Skip to main content

Advertisement

SpringerLink
Log in

Achilles tendon injuries

  • Foot and Ankle Sports Medicine (M Drakos, section editor)
  • Published:
Current Reviews in Musculoskeletal Medicine Aims and scope Submit manuscript

Abstract

Purpose of review

The purpose of this study is to review the current literature of Achilles tendon injuries, specifically chronic tendinopathy and acute ruptures in regard to etiology, diagnosis, treatment options, and outcomes.

Recent findings

The incidence of Achilles tendon injuries is increasing, but the necessity for surgical intervention is decreasing due to improved conservative therapies, which may provide comparable outcomes without the implied surgical risk. If surgery is undertaken, no difference has been noted between open and minimally invasive techniques. The majority of patients are able to return to pre-injury level of activity, with the elite athlete as an unfortunate exception.

Summary

Achilles injuries can be devastating injuries, but if addressed early and appropriately, most patients have good self-reported long-term outcomes regardless of the treatment modality implemented. Further research is needed into the etiology, potential preventative measures, and longer-term outcomes of the different treatment options for wide range of Achilles pathology.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Holmes GB, Lin J. Etiologic factors associated with symptomatic Achilles tendinopathy. Foot Ankle Int. 2006;27(11):952–9.

    Article  PubMed  Google Scholar 

  2. Sode J, Obel N, Hallas J, Lassen A. Use of fluroquinolone and risk of Achilles tendon rupture: a population-based cohort study. Eur J Clin Pharmacol. 2007;63(5):499–503.

    Article  CAS  PubMed  Google Scholar 

  3. Corrao G, Zambon A, Bertù L, et al. Evidence of tendinitis provoked by fluoroquinolone treatment. Drug Saf. 2006;29(10):889–96.

    Article  CAS  PubMed  Google Scholar 

  4. Van Der Linden PD, van Puijenbroek EP, Feenstra J, et al. Tendon disorders attributed to fluoroquinolones: a study on 42 spontaneous reports in the period 1988 to 1998. Arthritis Care & Research. 2001;45(3):235–9.

    Article  CAS  Google Scholar 

  5. van der Linden PD, Sturkenboom MC, Herings RM, Leufkens HM, Rowlands S, BHC S. Increased risk of Achilles tendon rupture with quinolone antibacterial use, especially in elderly patients taking oral corticosteroids. Arch Intern Med. 2003;163(15):1801–7.

    Article  PubMed  Google Scholar 

  6. Wise BL, Peloquin C, Choi H, Lane NE, Zhang Y. Impact of age, sex, obesity, and steroid use on quinolone-associated tendon disorders. Am J Med. 2012;125(12):1228. e23-1228. e28

    Article  PubMed  PubMed Central  Google Scholar 

  7. Longo UG, Ronga M, Maffulli N. Acute ruptures of the Achilles tendon. Sports Med Arthrosc. 2009;17(2):127–38.

    Article  PubMed  Google Scholar 

  8. Arner O, Lindholm A, ORELL SR. Histologic changes in subcutaneous rupture of the Achilles tendon; a study of 74 cases. Acta Chir Scand. 1959;116(5–6):484–90.

    CAS  PubMed  Google Scholar 

  9. Davidsson L, Salo M. Pathogenesis of subcutaneous tendon ruptures. Acta Chir Scand. 1969;135(3):209–12.

    CAS  PubMed  Google Scholar 

  10. Jozsa L, Kannus P, Balint J, Reffy A. Three-dimensional infrastructure of human tendons. Cells Tissues Organs (Print). 1991;142(4):306–12.

    Article  CAS  Google Scholar 

  11. Jozsa L, Kannus P. Histopathological findings in spontaneous tendon ruptures. Scand J Med Sci Sports. 1997;7(2):113–8.

    Article  CAS  PubMed  Google Scholar 

  12. Kannus P, Jozsa L. Histopathological changes preceding spontaneous rupture of a tendon. A controlled study of 891 patients. J Bone Joint Surg Am. 1991;73(10):1507–25.

    Article  CAS  PubMed  Google Scholar 

  13. Barfred T. Achilles tendon rupture: aetiology and pathogenesis of subcutaneous rupture assessed on the basis of the literature and rupture experiments on rats. Acta Orthop Scand. 1973;44(sup152):1–126.

    Article  Google Scholar 

  14. Inglis AE, Sculco TP. Surgical repair of ruptures of the tendo achillis. Clin Orthop. 1981;156:160–9.

    Google Scholar 

  15. Rompe JD, Furia JP, Maffulli N. Mid-portion Achilles tendinopathy—current options for treatment. Disabil Rehabil. 2008;30(20–22):1666–76.

    Article  PubMed  Google Scholar 

  16. Rolf C, Movin T. Etiology, histopathology, and outcome of surgery in achillodynia. Foot Ankle Int. 1997;18(9):565–9.

    Article  CAS  PubMed  Google Scholar 

  17. Magnan B, Bondi M, Pierantoni S, Samaila E. The pathogenesis of Achilles tendinopathy: a systematic review. Foot and Ankle Surgery. 2014;20(3):154–9.

    Article  PubMed  Google Scholar 

  18. 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):266–70.

    CAS  PubMed  Google Scholar 

  19. Roche AJ, Calder JD. Achilles tendinopathy: a review of the current concepts of treatment. Bone Joint J. 2013;95-B(10):1299–307.

    Article  CAS  PubMed  Google Scholar 

  20. Hutchison A, Evans R, Bodger O, et al. What is the best clinical test for Achilles tendinopathy? Foot and Ankle Surgery. 2013;19(2):112–7.

    Article  PubMed  Google Scholar 

  21. Paavola M, Paakkala T, Kannus P, Järvinen M. Ultrasonography in the differential diagnosis of Achilles tendon injuries and related disorders: a comparison between pre-operative ultrasonography and surgical findings. Acta Radiol. 1998;39(6):612–9.

    Article  CAS  PubMed  Google Scholar 

  22. Paavola M, Kannus P, Paakkala T, Pasanen M, Jarvinen M. Long-term prognosis of patients with Achilles tendinopathy. An observational 8-year follow-up study. Am J Sports Med. 2000;28(5):634–42.

    Article  CAS  Google Scholar 

  23. Öhberg L, Alfredson H. Effects on neovascularisation behind the good results with eccentric training in chronic mid-portion Achilles tendinosis? Knee Surg Sports Traumatol Arthrosc. 2004;12(5):465–70.

    Article  PubMed  Google Scholar 

  24. Alfredson H, Pietila T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med. 1998;26(3):360–6.

    CAS  PubMed  Google Scholar 

  25. Drew BT, Smith TO, Littlewood C, Sturrock B. Do structural changes (eg, collagen/matrix) explain the response to therapeutic exercises in tendinopathy: a systematic review. Br J Sports Med. 2014;48(12):966–72.

    Article  PubMed  Google Scholar 

  26. Chan O, O'Dowd D, Padhiar N, et al. High volume image guided injections in chronic Achilles tendinopathy. Disabil Rehabil. 2008;30(20–22):1697–708.

    Article  PubMed  Google Scholar 

  27. Loppini M, Maffulli N. Conservative management of tendinopathy: an evidence-based approach. MLTJ Muscles, Ligaments and Tendons Journal. 2011;1(4):134–7.

    PubMed  Google Scholar 

  28. de Vos RJ, Weir A, van Schie HT, et al. Platelet-rich plasma injection for chronic Achilles tendinopathy: a randomized controlled trial. JAMA. 2010;303(2):144–9.

    Article  PubMed  Google Scholar 

  29. Silbernagel KG, Brorsson A, Lundberg M. The majority of patients with Achilles tendinopathy recover fully when treated with exercise alone: a 5-year follow-up. Am J Sports Med. 2011;39(3):607–13.

    Article  PubMed  Google Scholar 

  30. Maffulli N, Via AG, Oliva F. Chronic Achilles tendon disorders: tendinopathy and chronic rupture. Clin Sports Med. 2015;34(4):607–24.

    Article  PubMed  Google Scholar 

  31. Lohrer H, David S, Nauck T. Surgical treatment for Achilles tendinopathy–a systematic review. BMC Musculoskelet Disord. 2016;17(1):1.

    Article  Google Scholar 

  32. Laborde JM, Weiler L. Achilles tendon pain treated with gastrocnemius-soleus recession. Orthopedics. 2011;34(4):289–91.

    Article  PubMed  Google Scholar 

  33. Nawoczenski DA, Barske H, Tome J, Dawson LK, Zlotnicki JP, DiGiovanni BF. Isolated gastrocnemius recession for Achilles tendinopathy: strength and functional outcomes. J Bone Joint Surg Am. 2015;97(2):99–105.

    Article  PubMed  Google Scholar 

  34. Schepsis AA, Jones H, Haas AL. Achilles tendon disorders in athletes. Am J Sports Med. 2002;30(2):287–305.

    PubMed  Google Scholar 

  35. Uquillas CA, Guss MS, Ryan DJ, Jazrawi LM, Strauss EJ. Everything Achilles: knowledge update and current concepts in management: AAOS exhibit selection. J Bone Joint Surg Am. 2015;97(14):1187–95.

    Article  PubMed  Google Scholar 

  36. DeOrio MJ, Easley ME. Surgical strategies: insertional Achilles tendinopathy. Foot & ankle international. 2008;29(5):542–50.

    Article  Google Scholar 

  37. McGarvey WC, Palumbo RC, Baxter DE, Leibman BD. Insertional Achilles tendinosis: surgical treatment through a central tendon splitting approach. Foot Ankle Int. 2002;23(1):19–25.

    Article  PubMed  Google Scholar 

  38. Hunt KJ, Cohen BE, Davis WH, Anderson RB, Jones CP. Surgical treatment of insertional Achilles tendinopathy with or without flexor hallucis longus tendon transfer: a prospective, randomized study. Foot Ankle Int. 2015;36(9):998–1005.

    Article  PubMed  Google Scholar 

  39. Ellison P, Mason LW, Molloy A. Chronic Achilles tendon rupture reconstructed using hamstring tendon autograft: a case report. Foot. 2016;26:41–4.

    Article  Google Scholar 

  40. El Shazly O, Abou El Soud MM, El Mikkawy DM, El Ganzoury I, Ibrahim AM. Endoscopic-assisted Achilles tendon reconstruction with free hamstring tendon autograft for chronic rupture of Achilles tendon: clinical and isokinetic evaluation. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2014;30(5):622–8.

    Article  Google Scholar 

  41. Leppilahti J, Puranen J, Orava S. Incidence of Achilles tendon rupture. Acta Orthop Scand. 1996;67(3):277–9.

    Article  CAS  PubMed  Google Scholar 

  42. Möller A, Åström M, Westlin NE. Increasing incidence of Achilles tendon rupture. Acta Orthop Scand. 1996;67(5):479–81.

    Article  PubMed  Google Scholar 

  43. Lagergren C, Lindholm A. Vascular distribution in the Achilles tendon; an angiographic and microangiographic study. Acta Chir Scand. 1959;116(5–6):491–5.

    CAS  PubMed  Google Scholar 

  44. Jozsa L, Kvist M, Balint BJ, et al. 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):338–43.

    Article  CAS  PubMed  Google Scholar 

  45. Houshian S, Tscherning T, Riegels-Nielsen P. The epidemiology of Achilles tendon rupture in a Danish county. Injury. 1998;29(9):651–4.

    Article  CAS  PubMed  Google Scholar 

  46. Lantto I, Heikkinen J, Flinkkilä T, Ohtonen P, Leppilahti J. Epidemiology of Achilles tendon ruptures: increasing incidence over a 33 year period. Scand J Med Sci Sports. 2015;25(1):e133–8.

    Article  CAS  PubMed  Google Scholar 

  47. Huttunen TT, Kannus P, Rolf C, Fellander-Tsai L, Mattila VM. Acute Achilles tendon ruptures: incidence of injury and surgery in Sweden between 2001 and 2012. Am J Sports Med. 2014;42(10):2419–23.

    Article  PubMed  Google Scholar 

  48. Ganestam A, Kallemose T, Troelsen A, Barfod KW. Increasing incidence of acute Achilles tendon rupture and a noticeable decline in surgical treatment from 1994 to 2013. A nationwide registry study of 33,160 patients. Knee Surgery, Sports Traumatology, Arthroscopy. 2016 Dec;24(12):3730–7.

  49. Gross CE, Nunley II JA. Acute Achilles tendon ruptures. Foot Ankle Int. 2016;37(2):233–9.

    Article  PubMed  Google Scholar 

  50. Kou J. AAOS Clinical Practice Guideline: acute Achilles tendon rupture. J Am Acad Orthop Surg. 2010;18(8):511–3.

    Article  PubMed  Google Scholar 

  51. Garras DN, Raikin SM, Bhat SB, Taweel N, Karanjia H. MRI is unnecessary for diagnosing acute Achilles tendon ruptures: clinical diagnostic criteria. Clin Orthop Relat Res. 2012;470(8):2268–73.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Margetić P, Miklić D, Rakić-Eržek V, Doko Z, Ivan Lubina Z, Brkljačić B. Comparison of ultrasonographic and intraoperative findings in Achilles tendon rupture. Coll Antropol. 2007;31(1):279–84.

    PubMed  Google Scholar 

  53. Kotnis R, David S, Handley R, Willett K, Ostlere S. Dynamic ultrasound as a selection tool for reducing Achilles tendon reruptures. Am J Sports Med. 2006;34(9):1395–400.

    Article  PubMed  Google Scholar 

  54. Kayser R, Mahlfeld K, Heyde CE. Partial rupture of the proximal Achilles tendon: a differential diagnostic problem in ultrasound imaging. Br J Sports Med. 2005;39(11):838–42. discussion 838-42

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  55. Wallace RG, Traynor IE, Kernohan WG, Eames MH. Combined conservative and orthotic management of acute ruptures of the Achilles tendon. J Bone Joint Surg Am. 2004;86-A(6):1198–202.

    Article  PubMed  Google Scholar 

  56. Saleh M, Marshall PD, Senior R, MacFarlane A. The Sheffield splint for controlled early mobilisation after rupture of the calcaneal tendon. A prospective, randomised comparison with plaster treatment. J Bone Joint Surg Br. 1992;74(2):206–9.

    CAS  PubMed  Google Scholar 

  57. Barfod KW, Bencke J, Lauridsen HB, Ban I, Ebskov L, Troelsen A. Nonoperative dynamic treatment of acute Achilles tendon rupture: the influence of early weight-bearing on clinical outcome: a blinded, randomized controlled trial. J Bone Joint Surg Am. 2014;96(18):1497–503.

    Article  PubMed  Google Scholar 

  58. Porter MD, Shadbolt B. Randomized controlled trial of accelerated rehabilitation versus standard protocol following surgical repair of ruptured Achilles tendon. ANZ J Surg. 2015;85(5):373–7.

    Article  PubMed  Google Scholar 

  59. Gigante A, Moschini A, Verdenelli A, Del Torto M, Ulisse S, De Palma L. Open versus percutaneous repair in the treatment of acute Achilles tendon rupture: a randomized prospective study. Knee Surg Sports Traumatol Arthrosc. 2008;16(2):204–9.

    Article  CAS  PubMed  Google Scholar 

  60. Aktas S, Kocaoglu B. Open versus minimal invasive repair with achillon device. Foot Ankle Int. 2009;30(5):391–7.

    Article  PubMed  Google Scholar 

  61. Valencia JAA, Alcalá MÁG. Repair of acute Achilles tendon rupture. Comparative study of two surgical techniques. Acta Ortopédica Mexicana. 2009;23(3):125–9.

    Google Scholar 

  62. Li Q, Wang C, Huo Y, Jia Z, Wang X. Minimally invasive versus open surgery for acute Achilles tendon rupture: a systematic review of overlapping meta-analyses. J Orthop Surg Res. 2016;11(1)

  63. McMahon SE, Smith TO, Hing CB. A meta-analysis of randomised controlled trials comparing conventional to minimally invasive approaches for repair of an Achilles tendon rupture. Foot and Ankle Surgery. 2011;17(4):211–7.

    Article  PubMed  Google Scholar 

  64. Clanton TO, Haytmanek CT, Williams BT, et al. A biomechanical comparison of an open repair and 3 minimally invasive percutaneous Achilles tendon repair techniques during a simulated, progressive rehabilitation protocol. Am J Sports Med. 2015;43(8):1957–64.

    Article  PubMed  Google Scholar 

  65. Wong MWN, Ng VWS. Modified flexor hallucis longus transfer for Achilles insertional rupture in elderly patients. Clin Orthop. 2005;431:201–6.

    Article  Google Scholar 

  66. Khan RJ, Fick D, Keogh A, Crawford J, Brammar T, Parker M. Treatment of acute Achilles tendon ruptures. A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am. 2005;87(10):2202–10.

    PubMed  Google Scholar 

  67. Soroceanu A, Sidhwa F, Aarabi S, Kaufman A, Glazebrook M. Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials. J Bone Joint Surg Am. 2012;94(23):2136–43.

    Article  PubMed  PubMed Central  Google Scholar 

  68. Erickson BJ, Mascarenhas R, Saltzman BM, et al. Is operative treatment of Achilles tendon ruptures superior to nonoperative treatment? A systematic review of overlapping meta-analyses. Orthopaedic Journal of Sports Medicine. 2015;3(4):2325967115579188.

    Article  PubMed  PubMed Central  Google Scholar 

  69. Lantto I, Heikkinen J, Flinkkila T, et al. A prospective randomized trial comparing surgical and nonsurgical treatments of acute Achilles tendon ruptures. Am J Sports Med. 2016;44(9):2406–14.

    Article  PubMed  Google Scholar 

  70. Moller M, Movin T, Granhed H, Lind K, Faxen E, Karlsson J. Acute rupture of tendon achillis. A prospective randomised study of comparison between surgical and non-surgical treatment. J Bone Joint Surg Br. 2001;83(6):843–8.

    Article  CAS  PubMed  Google Scholar 

  71. Zellers JA, Carmont MR, Gravare Silbernagel K. Return to play post-Achilles tendon rupture: a systematic review and meta-analysis of rate and measures of return to play. Br J Sports Med. 2016.

  72. Roos EM, Brandsson S, Karlsson J. Validation of the foot and ankle outcome score for ankle ligament reconstruction. Foot Ankle Int. 2001;22(10):788–94.

    Article  CAS  PubMed  Google Scholar 

  73. Martin RL, Irrgang JJ, Burdett RG, Conti SF, Van Swearingen JM. Evidence of validity for the foot and ankle ability measure (FAAM). Foot Ankle Int. 2005;26(11):968–83.

    PubMed  Google Scholar 

  74. Nilsson-Helander K, Thomee R, Silbernagel KG, et al. The Achilles Tendon Total Rupture Score (ATRS): development and validation. Am J Sports Med. 2007;35(3):421–6.

    Article  PubMed  Google Scholar 

  75. Halasi T, Kynsburg A, Tallay A, Berkes I. Development of a new activity score for the evaluation of ankle instability. Am J Sports Med. 2004;32(4):899–908.

    Article  PubMed  Google Scholar 

  76. Olsson N, Petzold M, Brorsson A, Karlsson J, Eriksson BI, Silbernagel KG. Predictors of clinical outcome after acute Achilles tendon ruptures. Am J Sports Med. 2014;42(6):1448–55.

    Article  PubMed  Google Scholar 

  77. Hansen MS, Christensen M, Budolfsen T, et al. Achilles tendon total rupture score at 3 months can predict patients’ ability to return to sport 1 year after injury. Knee Surg Sports Traumatol Arthrosc. 2016;24(4):1365–71.

    Article  PubMed  Google Scholar 

  78. Olsson N, Nilsson-Helander K, Karlsson J, et al. Major functional deficits persist 2 years after acute Achilles tendon rupture. Knee Surg Sports Traumatol Arthrosc. 2011;19(8):1385–93.

    Article  PubMed  Google Scholar 

  79. Horstmann T, Lukas C, Merk J, Brauner T, Mündermann A. Deficits 10-years after Achilles tendon repair. Int J Sports Med. 2012;33(06):474–9.

    Article  CAS  PubMed  Google Scholar 

  80. Parekh SG, Wray WH, Brimmo O, Sennett BJ, Wapner KL. Epidemiology and outcomes of Achilles tendon ruptures in the national football league. Foot & ankle specialist. 2009;2(6):283–6.

    Article  Google Scholar 

  81. Amin NH, Old AB, Tabb LP, Garg R, Toossi N, Cerynik DL. Performance outcomes after repair of complete Achilles tendon ruptures in national basketball association players. Am J Sports Med. 2013;41(8):1864–8.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, The Cleveland Clinic Foundation, 2049 E 100th St, Desk A40, Cleveland, OH, 44195, USA

    Anthony C. Egger & Mark J. Berkowitz

Authors
  1. Anthony C. Egger
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mark J. Berkowitz
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Anthony C. Egger.

Ethics declarations

Conflict of interest

Anthony C. Egger and Mark J. Berkowitz declare that they have no conflict of interest.

Human and animal rights and informed consent

This article does not contain any studies with animal subjects performed by any of the authors. With regard to the authors’ research cited in this paper, all procedures were followed in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2000 and 2008.

Additional information

This article is part of the Topical Collection on Foot and Ankle Sports Medicine

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Egger, A.C., Berkowitz, M.J. Achilles tendon injuries. Curr Rev Musculoskelet Med 10, 72–80 (2017). https://doi.org/10.1007/s12178-017-9386-7

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12178-017-9386-7

Keywords

Search

Navigation