Chou: OKU: Foot and Ankle 7

Section 7: Tendon Disorders and Sports-Related Foot and Ankle Injuries

has been associated with inflammatory or autoimmune disorders, systemic or injectable steroid use, collagen abnormality, exposure to fluoroquinolones, repetitive microtrauma, metabolic disorders, and overpronation of the foot. An acute rupture usually can be diagnosed on the basis of the patient’s history and physical examination. Most patients have a history of a traumatic event and describe a feeling of being kicked in the heel. Walking and climbing or descending stairs may be difficult. Examination reveals decreased plantar flexion strength, swelling around the tendon and loss of tendon contour, a palpable gap, lack of ankle movement when the calf is squeezed (the Thompson test), and an increased dorsiflex ion position of the ankle when the patient is prone and the knee is bent to 90° ( Figure 1 ). Imaging is rarely needed to confirm diagnosis of an acute Achilles tendon rupture. In fact, a retrospective study comparing patients with confirmed intraoperative Achilles tendon ruptures who had undergone preoperative MRI with those who did not undergo preoperative MRI found that a positive physical examination was more sensitive in diagnosing Achilles tendon rupture than radiologists’ interpretation of MRI. The authors suggest that MRI evaluation be reserved for patients with equivocal examination findings, or in the setting of chronic injuries for preoperative planning. 3 The treatment of an acute Achilles tendon rupture remains controversial. Nonsurgical treatment traditionally

has consisted of prolonged immobilization in plantar flexion, with avoidance of weight bearing. Advocates of nonsurgical treatment emphasize the complications of sur gical treatment, including wound healing–related issues. Surgical treatment traditionally has been recommended for active patients because of the belief that rerupture rates are higher after nonsurgical treatment. Many studies have attempted to answer the question of whether surgical or nonsurgical treatment is superior. In a retrospective study of 945 patients with a nonsur gically treated Achilles tendon rupture, the decision for nonsurgical treatment was based on a palpation finding that the tendon ends were well approximated. 4 Patients were treated with an equinus cast for 4 weeks, a walker boot for the subsequent 4 weeks, and finally physical therapy. All patients were able to return to work and a preinjury level of sports activity. The rerupture rate was 2.8%. Almost all of the patients (99.4%) reported a good or excellent result. A historical control group of surgically treated patients was studied for comparison. A retrospective study of 363 patients who underwent an identical functional rehabilitation program after sur gical or nonsurgical treatment found a rerupture rate of 1.4% after surgical treatment and 8.6% after nonsurgical treatment. 2 The study was limited by the absence of stan dardized criteria for assignment to a treatment group. The patients who were surgically treated tended to be younger and have higher physical demands than those who were nonsurgically treated, or they had sought treatment more than 24 hours after injury. The study findings included no functional or outcome measures. Another study evaluated the functional outcomes of 80 patients who were randomly assigned to surgical or nonsurgical treatment. 5 No signif icant between-group difference was found in peak torque or total work at 1-year follow-up. Patients in both groups had decreased peak torque in the injured leg, however, in comparison with the uninjured leg. Cast immobilization was used for 6 weeks after surgery and for 10 weeks in nonsurgical treatment. The rerupture rates (5.4% in the patients who were surgically treated and 10.3% in those who were nonsurgically treated) were not considered to be statistically significantly different. Early mobilization has been emphasized in the treat ment of Achilles tendon ruptures. A randomized study of 97 patients evaluated functional outcomes when early mobilization was used after surgical or nonsurgical treat ment. 6 All treatment was initiated within 72 hours of injury, and patients in both groups used a removable boot after 2 weeks of immobilization in a short leg equinus cast. The rerupture rate was 4% in patients who were surgically treated and 12% in those who were nonsurgically treated. Functional testing at 6-month follow-up revealed much better results in the patients who were surgically treated, but at 12-month follow-up

Section 7: Tendon Disorders and Sports Related Foot and Ankle Injuries

FIGURE 1 Clinical photograph showing the Matles test, in which the leg with an Achilles tendon rupture has greater dorsiflexion than the normal leg in the background. Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2023

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Orthopaedic Knowledge Update ® : Foot and Ankle 7