A gentleman in his mid-40s was referred to our clinic by his GP. He acutely injured himself with pain being felt at the posterior ankle four months ago when running for a bus. At the time he experienced acute and severe pain and was unable to bear weight. He went to A&E where he had an x-ray which was reported as normal. He was then re-assured that it was only a sprain and that things would improve of its own accord with time.
He again re-injured the same site a month later or so when rushing around in the street. This was quite a setback and he had difficulty mobilising which lasted longer than after the first injury and he continued to walk with a limp. He saw one of my physio colleagues who felt that his level of impairment in combination with the fluctuating and palpable lump on the posterior Achilles tendon should warrant further investigation hence he was sent to me.
Clinical examination showed significant weakness on resisted plantarflexion. Heel raise was very difficult on this side compared to the asymptomatic side. Squeeze test/Thompson test was negative. There was no pain. The tendon was very enlarged.
Ultrasound showed an enlarged tendinopathic tendon with reduced fibrillar echotexture (Figure 1) throughout. On long view there was a large (5cm) anechoic defect in the tendon which was located in the mid portion of the Achilles tendon (Figure 2). I initially thought that this was a full thickness tear with a fluid collection. On closer inspection it appeared that the paratenon +/- marginal tendon fibres were still intact on both the anterior and posterior aspect. Effectively this created what appears to be a large fluid filled cavity (Figure 3) within the fascial/paratenon margins.
I advised low impact exercise and to avoid any high impact for now. I then referred to Orthopaedics.
Evidence base on management options...
Mundi for Cochrane in CORR (2013) did a review of Surgical Interventions for Treating Acute Achilles tendon rupture. Their take home message: Open surgical repair for the management of acute Achilles tendon ruptures appears favourable to nonsurgical management with respect to decreasing the risk of tendon re-rupture, but has a higher risk of associated wound and nerve complications. Both surgical and nonsurgical management of such patients remain valid treatment options, as neither has proven superior in all patient important outcomes. Cochrane do go on to say that studies that were identified by the authors at the time of the review but that were not available for inclusion: Soroceanu (2012) and Willits (2010) found no significant difference in re-rupture rates between the surgical and nonsurgical treatment.
As such the Cochrane review concluded the decision to proceed with surgical versus nonsurgical treatment in the management of acute Achilles tendon ruptures remains a matter of ongoing debate. Given the available evidence, treatment decisions should largely be made based on the available rehabilitation protocol and the preferences of a well informed patient.
References of interest
Mundi, R., Madden, K., & Bhandari, M. (2014). Cochrane in CORR®: Surgical Interventions for Treating Acute Achilles Tendon Ruptures (Review).Clinical Orthopaedics and Related Research®,472(6), 1703-1708.
Rosso, C., Buckland, D. M., Polzer, C., Sadoghi, P., Schuh, R., Weisskopf, L. et al (2013). Long-term biomechanical outcomes after Achilles tendon ruptures. Knee Surgery, Sports Traumatology, Arthroscopy, 1-9.
Soroceanu, A., Sidhwa, F., Aarabi, S., Kaufman, A., & Glazebrook, M. (2012). Surgical Versus Nonsurgical Treatment of Acute Achilles Tendon Rupture. The Journal of Bone & Joint Surgery,94(23), 2136-2143.
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