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Have I Got A Ruptured Achilles Tendon?

Overview

Achilles tendon rupture is when the achilles tendon breaks. The achilles is the most commonly injured tendon. Rupture can occur while performing actions requiring explosive acceleration, such as pushing off or jumping. The male to female ratio for Achilles tendon rupture varies between 7:1 and 4:1 across various studies.


Causes
Inflammation/strain of the tendon is usually caused by overuse, for example, frequent jumping in volleyball, netball or basketball. It is often also caused by a sudden increase in certain types of training, such as hill sprinting or track running, particularly when running in spikes. Tendinopathy can also be associated with ageing. Our ability to regenerate damaged tissue decreases as we age and the quality of the tendon deteriorates. However, the better news is that sensible training can actually strengthen all our soft tissue (tendons, ligaments and muscle). Tightness in the calf muscles will demand greater flexibility of the tendon, which inevitably results in overuse and injury. Biomechanically, the tightness can reduce the range of dorsiflexion (toe up position) in the ankle, which increases the amount and duration of pronation. This problem is known as overpronation.* This reduces the ability of the foot to become a rigid lever at push off and places more lateral and linear forces through the tendon. This imbalance can translate into altered rotation of the tibia (shin bone) at the knee joint and, in turn, produce compensatory rotation at the hip joint with subsequent injuries to the shin, knee and hip. Pronation is part of the natural movement of the subtalar joint in the foot. It allows ?eversion? (turning the sole outwards), dorsiflexion and abduction (pointing the toes out to the side). Pronation is a normal part of the gait cycle, when walking and running, and it helps to provide shock absorption in the foot. When pronation is excessive, the foot has a tendency to roll inward more than normally acceptable. One sign of overpronation is greater wear on the inside of your running shoes than on the midsole. Lack of stability around the ankle joint can also be a contributory factor, as recurrent ankle sprains appear to be associated with a high incidence of Achilles tendonopathy. Wearing shoes that don?t fit or support the foot properly can be a major contributing cause of Achilles tendon injury.


Symptoms
Patients with an Achilles tendon rupture will often complain of a sudden snap in the back of the leg. The pain is often intense. With a complete rupture, the individual will only be ambulate with a limp. Most people will not be able to climb stairs, run, or stand on their toes. Swelling around the calf may occur. Patients may often have had a sudden increase in exercise or intensity of activity. Some patients may have had recent corticosteroid injections or use of fluoroquinolone antibiotics. Some athletes may have had a prior injury to the tendon.


Diagnosis
A consultation and physical exam with a qualified musculoskeletal expert is the first step. X-ray or MRI scanning may be required for a diagnosis. Once a rupture is diagnosed it should be treated to prevent loss of strength and inadequate healing.


Non Surgical Treatment
Your doctor will advise you exactly when to start your home physical therapy program, what exercises to do, how much, and for how long to continue them. Alphabet Range of Motion exercises. Typically, the first exercise to be started (once out of a non-removable cast). While holding your knee and leg still (or cross your leg), you simply write the letters of the alphabet in an imaginary fashion while moving your foot and ankle (pretend that the tip of your toe is the tip of a pencil). Motion the capital letter A, then B, then C, all the way through Z. Do this exercise three times per day (or as your doctor advises). Freeze a paper cup with water, and then use the ice to massage the tendon area as deeply as tolerated. The massage helps to reduce the residual inflammation and helps to reduce the scarring and bulkiness of the tendon at the injury site. Do the ice massage for 15-20 minutes, three times per day (or as your doctor advises). Calf Strength exercises. This exercise is typically delayed and not used in the initial stages of rehabilitation, begin only when your doctor advises. This exercise is typically done while standing on just the foot of the injured side. Sometimes, the doctor will advise you to start with standing on both feet. Stand on a step with your forefoot on the step and your heel off the step. The heel and forefoot should be level (neither on your tip toes nor with your heel down). Lower your heel very slowly as low as it will go, then rise back up to the level starting position, again very slowly. This is not a fast exercise. Repeat the exercise as tolerated. The number of repetitions may be very limited at first. Progress the number of repetitions as tolerated. Do this exercise one to two times per day (or as your doctor advises).


Surgical Treatment
While it is possible to treat an Achilles tendon rupture without surgery, this is not ideal since the maximum strength of the muscle and tendon rarely returns. The reason is the ends of the tendon are ruptured in a very irregular manner, almost like the ends of a paint brush. As soon as the tendon ruptures, the calf muscle (gastrocnemius muscle) continues to pull on the tendon and the end of the ruptured tendon pulls back into the leg, which is called retraction. Once the tendon retracts, it is never possible to get sufficient strength back without surgery, because the muscle no longer functions at the correct biomechanical length and is now stretched out. There are patients for whom surgery cannot be performed, in particular, due to existing medical conditions that may add to potential for complications following surgery. For these patients, a specially designed boot that positions the foot correctly and takes the pressure and tension off the muscle and tendon is used. Most importantly, a cast is never used because it causes permanent shrinkage (atrophy) of the calf muscle. The special boot permits pressure on the foot with walking. The boot also has a hinge to permit movement of the ankle. Many studies of Achilles tendon ruptures have shown that this movement of the foot in the boot while walking is ideal for tendon healing. If surgery is not recommended, it is essential to obtain special tests to check that the ends of the tendon are lying next to each other so that healing can occur. The best test to do this is an ultrasound and not an MRI.

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