Makindo Medical Notes

Achilles tendon injuries are common in athletes, but they can also occur in non-athletes due to trauma, degenerative changes, or the use of certain medications. Fluoroquinolones (e.g., Ciprofloxacin) and corticosteroid injections in the ankle have been associated with weakening of the tendon, increasing the risk of rupture.

About Achilles Tendon Injury

• Achilles tendon injuries can sometimes present subtly, with symptoms that are not immediately obvious.
• Despite being the strongest and thickest tendon in the body, the Achilles tendon is vulnerable to significant forces that may cause it to rupture.

Aetiology (Causes)

• Achilles tendon injuries are most commonly seen in athletes or middle-aged, occasional sports participants.
• The tendon naturally thins with age, which increases the likelihood of rupture, especially in individuals with underlying conditions such as diabetes or arthritis.
• Use of certain antibiotics, particularly fluoroquinolones (e.g., Ciprofloxacin), can inhibit DNA Gyrase, leading to tendon weakening and increased risk of rupture.
• Repeated use of corticosteroid injections in the ankle area is another significant risk factor for tendon degeneration and rupture.

Clinical Features

• A common presentation is a sudden, sharp "kick" or "snap" sensation in the ankle, which often signals the tendon rupture.
• Symptoms can be subtle, sometimes leading to delayed recognition or diagnosis of the injury.
• Patients may still be able to walk flat-footed, but running is typically not possible due to weakness in the tendon.
• A palpable depression at the site of the rupture is often noted, and there is weakness in plantar flexion.
• In the "Thompson test," squeezing the calf muscle typically fails to produce the expected plantar flexion, and the test may cause pain at the rupture site.
• Partial ruptures of the tendon can present with similar symptoms but less severity compared to full ruptures.
• Some patients may still be able to stand on tiptoes with both feet together, but not with the injured limb alone.

Investigations

• Ultrasound (USS): An effective and non-invasive imaging tool that allows for visualization of the Achilles tendon and the extent of the injury.
• MRI: Useful for confirming the diagnosis, especially in cases where the injury is not clearly visible on ultrasound. However, MRI is not always necessary and can sometimes provide misleading results.

Management

• Non-Surgical Treatment: This is typically recommended for less active individuals or those with partial tears. Treatment involves rest, ice, compression, and elevation (RICE), along with immobilization in a cast or boot to keep the foot in plantar flexion, allowing the tendon to heal naturally. This approach may be sufficient for those who are not heavily involved in physical activity.
• Surgical Treatment: Surgical intervention is often indicated for complete tears or for active individuals who require a faster recovery. The torn ends of the tendon are stitched back together during surgery. Post-surgery, the patient will undergo immobilization followed by a structured physical therapy regimen to regain strength and flexibility.
• Rehabilitation: Rehabilitation is a key component of treatment for both non-surgical and surgical cases. It involves physical therapy aimed at restoring strength, flexibility, and overall function. Full recovery can take several months, and athletes may require up to a year to return to pre-injury levels of activity.