely have a near-complete rupture (just a few strands still hanging on). If you lay on your belly on a bed with your feet hanging off and someone lifts the calf muscles of the good leg, they will see the toe on the good leg point. If the other is ruptured, when they then lift the calf muscles of the hurt leg, that toe won't point (as much). Obviously, an orthopedic doctor can do this (Thompson's sign check) better than your sister. If there is still doubt, a doctor practicing proper sterilization procedures can stick a needle through the skin into the tendon and see what happens when you try to point your toe. Usually, the clinical signs are enough for diagnosis. Alternately, ultrasound or an MRI can image soft tissue and thus provide a more definitive diagnosis, for a price. An X-ray is rarely of value, though theoretically similar signs might arise if the part of the heel bone attached to the tendon snapped off, and a low-dose sensitive X-ray with fast film might help see that.

Immediate things to do if you may have a partial or full Achilles tendon rupture

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1. Unless you know an orthopedic surgeon who will see you right away, get to an emergency room. You need a good diagnosis, immobilization, crutches, and advice, no matter what comes next, and an emergency room is a good bet to provide them. Do this ASAP.
2. Until you see the E.R. Doctors, keep the foot immobilized and follow the RICE formula as best you can: Rest, Ice, Compression, and Elevation. Rest for immobilization, Ice for less pain, inflammation, less blood), Compression (support stocking or ace bandage on swollen areas and leg muscle), and Elevation (to at or above the level of the heart). Compression and elevation help reduce risk of deep vein thrombosis, since you won't be moving the muscle much, and a moving muscle is what the heart relies on to keep blood from pooling and clotting in the legs. Keep the leg elevated to heart height or higher until your doctor tells you it's safe to quit.
3. After getting a diagnosis The best immobilization is a walking boot fixed with the toe pointed at about 15 to 20 degrees to keep your foot immobilized and slightly pointed so your Achilles is protected from further damage while you figure out what else to do. Many emergency departments don't have walking boots in stock, in which case you will need a cast or half-cast. Not all emergency staff know that the foot must be cast, or the walking boot must be locked, with your toe slightly pointed. This is very important, no matter what happens next. You will also need crutches.
4. You might also ask the E.R. doctor for muscle relaxers such as Skelaxin or Valium, because you are likely to get painful leg cramps the first few nights after the rupture, which can risk further rupturing an injured Achilles. Cramps are a challenge because many of the usual maneuvers to relieve them involve stressing the Achilles tendon. Cramps can be avoided or reduced by increasing intake of magnesium malate, magnesium aspartate (fewer bowel effects), or magnesium oxide. Also, maintain adequate hydration, and try to avoid getting the calf muscles too chilled (chill the tendon, not the calf muscles -- a challenge).
5. Also, ask the E.R. doctor for an immediate referral to an orthopedic surgeon for a consultation, preferably to a foot and ankle specialist.

After the E.R. visit (or while in the waiting room) make an appointment at once to consult one or more orthopedic surgeons, because if surgery is chosen, a better outcome is most commonly expected if surgery can be scheduled and performed within five days or preferably less. However a recent study failed to find any substantial benefit so long as surgery occurred during the first month.

Many general orthopedic surgeons will undertake to re-join a ruptured Achilles tendon. This is one of the most common orthopedic surgeries. You might have the best results if you can locate a foot and ankle specialist with a good record regularly performing many such surgeries, such as a specialist to whom the local doctors refer more difficult surgeries involving re-dos.

A growing subset of orthopedic surgeons are increasingly steering their patients away from surgery or not performing it themselves, in response to the latest randomized trials that all show equivalent or superior results from simple immobilization in a removable boot, with prompt weight-bearing and early physiotherapy. Depending on the locality, Achilles rupture patients may have to become strong patient advocates in order to avoid unnecessary surgery or unnecessarily long immobilization and slow rehabilitation, in a series of non-removable casts instead of a removable boot.

Editorial Comments

Needs a section on incidence (how often does this occur? in whom?) There's a study showing very significantly higher risk of rupturing the OTHER Achilles tendon after you've ruptured the first, ca. 200 times the background risk (though still only 1-2% probability, at least during the first few years).

This Wikipedia article cites prior rupture of the SAME Achilles tendon as a risk factor, but I am unaware of any study that substantiates that claimed risk factor, after complete healing. On the contrary, there is at least extensive anecdotal evidence that a healed Achilles rupture "cures" prior Achilles tendinosis.

Treatment and Rehabilitation section needs to be made into separate paragraphs, and needs links to other papers and citations. Scholarchanter (talk) 01:04, 1 June 2010 (UTC)

Celebrities

Would it be okay to create a section where we note athletic celebrities who have sustained this type of injury? Two that come to mind are David Beckham and Adam Copeland. I am not sure how frequent this is, if it became too numerous we could come up with some policy to narrow it down I suppose. Nym (talk) 18:17, 4 August 2010 (UTC)

Those kinds of sections are generally avoided. A conglomeration of random occurrences is not very encyclopedic.--NYMFan69-86 (talk) 06:47, 10 October 2010 (UTC)

The article seems somewhat unclear

This is my first time reading the article and though it is adequately detailed in the causes and symptoms and treatments of an Achilles tendon Rupture, it still neglects to basically state what an Achilles tendon rupture is. Obviously one can extrapolate from the definition of the word rupture and the fact that it is a rupture applied to this tendon in the leg, but it should be stated as such in the article, with no need for extrapolation. Rajrajmarley (talk) 17:14, 23 March 2011 (UTC)

Concerns regarding this article

The final paragraph of the Achilles tendon rupture#Treatment section (just before surgery) reads like editorialising and original research on behalf of the submitting editor. Additionally, the use of parentheses around the word "experts" is clearly pushing a point of view as to the competency of said experts in an unencyclopedic manner. This paragraph needs to be rewritten to attribute and properly cite all opinions and fact presented, using language appropriate to an encyclopedia.

While the rest of the article appears to have a decent level of citation, the Achilles tendon rupture#Rehabilitation section seems lacking in this regard.

Regrettably I do not have sufficient expertise in medicine to rectify these shortcomings and so have tagged these sections appropriately. I hope other editors will be able to assist.

Thank you, --MegaSloth (talk) 20:56, 2 January 2012 (UTC)

Capitalisation of the word "Achilles" (Vs "achilles)

I can see that a capital "A" is used for Achilles throughout (most of) this article, and I understand that the name comes from the Greek warrior. However I also understand that names of tendons and other body parts would not normally be capitalised. I won't change the article, however I don't think all the capital A's are warranted. 14.200.208.126 (talk) 20:58, 11 July 2015 (UTC)

Wiki Education assignment: WikiMed Feb-Mar 2022 UCSF SOM

This article was the subject of a Wiki Education Foundation-supported course assignment, between 28 February 2022 and 27 March 2022. Further details are available on the course page. Student editor(s): Xkirex (article contribs). Peer reviewers: Joeception.

Milepost Date Xkirex (talk) 03:07, 5 March 2022 (UTC) Mon 2/28 Course Day 1 ● reviewed Wikiproject Medicine’s website ● completed all 9 required Wiki Ed training modules ● begun thinking about what article I want to work on this month Tues 3/1 Course Day 2 • Chosen an article Fri 3/4 WP-WIP #1 • Finish WIP template • Decide what areas of the article I want to improve • Look for sources Wed 3/9 WP-WIP #2 • Contribute and revise Signs and Symptoms section • Add an Incidence section Wed 3/16 WP-WIP #3 • Add Citations to Causes section and other revisions Mon 3/21 WP-WIP #4 • Finish peer review Fri 3/25 Course Wrap-up • Finish final revisions

Peer Review

In reviewing the original state of the article versus the direction and edits that you have made, I want to start by saying that you clearly spent time and were thoughtful in your approach to this challenging and vital topic.

Causes

·The information presented is great. I would suggest, however, to best try and match the wiki suggested guidelines and the format of the rest of the article by combining the information into a paragraph.

·Quinolone antibiotics are mentioned in two different parts of this section. I would combine this information.

·“Yet, recent studies have shown that Achilles’ tendon ruptures are rising in all ages up to 60 years of age. This is because remaining active has become popularized around the world.”

o  Possibly rephrase as this is a theory as to why the incidence is increasing, the actual cause may yet to be discovered or if it was from a recently published study the inactivity that occurred during the beginning of the covid pandemic in the US followed by a return to the same level of activity led anecdotally at least to a significant increase in these types of injuries which is often why this can also be referred to as the “weekend warrior” injury.

Diagnosis

· “An ultrasound is recommended over MRI, and MRI is generally not needed.”

o  Achilles tendon rupture is often a clinical diagnosis that can be made based on the history and physical exam findings. However, if an equivocal or partial tear is suspect, ultrasound or MRI are the most helpful imaging modalities with nearly equivalent sensitivity and specificity. So, as it gets into later under the imaging section and US is the first line, and typically all that would be needed, it is operator dependent, and an MRI would be better for catching partial tears. I would suggest rephrasing this to reflect this exception and the reasoning behind US v. MRI.

·  DDX

o  There is a differential in the summary box near the intro but not in the diagnosis section itself. I wouldn’t make it super detailed, but it would be good to see similarities in differences for Achilles tendinopathy. You could even link to the page and borrow some of the content written in the article.

Treatment

· In the intro to this section, I would combine the final sentence into the body of the paragraph rather than two separate paragraphs.

· There is a lot of great information regarding complications in this section. I think it could warrant its own prognosis or outcomes section. Following the wikimed template, this would follow the treatment section.

o  Treatment of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis of Complication Rates With Best- and Worst-Case Analyses for Rerupture Rates.

o  Seow D, Yasui Y, Calder JDF, Kennedy JG, Pearce CJ  

o  Am J Sports Med. 2021;49(13):3728. Epub 2021 Mar 30.

o  An updated reference that discusses complications from surgical v non-surgical approaches

·There could also be added information regarding non-surgical approaches to treatment and initial approaches and what is done in a partial versus complete tear.

o  For example, from UpToDate: “Initial care — Initial management of Achilles tendon rupture consists of ice applied to the area, analgesics (acetaminophen and/or NSAIDs are generally sufficient), rest (ie, non-weightbearing with crutches), immobilization with the ankle in some plantarflexion (generally a short-leg splint is used (picture 4)), and referral to an orthopedic surgeon.”

·Rehabilitation

o  I agree with the banner suggesting adding to the citations of this subheading.

Epidemiology

·“There are 2 age groups more likely to suffer from an Achilles tendon rupture. A younger age group between 25-40 and an older age group over 60.”

o  Could rephrase to say something along the lines of Achilles tendon rupture tends to occur most frequently between the ages of 25-40 and over 60 years of age.

~~~ Joeception (talk) 23:26, 18 March 2022 (UTC)

Thank you for taking the time to carefully review my work in progress. You bring up some valid suggestions in each of the sections. I agree with you, and will address each point you made and make those revisions. Xkirex (talk) 23:51, 23 March 2022 (UTC)