Rupture of the Achilles and patellar tendons
Section snippets
Epidemiology
The Achilles tendon is strongest tendon in the body, closely followed by the patellar tendon. Many possible etiological factors have been involved in its rupture, and these can broadly be divided into high-energy disruptions, degenerative changes, and mechanical imbalance. Injuries acquired from participation in sports account for the majority of ruptures [2]. Acute injuries result from rapid force shifts to the lower limb in sports like football, basketball, track and field, volleyball,
Basic science
Tendons were regarded as relatively inert tissue. The cellular elements in a tendon are very active, however, and allow for transmission of high tensile forces, elastic recoil, and longitudinal movement. In the response to physiological strain, microtears can form in the tendon substance, with new collagen being formed simultaneously, thus allowing for tendon remodeling [26]. Due to the helical arrangement of the tendon fibrils and the actin and myosin content, tendons can stretch up to 4%
Achilles tendon
Tensile force normalized to subject weight can be from 2.6 kN when walking to 9 kN when running [30], and the tendon can withstand approximately 50 to 100 N/mm. The mechanism of rupture has been classified into three main categories [31]: (1) 53% arising from weight-bearing, forefoot pushoff with knee in extension (eg, sprinting, jumping sports); (2) 17% occurring following sudden unexpected dorsiflexion of the ankle, such as slipping into a hole or falling downstairs; and (3) 10% arising
Clinical presentation
A detailed history and comprehensive physical examination are essential and often provide enough information for the diagnosis of lower limb tendon rupture.
Investigations
The diagnosis of Achilles and patellar rupture is formulated on a clinical basis. When the diagnosis is dubious, however, various investigations can clarify the diagnosis.
Management
There exists an extensive variety of methods for the management of Achilles tendon ruptures, ranging from those that are managed in an equinus cast to those that an external fixation device are applied to. This reflects the controversy over the best means of treatment [48]. Patellar tendon rupture is best managed by operative reconstruction of the extensor apparatus. The method of choice depends upon timing of repair and operator preference.
Acute Achilles tendon repair
Our method of choice for repairing acute Achilles tendon ruptures is based on the procedure described by Webb and Bannister [17], [66]. This involves a three-incision percutaneous repair under local anesthesia. After infiltration of local anesthesia around the Achilles tendon, the patient is placed prone, and a pillow is placed beneath the anterior aspect of the ankles to allow the feet to hang free. The operating table is angled 20° cranially to reduce venous pooling in the feet and ankles.
Summary
Certain similarities can clearly be appreciated between Achilles and patellar tendon ruptures. Both are strong tendons that transmit force bridging at least one joint of the lower limb. When healthy, both require massive forces to be disrupted, and both can be weakened through certain systemic disease processes, steroids, and fluoroquinones. Both allow for a variety of innovative management possibilities that ultimately lend themselves to individual surgical preference. We feel that, although
References (70)
- et al.
Patellar tendon rupture 3 years after anterior cruciate ligament reconstruction with a central one third bone-patellar tendon-bone graft
Arthroscopy
(2001) - et al.
Overuse tendon injuries: basic science and classification
Oper Tech Sports Med
(1997) - et al.
Demonstration of quantitative fabric analysis of tendon collagen using two-dimensional polarized light microscopy
Matrix
(1991) Relevance of in vivo force measurements to human biomechanics
J Biomech
(1990)- et al.
Pictorial review: the sonographic diagnosis of pathology in the Achilles tendon
Clin Radiol
(1993) - et al.
An audit of the combined non-operative and orthotic management of ruptured tendo Achillis
Injury
(1997) - et al.
Reconstruction of an Achilles tendon defect utilizing an Achilles tendon allograft
J Foot Ankle Surg
(1996) - et al.
Achilles allograft reconstruction of a chronic patellar tendon rupture
Arthroscopy
(1998) - et al.
Chronic rupture of a patellar tendon: a technique for reconstruction with Achilles allograft
Arthroscopy
(1996) - et al.
Carbon fibre used in the late reconstruction of rupture of the extensor mechanism of the knee
Injury
(1987)
Increasing incidence of Achilles tendon rupture
Acta Orthop Scand
Etiology and pathophysiology of tendon ruptures in sports
Scand J Med Sci Sports
Acute Achilles tendon rupture in badminton players
Am J Sports Med
Achilles tendon ruptures in South-East Finland between 1986–1996, with special reference to epidemiology, complications of surgery and hospital costs
Ann Chir Gynaecol
Ruptured Achilles tendons are significantly more degenerated than tendinopathic tendons
Med Sci Sports Exerc
Achilles tendonitis: are corticosteroid injections useful or harmful?
Clin J Sport Med
Bilateral patellar tendon rupture secondary to repeated local steroid injections
J Accid Emerg Med
Spontaneous bilateral rupture of the Achilles tendon in a patient with chronic obstructive pulmonary disease
Respirology
Achilles tendon rupture: an underrated complication of corticosteroid treatment
Thorax
Achilles tendon disease in lung transplant recipients: association with ciprofloxacin
Eur Respir J
Ciprofloxacin-associated Achilles tendon rupture in a hemodialysis patient
J Nephrol
Simultaneous and spontaneous bilateral rupture of the patellar tendon in rheumatoid arthritis. A case report
Acta Orthop Scand
Spontaneous infrapatellar tendon rupture in a patient with systemic lupus erythematosus
Ugeskr Laeger
Patellar tendon rupture in systemic lupus erythematosus
J Rheumatol
Patellar tendon rupture with underlying systemic disease
AJR Am J Roentgenol
Tendon rupture in chronic kidney insufficiency–“uremic tendonopathy”? A literature-supported documentation of 3 cases
Chirurg
Percutaneous repair of the ruptured tendo Achillis
J Bone Joint Surg Br
Achilles tendon lesions in sport
Sports Medicine
Sonographic incidence of tendon microtears in athletes with chronic Achilles tendinosis
Br J Sports Med
Histopathological findings in spontaneous tendon ruptures
Scand J Med Sci Sports
Bilateral rupture of the patella tendon in an otherwise healthy male patient following minor trauma
J Trauma
Patellar and quadriceps tendon ruptures—jumper's knee
Am J Sports Med
Reconstruction of patellar tendon rupture after total knee arthroplasty with an extensor mechanism allograft
Clin Orthop
Rupture of the patellar ligament after use of its central third for anterior cruciate reconstruction. A report of two cases
J Bone Joint Surg Am
Patellar tendon matrix changes associated with aging and voluntary exercise
J Appl Physiol
Cited by (53)
Outcomes following quadriceps tendon repair using transosseous tunnels versus suture anchors: A systematic review
2021, InjuryCitation Excerpt :It is most often seen in the sixth and seventh decades of life; this demographic age is higher than the average age of patients suffering patellar tendon ruptures [2]. Men are at greater risk with the incidence favoring male-to-female ratio at 8:1 [2]. Typically, the tendon ruptures at or superior to the patellar insertion site following an acute traumatic event [1,2].
Surgical Treatment for Chronic Rupture of the Patellar Tendon Performed in 2 Stages
2020, Arthroscopy TechniquesTotal bilateral ruptures of the knee extensor apparatus
2017, Revista Brasileira de OrtopediaAdult native knee extensor mechanism ruptures
2016, InjuryCitation Excerpt :This has prompted rehabilitation protocols that allow early passive flexion between 30° −90° of flexion from the first post-operative day [86,87]. Although these protocols have demonstrated a return to pre-injury sporting activity [73,80,88], controversy remains over the optimal weight-bearing status following surgery [66,88,89]. The risk of re-rupture is of particular concern with up to 40% being reported in patients with previous total knee arthroplasty [90].
Patellar tendon: From tendinopathy to rupture
2015, Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and TechnologyDiagnosis of patellar tendon rupture by emergency ultrasound
2014, Journal of Emergency MedicineCitation Excerpt :Rupture requires a force of 17.5 times body weight in a healthy adult (2). Risk for rupture increases in chronic medical conditions such as hyperparathyroidism, rheumatoid arthritis, immunosuppression, systemic lupus erythematosus, and with the use of steroids and fluoroquinolones (3–6). Patella tendon ruptures are more common in patients < 40 years old participating in athletics where the extensor mechanism is overloaded (7).