Archive for April, 2013

Achilles Tendon Injury

April 12, 2013

Image

Definition

The Achilles tendon plays an essential role in the day-to-day movement of an individual no matter their level of physical activity.  This tendon connects the muscles of the calf to the heel bone, and helps to raise the heel when standing or flexing the foot away from the body.  It is a very thick band of tissue and can be easily seen and felt along the back of the lower leg, behind the ankle.  Without the Achilles tendon, it would be hard to do simple activities such as walking, running and jumping.

Damage to the Achilles tendon can lead to pain in the back of the lower leg, just above the heel.  Injury usually occurs when there is a sudden increase in stressful force on the tendon.  The three most common types of Achilles injuries are Tendinopathy, Partial Tendon Tear and Complete Tendon Rupture.

 

Achilles Tendonopathy

The term Achilles tendonitis is very commonly used to describe injury to the tendon that has not progressed to partial or complete tear.  The suffix “-itis” is used to describe a state of inflammation, which indicates a very specific sequence of reactions that occur when the body is injured.  Thus, the word “tendonitis” refers to the inflammation of a tendon.  Although tendonitis is often a cause of tendon pain, damage to the Achilles tendon does not always involve inflammation; the disease of the tendon is sometime caused by chronic degeneration.  Therefore, the term “Tendinopathy” which includes all categories of tendon disease, with or without inflammation, will be used in this article to refer to Achilles tendon injuries other than partial or complete tendon tear.

Patients suffering from Achilles tendinopathy will often complain of pain or stiffness just above their heel.

Partial or Complete Rupture

When an intense stress is suddenly placed on the Achilles tendon it can rupture or tear.  The amount of stress needed to tear the tendon can depend on the individual.  Even seemingly small increases in stress, if brought on suddenly, can cause a tendon rupture.  Athletic activities that may result in a tear include sudden pivoting or activities that involve quickly accelerating and decelerating.

Patients who suffer from partial or complete tendon rupture may describe hearing a “pop” followed by sudden pain.  Experiencing sudden pain and a loss or decreased ability to raise the heel increases the probability of a tendon rupture.  It is possible to have a tendon rupture without experiencing pain, so patients complaining of pain in the back of the heel or decreased ability to raise the heel should be evaluated for possible tendon rupture.

Physical Exam

A proper physical exam must assess the patient’s complaints and rule out all other potential diagnoses.  The Achilles tendon should be palpated for any signs of tenderness, thickening/thinning, swelling or other abnormalities.  If pain is present, it is typically felt 2-6 cm above the attachment of the tendon to the heel bone.

In every instance of Achilles injury, it is important to evaluate the tendon for possible rupture.  The tendon should be tested with the patient standing and off weight bearing in order to assess any loss of function.  Specific tests like the Thompson Test (squeezing the patient’s calf while they are relaxed on the exam table with their feet off the table) can be used to check for tendon rupture.

Imaging

X-ray and Ultrasound imaging can be used to evaluate the degree of tendon injury, and may help rule out other possible causes of the patient’s complaints.  If there is a high suspicion of tendon rupture, MRI imaging is frequently used to assess the severity of the tear and to help plan for proper treatment.

Treatment

Achilles tendinopathy can often be treated non-surgically.  Patients should avoid any activities that might cause pain or worsening of symptoms.  Ice can be used whenever symptoms occur, and nonsteroidal anti-inflammatory drugs (Ibuprofen for example) may be recommended.  Shoe wear modifications, inserts or medical orthotics may be used to help prevent continual injury.  Patients may expect to gradually return to normal activity over the course of 6 to 8 weeks.  Stretching, physical therapy, and laser treatment may also be recommended.  If the pain is severe, a CAM boot may be required for several weeks.  If the Tendinopathy does not resolve within 3 months, the patient should be re-evaluated.

Partial or complete tendon rupture may require surgical care.  Ice, pain medication, rest and immobilization of the ankle are used initially until surgical care is deemed necessary.  Once a patient suffers an Achilles tendon rupture there is an increased risk of repeat injury.

Platelet-Rich Plasma Injections

Platelet-Rich Plasma (“PRP”) injection is a relatively new therapy that has been developed to treat various forms of injury.  Concentrating platelets and other growth factors that contribute to the healing process which are naturally found in the blood forms the PRP.  The blood is taken from the patient.  Spinning the blood at high speeds separates the different components of the blood.  Once separated, the portion of the blood rich in platelets and growth factors is extracted and injected into the site of injury.  Studies have shown that PRP injections into acute injuries may increase the speed of recovery, and injections into long-standing (chronic) injuries may cause the body to renew the healing process.

The application of PRP injections are still being investigated, but the treatment has already been used for various forms of injury with positive results.  PRP treatment has been used to help treat Achilles tendon injury, and is typically reserved for patients who fail traditional therapy.  PRP injection therapy may not be for everyone, and treatment must be considered on an individual basis.

Source Material

Achilles Injury

Alfredson, H; Lorentzon, R.  Chronic Achilles tendinosis: recommendations for treatment and prevention.Sports Med. 2000;29(2):135.

Jozsa, L; Kvist, M; Balint, BJ; Reffy, A; Jarvinen, M; Lehto, M; Barzo, M. The role of recreational sport activity in Achilles tendon rupture: A clinical, pathoanatomical and sociological study of 292 cases. Am J Sports Med. 1989; 17(3): 338.

Gravlee, JR; Hatch, RL; Galea, AM.  Achilles tendon rupture: a challenging diagnosis. J Am Board Fam Pract. 2000; 13(5):371.

Maffulli, N.  The clinical diagnosis of subcutaneous tear of the Achilles tendon: A prospective study in 174 patients.  Am J Sports Med. 1998; 26(2):266.

Mayer, F; Hirschmuller, A; Muller, S; Schuberth, M; Baur, H.  Effects of short-term treatment strategies over 4 weeks in Achilles tendinopathy.  Br J Sports Med. 2007; 41(7):e6.

Khan, RJ, Carey Smith, RL. Surgical interventions for treating acute Achilles tendon ruptures. Cochrane Database Syst Rev. 2010.

PRP Injections

de Jonge, S; de Vos, RJ; Weir, A; van Schie, HT; Bierma-Zeinstra, SM; Verhaar, JA; Weinans, H; Tol, JL. One-year follow-up of platelet-rich plasma treatment in chronic Achilles tendinopathy: a double-blind randomized placebo-controlled trial. Am J Sports Med. 2011 Aug;39(8):1623-9.

Griffin, LY.  Treating tendinopathy with PRP.  AAOS. 2010 Sept; 7(3). http://www.aaos.org/news/aaosnow/sep10/clinical2.asp .

Mautner, K; Colberg, RE; Malanga, G; Borg-Stein, JP; Harmon, KG; Dharamsi, AS; Chu, S; Homer, P. Outcomes after ultrasound-guided platelet-rich plasma injections for chronic tendinopathy: a multicenter, retrospective review.  PM R. 2013 Mar;5(3):169-75.

Monto, RR. Platelet rich plasma treatment for chronic Achilles tendinosis.  Foot Ankle Int. 2012 May; 33(5):379-85.

Soomekh, D; Yau, SK; Baravarian, B. A Closer Look At Platelet-Rich Plasma For Achilles Tendon Pathology. Podiatry Today. 2011 Nov; 24(11):50.

Storrs, C.  Is Platelet-Rich Plasma an Effective Healing Therapy? Scientific American.  Dec 18, 2009. http://www.scientificamerican.com/article.cfm?id=platelet-rich-plasma-therapy-dennis-cardone-sports-medicine-injury.