Achilles tendon rupture

Last updated
Achilles tendon rupture
Other namesAchilles tendon tear, [1] Achilles rupture [2]
Achilles Tendon Tear.png
The achilles tendon
Specialty Orthopedics, emergency medicine
Symptoms Pain in the heel [3]
Usual onsetSudden [3]
CausesForced plantar flexion of the foot, direct trauma, long-standing tendonitis [4]
Risk factors Fluoroquinolones, significant change in exercise, rheumatoid arthritis, gout, corticosteroids [1] [5]
Diagnostic method Based on symptoms and examination, supported by medical imaging [5]
Differential diagnosis Achilles tendinitis, ankle sprain, avulsion fracture of the calcaneus [5]
Treatment Casting or surgery [6] [5]
Frequency1 per 10,000 people per year [5]

Achilles tendon rupture is when the Achilles tendon, at the back of the ankle, breaks. [5] Symptoms include the sudden onset of sharp pain in the heel. [3] A snapping sound may be heard as the tendon breaks and walking becomes difficult. [4]

Contents

Rupture typically occurs as a result of a sudden bending up of the foot when the calf muscle is engaged, direct trauma, or long-standing tendonitis. [4] [5] Other risk factors include the use of fluoroquinolones, a significant change in exercise, rheumatoid arthritis, gout, or corticosteroid use. [1] [5] Diagnosis is typically based on symptoms and examination and supported by medical imaging. [5]

Prevention may include stretching before activity and gradual progression of exercise intensity. [4] Treatment may consist of surgical repair or conservative management. [6] [2] Quick return to weight bearing (within 4 weeks) appears okay and is often recommended. [6] [7] While surgery traditionally results in a small decrease in the risk of re-rupture, the risk of other complications is greater. [2] Non surgical treatment is an alternative as there are supporting evidences that rerupture rates and satisfactory outcomes are comparable to surgery. [2] If appropriate treatment does not occur within 4 weeks of the injury outcomes are not as good. [8]

Achilles tendon rupture occurs in about 1 per 10,000 people per year. [5] Males are more commonly affected than females. [1] People in their 30s to 50s are most commonly affected. [5]

Signs and symptoms

The main symptom of an Achilles tendon rupture is the sudden onset of sharp pain in the heel. Additionally, a snap or "pop" may be heard as the tendon breaks. Some people describe the pain as a hit or kick behind the lower leg. There is difficulty walking immediately. It may be difficult to push off or stand on the toes of the injured leg. Swelling may be present around the heel. [4]

Causes

The Achilles tendon is most often injured by sudden downward or upward movement of the foot, or by forced upward flexion of the foot outside its normal range of motion. [9] Other ways the Achilles tendon can be torn involve sudden direct trauma or damage to the tendon, or sudden use of the Achilles after prolonged periods of inactivity, such as bed rest or leg injury. Some other common tears can happen from intense sports overuse. Twisting or jerking motions can also contribute to injury. [4] Some antibiotics, such as levofloxacin, may increase the risk of tendon injury or rupture. These antibiotics are known as Fluoroquinolones. [10] As of 2016 the mechanism through which quinolones cause this was unclear. [10]

Many people may develop an Achilles rupture or tear, such as recreational athletes, older people, or those with a previous Achilles tendon injury. Tendon injections, quinolone use, and extreme changes in exercise intensity can contribute. [4] Most cases of Achilles tendon rupture are traumatic sports injuries. The average age of patients is 29–40 years with a male-to-female ratio of nearly 20:1. Yet, recent studies have shown that Achilles tendon ruptures are rising in all ages up to 60 years of age. It has been theorized that this is due to the popularity of remaining active with older age. [11] Additionally, even the occasional weekend exercise activity for "weekend warriors" may put one at risk. The risk continues to be higher in people who are older than 60, and also taking corticosteroids, or have kidney disease. Risk also increases with dose amount and for longer periods of time. [11]

Anatomy

Achilles anatomy 1123 Muscles of the Leg that Move the Foot and Toes b.png
Achilles anatomy

The Achilles tendon is the strongest and thickest tendon in the body. [12] It connects the calf muscles to the heel bone of the foot. The calf muscles are the gastrocnemius, soleus and the heel bone is called the calcaneus. It is approximately 15 centimeters (5.9 inches) long and begins near the middle part of the calf. Contraction of the calf muscles flexes the foot down. This is important in activities such as walking, jumping, and running. The Achilles tendon receives its blood supply from its muscular and tendon junction. Its nerve supply is from the sural nerve and to a lesser degree from the tibial nerve. [12]

Diagnosis

Calf squeeze test in a person with a right Achilles tendon rupture

Diagnosis is based on symptoms and history of the event. People describe it like being kicked or shot behind the ankle. During physical examination, a gap may be felt above the heel unless swelling is present. A common physical exam test the doctor or provider may perform is the Simmonds' test (aka Thompson test). To perform the test, have the person lay on their stomach, face down, and with their feet hanging from the exam table. The test is positive if squeezing the calf muscles of the affected side results in no movement (no passive plantarflexion) of the foot. The test is negative with an intact Achilles tendon and squeezing the calf muscle results in the foot flexing down. Walking is usually impaired, as the person will be unable to step off the ground using the injured leg. The person will also be unable to stand up on the toes of that leg, and pointing the foot downward (plantarflexion) is impaired. Pain may be severe, and swelling around the ankle is common. [13]

Although a tear may be diagnosed by history and physical exam alone, an ultrasound scan is sometimes required to clarify or confirm the diagnosis. Once diagnosis is made, ultrasound imaging is an effective way to monitor the healing progress of the tendon over time. An ultrasound is recommended over MRI and MRI is generally not needed. [11] [14] Both MRI and ultrasound are effective tools and have their strengths and limitations. However, when it comes to an Achilles tendon tear, an ultrasound is usually recommended first because of convenience, quick availability, and cost. [15]

Imaging

Achilles tendon rupture seen on ultrasound. Note discontinuity over several centimeters (red line). No fracture or avulsion (radiograph). Achillessehnenruptur Sono.jpg
Achilles tendon rupture seen on ultrasound. Note discontinuity over several centimeters (red line). No fracture or avulsion (radiograph).

Ultrasonography can be used to determine the tendon thickness, character, and presence of a tear. It works by sending harmless high frequencies of sound waves through the body. Some of these sound waves reflect back off the spaces between fluid and soft tissue or bone. These reflected images are analyzed and created into an image. These images capture in real time and are helpful in detecting movement of the tendon and visualizing injuries or tears. This device makes it possible to identify injuries and observe healing over time. Ultrasound is inexpensive and involves no harmful radiation. It is operator-dependent and so requires a level of skill and practice for it to be used effectively. [15]

MRI can be used to distinguish incomplete ruptures from degeneration of the Achilles tendon. MRI can also distinguish between paratenonitis, tendinosis, and bursitis. This technique uses a strong uniform magnetic field to align millions of protons running through the body. These protons are then bombarded with radio waves that knock some of them out of alignment. When these protons return they emit their own unique radio waves that is analyzed by a computer in 3D to create a sharp cross sectional image of the area. MRI provides excellent soft tissue imaging making it easier for technicians to spot tears or other injuries. [16]

Radiography can also be used to indirectly identify Achilles tendon tears. Radiography uses X-rays to analyze the point of injury. This is not very effective at identifying soft tissue injuries. X-rays are created when high energy electrons hit a metal source. X-ray images are acquired by utilizing the different densities of the bone or tissue. When these rays pass through tissue they are captured on film. X-rays are generally best for dense objects such as bone while soft tissue is shown poorly. Radiography is not the best for assessing an Achilles tendon injury. It is more useful for ruling out other injuries such as heal bone fractures. [14]

Differential diagnosis

Some conditions to consider when diagnosing an Achilles tendon tear are Achilles tendinitis, ankle sprain, and avulsion fracture of the calcaneus.

Treatment

Surgical repair of a ruptured Achilles tendon. Ruptured achilles tendon.jpg
Surgical repair of a ruptured Achilles tendon.

Treatment options include surgery and non-surgical rehabilitation. [3] Surgery has shown a lower risk of re-rupture. However, it has a higher rate of short-term problems. [3] Surgery complications include leg clots, nerve damage, infection, and clots in the lungs. The most common problem after non-surgical treatment is leg clots. The main problem after surgery is infection. [17] Certain rehabilitation techniques have shown similar re-rupture rates to surgery. [3] In centers without early range of motion rehabilitation available, surgery is preferred to decrease re-rupture rates. [18]

Surgery

There are at least four different types of surgeries; open surgery, percutaneous surgery, ultrasound-guided surgery, and WALANT surgery. [19]

During an open surgery, an incision is made in the back of the leg and the Achilles tendon is stitched together. In complete ruptures, the tendon of another muscle is used and wrapped around the Achilles tendon. Commonly, the tendon of the plantaris is used and this wrapping increases the strength of the repaired tendon. [17] If the quality of tissues is poor, such as from a neglected injury, a reinforcement mesh is an option. These meshes can be of collagen, Artelon or other degradable material. In the case of both poor tissue and significant loss of the Achilles tendon, the flexor hallucis longus tendon can be used. The flexor hallucis longus tendon of the big toe is transferred with free tissue (skin flap) in a process described as a one-stage repair. [18]

In percutaneous surgery, several small incisions are made, rather than one large incision. The tendon is sewn back together through the incision(s). Surgery is often delayed for about a week after the rupture to let the swelling go down. [20] For sedentary patients and those who have vascular diseases or risks for poor healing, percutaneous surgical repair may be the better surgical option. [21] Surgical care is evolving, with minimally invasive and percutaneous surgical techniques. These developments hope to lessen the risk of wound complications and infections found with open surgery. These techniques are more challenging than traditional open surgery, with a learning curve for surgeons, and are not yet widely used. [22]

Rehabilitation

Non-surgical treatment used to be long and a tedious process. It involved a series of casts, and took longer to complete than surgical treatment. Recently, both surgical and non-surgical rehabilitation protocols have become quicker and more successful. [23] Before, patients who underwent surgery would wear a cast for approximately 4 to 8 weeks. After surgery, they were only allowed to gently move the ankle once out of the cast. Recent studies have shown that is not the best method. Patients that are allowed to gently move and stretch the ankle immediately after surgery, have faster and more successful recoveries. [23] They will wear removable boots to ensure their safety with these exercises. For surgical and non-surgical patients, they will still generally limit non-weightbearing (NWB) activity to two weeks. [20] This is done using modern removable boots, either fixed or hinged, rather than casts. Physiotherapy is often begun as early as two weeks regardless of surgical or non-surgical treatment. [23] This includes weightbearing and range of motion exercises. This is followed by progressive strengthening and general conditioning of the muscle and tendon. [20]

There are three things to consider with Achilles rupture rehabilitation. These are range of motion, functional strength, and sometimes orthotic support. [23] Range of motion is important because it takes into mind the tightness of the repaired tendon. When beginning rehabilitation, a person should perform light stretches. Over time, the goal should be to increase the intensity of that stretch. Stretching the tendon is important because it stimulates connective tissue repair. [23] This can be done while performing the "runner's stretch". The runner's stretch involves putting the toes a few inches up a wall while the heel is on the ground. Doing stretches to gain functional strength is also important because it improves healing in the tendon. This will in turn lead to a quicker return to activities. These stretches should continue to increase in intensity over time. Over time the goal is to include some weight bearing, to reorient and strengthen the collagen fibers in the injured ankle. [23] A popular stretch used for this phase of rehabilitation is the toe raise on an elevated surface. The patient is to push up onto the toes and lower themselves as far down as possible and repeat several times. The other part of the rehab process is orthotic support. This doesn't have anything to do with stretching or strengthening the tendon, rather it is in place to keep the patient comfortable. [24] These are custom-made inserts that fit into the patient's shoe. They help with proper pronation of the foot, which is when the ankle leans toward the middle of the body.

In summary, the steps of rehabilitating a ruptured Achilles tendon begin with range of motion type stretching. Studies have shown that the earlier movement is started, the better. [23] This will allow the ankle to get used to moving again and get ready for weight-bearing activities. This is followed by functional strength. This is where weight-bearing should begin to strengthen the tendon. The intensity should gradually increase over time. The end goal is to get the person to resume their normal and athletic activities. [21] [22]

Epidemiology

Of all the large tendon ruptures, 1 in 5 will be an Achilles tendon rupture. An Achilles tendon rupture is estimated to occur in a little over 1 per 10,000 people per year. Males are also over 2 times more likely to develop an Achilles tendon rupture as opposed to women. Achilles tendon rupture tends to occur most frequently between the ages of 25-40 and over 60 years of age. Sports and high-impact activity is the most common cause of rupture in younger people, whereas sudden rupture from chronic tendon damage is more common in older people. [25] The rate of return to sports in the months or years following the rupture (whether operated on or not, partial or total) is 70 to 80%. [26]

Related Research Articles

<span class="mw-page-title-main">Rotator cuff</span> Group of muscles

The rotator cuff is a group of muscles and their tendons that act to stabilize the human shoulder and allow for its extensive range of motion. Of the seven scapulohumeral muscles, four make up the rotator cuff. The four muscles are:

<span class="mw-page-title-main">Tendinopathy</span> Inflammation of the tendon

Tendinopathy is a type of tendon disorder that results in pain, swelling, and impaired function. The pain is typically worse with movement. It most commonly occurs around the shoulder, elbow, wrist, hip, knee, or ankle.

<span class="mw-page-title-main">Achilles tendon</span> Tendon at the back of the lower leg

The Achilles tendon or heel cord, also known as the calcaneal tendon, is a tendon at the back of the lower leg, and is the thickest in the human body. It serves to attach the plantaris, gastrocnemius (calf) and soleus muscles to the calcaneus (heel) bone. These muscles, acting via the tendon, cause plantar flexion of the foot at the ankle joint, and flexion at the knee.

<span class="mw-page-title-main">Sprain</span> Damage to one or more ligaments in a joint

A sprain is a soft tissue injury of the ligaments within a joint, often caused by a sudden movement abruptly forcing the joint to exceed its functional range of motion. Ligaments are tough, inelastic fibers made of collagen that connect two or more bones to form a joint and are important for joint stability and proprioception, which is the body's sense of limb position and movement. Sprains may be mild, moderate, or severe, with the latter two classes involving some degree of tearing of the ligament. Sprains can occur at any joint but most commonly occur in the ankle, knee, or wrist. An equivalent injury to a muscle or tendon is known as a strain.

<span class="mw-page-title-main">Clubfoot</span> Bone development disease

Clubfoot is a congenital or acquired defect where one or both feet are rotated inward and downward. Congenital clubfoot is the most common congenital malformation of the foot with an incidence of 1 per 1000 births. In approximately 50% of cases, clubfoot affects both feet, but it can present unilaterally causing one leg or foot to be shorter than the other. Most of the time, it is not associated with other problems. Without appropriate treatment, the foot deformity will persist and lead to pain and impaired ability to walk, which can have a dramatic impact on the quality of life.

<span class="mw-page-title-main">Baker's cyst</span> Medical condition

A Baker's cyst, also known as a popliteal cyst, is a type of fluid collection behind the knee. Often there are no symptoms. If symptoms do occur these may include swelling and pain behind the knee, or knee stiffness. If the cyst breaks open, pain may significantly increase with swelling of the calf. Rarely complications such as deep vein thrombosis, peripheral neuropathy, ischemia, or compartment syndrome may occur.

<span class="mw-page-title-main">Plantar fascia</span> Aponeurosis of the sole of the foot

The plantar fascia or plantar aponeurosis is the thick connective tissue aponeurosis which supports the arch on the bottom of the foot. Recent studies suggest that the plantar fascia is actually an aponeurosis rather than true fascia. It runs from the tuberosity of the calcaneus forward to the heads of the metatarsal bones.

<span class="mw-page-title-main">Plantar fasciitis</span> Connective tissue disorder of the heel

Plantar fasciitis or plantar heel pain is a disorder of the plantar fascia, which is the connective tissue which supports the arch of the foot. It results in pain in the heel and bottom of the foot that is usually most severe with the first steps of the day or following a period of rest. Pain is also frequently brought on by bending the foot and toes up towards the shin. The pain typically comes on gradually, and it affects both feet in about one-third of cases.

<span class="mw-page-title-main">Achilles tendinitis</span> Medical condition of the ankle and heel

Achilles tendinitis, also known as achilles tendinopathy, occurs when the Achilles tendon, found at the back of the ankle, becomes sore. Achilles tendinopathy is accompanied by alterations in the tendon's structure and mechanical properties. The most common symptoms are pain and swelling around the affected tendon. The pain is typically worse at the start of exercise and decreases thereafter. Stiffness of the ankle may also be present. Onset is generally gradual.

<span class="mw-page-title-main">Rotator cuff tear</span> Shoulder injury

Rotator cuff tendinopathy is a process of senescence. The pathophysiology is mucoid degeneration. Most people develop rotator cuff tendinopathy within their lifetime.

<span class="mw-page-title-main">Snapping hip syndrome</span> Medical condition

Snapping hip syndrome, also referred to as dancer's hip, is a medical condition characterized by a snapping sensation felt when the hip is flexed and extended. This may be accompanied by a snapping or popping noise and pain or discomfort. Pain often decreases with rest and diminished activity. Snapping hip syndrome is commonly classified by the location of the snapping as either extra-articular or intra-articular.

<span class="mw-page-title-main">Anterior cruciate ligament injury</span> Ligament injury near the knee

An anterior cruciate ligament injury occurs when the anterior cruciate ligament (ACL) is either stretched, partially torn, or completely torn. The most common injury is a complete tear. Symptoms include pain, an audible cracking sound during injury, instability of the knee, and joint swelling. Swelling generally appears within a couple of hours. In approximately 50% of cases, other structures of the knee such as surrounding ligaments, cartilage, or meniscus are damaged.

<span class="mw-page-title-main">Unhappy triad</span> Medical condition of the knee

The unhappy triad, also known as a blown knee among other names, is an injury to the anterior cruciate ligament, medial collateral ligament, and meniscus. Analysis during the 1990s indicated that this 'classic' O'Donoghue triad is actually an unusual clinical entity among athletes with knee injuries. Some authors mistakenly believe that in this type of injury, "combined anterior cruciate and medial collateral ligament disruptions that were incurred during athletic endeavors" always present with concomitant medial meniscus injury. However, the 1990 analysis showed that lateral meniscus tears are more common than medial meniscus tears in conjunction with sprains of the ACL.

<span class="mw-page-title-main">Calcaneal fracture</span> Medical condition

A calcaneal fracture is a break of the calcaneus. Symptoms may include pain, bruising, trouble walking, and deformity of the heel. It may be associated with breaks of the hip or back.

A high ankle sprain, also known as a syndesmotic ankle sprain (SAS), is a sprain of the syndesmotic ligaments that connect the tibia and fibula in the lower leg, thereby creating a mortise and tenon joint for the ankle. High ankle sprains are described as high because they are located above the ankle. They comprise approximately 15% of all ankle sprains. Unlike the common lateral ankle sprains, when ligaments around the ankle are injured through an inward twisting, high ankle sprains are caused when the lower leg and foot externally rotates.

Posterolateral corner injuries of the knee are injuries to a complex area formed by the interaction of multiple structures. Injuries to the posterolateral corner can be debilitating to the person and require recognition and treatment to avoid long term consequences. Injuries to the PLC often occur in combination with other ligamentous injuries to the knee; most commonly the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL). As with any injury, an understanding of the anatomy and functional interactions of the posterolateral corner is important to diagnosing and treating the injury.

Running injuries affect about half of runners annually. The frequencies of various RRI depend on the type of running, such as speed and mileage. Some injuries are acute, caused by sudden overstress, such as side stitch, strains, and sprains. Many of the common injuries that affect runners are chronic, developing over longer periods as the result of overuse. Common overuse injuries include shin splints, stress fractures, Achilles tendinitis, Iliotibial band syndrome, Patellofemoral pain, and plantar fasciitis.

<span class="mw-page-title-main">Plantar fascial rupture</span> Medical condition

A plantar fascial rupture, is a painful tear in the plantar fascia. The plantar fascia is a connective tissue that spans across the bottom of the foot. The condition plantar fasciitis may increase the likelihood of rupture. A plantar fascial rupture may be mistaken for plantar fasciitis or even a calcaneal fracture. To allow for proper diagnosis, an MRI is often needed.

<span class="mw-page-title-main">Biceps tendon rupture</span> Complete or partial rupture of a tendon of the biceps brachii muscle

A biceps tendon rupture or bicep tear is a complete or partial rupture of a tendon of the biceps brachii muscle. It can affect any of the three biceps brachii tendons - the proximal tendon of the short head of the muscle belly, the proximal tendon of the long head of the muscle belly, or the distal tendon. The characteristic finding of a biceps tendon rupture is the Popeye sign. Patients often report an audible pop at the time of injury as well as pain, bruising, and swelling. Provocative physical exam maneuvers to assess for a rupture include Ludington's test, Hook test, and the Ruland biceps squeeze test. Treatment and prognosis are highly dependent on the site of the injury described in further detail below.

Posterior tibial tendon dysfunction is the dysfunction of the posterior tibial tendon. It is a progressive disease that has four stages and is the most common cause of adult flatfoot.

References

  1. 1 2 3 4 "Achilles Tendon Tears". MSD Manual Professional Edition. August 2017. Retrieved 26 June 2018.
  2. 1 2 3 4 Ochen Y, Beks RB, van Heijl M, Hietbrink F, Leenen LP, van der Velde D, et al. (January 2019). "Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis". BMJ. 364: k5120. doi:10.1136/bmj.k5120. PMC   6322065 . PMID   30617123.
  3. 1 2 3 4 5 6 Hubbard MJ, Hildebrand BA, Battafarano MM, Battafarano DF (June 2018). "Common Soft Tissue Musculoskeletal Pain Disorders". Primary Care. 45 (2): 289–303. doi:10.1016/j.pop.2018.02.006. PMID   29759125. S2CID   46886582.
  4. 1 2 3 4 5 6 7 Shamrock AG, Varacallo M (January 2018). "Achilles Tendon, Rupture". StatPearls. PMID   28613594.
  5. 1 2 3 4 5 6 7 8 9 10 11 Ferri FF (2015). Ferri's Clinical Advisor 2016 E-Book: 5 Books in 1. Elsevier Health Sciences. p. 19. ISBN   9780323378222.
  6. 1 2 3 El-Akkawi AI, Joanroy R, Barfod KW, Kallemose T, Kristensen SS, Viberg B (March 2018). "Effect of Early Versus Late Weightbearing in Conservatively Treated Acute Achilles Tendon Rupture: A Meta-Analysis". The Journal of Foot and Ankle Surgery. 57 (2): 346–352. doi:10.1053/j.jfas.2017.06.006. PMID   28974345. S2CID   3506883.
  7. ↑ van der Eng DM, Schepers T, Goslings JC, Schep NW (2012). "Rerupture rate after early weightbearing in operative versus conservative treatment of Achilles tendon ruptures: a meta-analysis". The Journal of Foot and Ankle Surgery. 52 (5): 622–628. doi:10.1053/j.jfas.2013.03.027. PMID   23659914.
  8. ↑ Maffulli N, Ajis A (June 2008). "Management of chronic ruptures of the Achilles tendon". The Journal of Bone and Joint Surgery. American Volume. 90 (6): 1348–1360. doi:10.2106/JBJS.G.01241. PMID   18519331.
  9. ↑ Shamrock AG, Varacallo M (January 2018). "Achilles Tendon, Rupture". StatPearls. PMID 28613594
  10. 1 2 Bidell MR, Lodise TP (June 2016). "Fluoroquinolone-Associated Tendinopathy: Does Levofloxacin Pose the Greatest Risk?". Pharmacotherapy. 36 (6): 679–693. doi:10.1002/phar.1761. PMID   27138564. S2CID   206359106.
  11. 1 2 3 Dams OC, Reininga IH, Gielen JL, van den Akker-Scheek I, Zwerver J (November 2017). "Imaging modalities in the diagnosis and monitoring of Achilles tendon ruptures: A systematic review" (PDF). Injury. 48 (11): 2383–2399. doi:10.1016/j.injury.2017.09.013. PMID   28943056. S2CID   25815282.
  12. 1 2 Doral MN, Alam M, Bozkurt M, Turhan E, Atay OA, Dönmez G, Maffulli N (May 2010). "Functional anatomy of the Achilles tendon". Knee Surgery, Sports Traumatology, Arthroscopy. 18 (5): 638–643. doi:10.1007/s00167-010-1083-7. PMID   20182867. S2CID   24159374.
  13. ↑ Cuttica DJ, Hyer CF, Berlet GC (January 2015). "Intraoperative value of the thompson test". The Journal of Foot and Ankle Surgery. 54 (1): 99–101. doi:10.1053/j.jfas.2014.09.014. PMID   25441265.
  14. 1 2 Achilles Tendon Injuries~differential at eMedicine
  15. 1 2 Aminlari A, Stone J, McKee R, Subramony R, Nadolski A, Tolia V, Hayden SR (November 2021). "Diagnosing Achilles Tendon Rupture with Ultrasound in Patients Treated Surgically: A Systematic Review and Meta-Analysis". The Journal of Emergency Medicine. 61 (5): 558–567. doi:10.1016/j.jemermed.2021.09.008. PMID   34801318. S2CID   244381264.
  16. ↑ Grover VP, Tognarelli JM, Crossey MM, Cox IJ, Taylor-Robinson SD, McPhail MJ (September 2015). "Magnetic Resonance Imaging: Principles and Techniques: Lessons for Clinicians". Journal of Clinical and Experimental Hepatology. 5 (3): 246–255. doi:10.1016/j.jceh.2015.08.001. PMC   4632105 . PMID   26628842.
  17. 1 2 "Achilles tendon rupture". Mayo Clinic. August 20, 2014.
  18. 1 2 Nazerali RS, Hakimi M, Giza E, Sahar DE. Single-stage reconstruction of achilles tendon rupture with flexor hallucis longus tendon transfer and simultaneous free radial fasciocutaneous forearm flap. Ann Plast Surg. 2013 Apr;70(4):416-8. doi: 10.1097/SAP.0b013e3182853d6c. PMID 23486135.
  19. ↑ "My Achilles tendon rupture | Fisiodue Fisioterapia Palma de Mallorca". Fisiodue (in Spanish). Retrieved 2022-05-09.
  20. 1 2 3 Zellers JA, Christensen M, Kjær IL, Rathleff MS, Silbernagel KG (November 2019). "Defining Components of Early Functional Rehabilitation for Acute Achilles Tendon Rupture: A Systematic Review". Orthopaedic Journal of Sports Medicine. 7 (11): 2325967119884071. doi:10.1177/2325967119884071. PMC   6878623 . PMID   31803789.
  21. 1 2 Cluett J (April 29, 2007). "Achilles Tendon Rupture: What is an Achilles Tendon Rupture". Archived from the original on September 5, 2015. Retrieved August 2, 2015.
  22. 1 2 Christensen KD (July 20, 2003). "Rehab of the Achilles Tendon". Archived from the original on November 29, 2009. Retrieved May 6, 2010.
  23. 1 2 3 4 5 6 7 Huang, Jiazhang; Wang, Chen; Ma, Xin; Wang, Xu; Zhang, Chao; Chen, Li (April 2015). "Rehabilitation Regimen After Surgical Treatment of Acute Achilles Tendon Ruptures: A Systematic Review With Meta-analysis". The American Journal of Sports Medicine. 43 (4): 1008–1016. doi:10.1177/0363546514531014. ISSN   0363-5465. PMID   24793572. S2CID   206528867.
  24. ↑ Scott, Lisa A.; Munteanu, Shannon E.; Menz, Hylton B. (January 2015). "Effectiveness of Orthotic Devices in the Treatment of Achilles Tendinopathy: A Systematic Review". Sports Medicine. 45 (1): 95–110. doi:10.1007/s40279-014-0237-z. ISSN   0112-1642. PMID   25108348. S2CID   25491960.
  25. ↑ Park SH, Lee HS, Young KW, Seo SG. Treatment of Acute Achilles Tendon Rupture. Clin Orthop Surg. 2020;12(1):1-8. doi:10.4055/cios.2020.12.1.1
  26. ↑ Tarantino, Domiziano; Palermi, Stefano; Sirico, Felice; Corrado, Bruno (2020-12-17). "Achilles Tendon Rupture: Mechanisms of Injury, Principles of Rehabilitation and Return to Play". Journal of Functional Morphology and Kinesiology. 5 (4): 95. doi: 10.3390/jfmk5040095 . ISSN   2411-5142. PMC   7804867 . PMID   33467310.
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.