Partial Achilles Tendon Rupture—A Neglected Entity: A Narrative Literature Review on Diagnostics and Treatment Options

Abstract

Partial ruptures in the Achilles tendon are rather uncommon and are often misinterpreted as aggravated Achilles tendinopathy, and not always considered as a differential diagnosis. The aim of this literature review was to characterize typical symptoms, to provide an overview of available diagnosis and treatment options, and to give reference points for future research. There were few studies and sparse knowledge of scientific value, making it difficult to give evidence-based recommendations. Based on the few studies and the authors’ clinical experience, a diagnosis should be based on a patient’s history with a typical sharp onset of pain and inability to fully load the tendon. Previous intratendinous cortisone injections might be present. Clinical findings are a localized tender region in the tendon and often weakness during heel raises. Ultrasound and Doppler examinations show a region with an irregular and bulging superficial tendon line, often together with localized high blood flow. Magnetic resonance Imaging (MRI) shows a hyperintense signal in the tendon on T1 and T2-weighted sequences. First-line therapy should be a conservative approach using a 2 cm heel lift for the first 6 weeks and avoiding tendon stretching (for 12 weeks). This is followed by a reduced heel lift of 1 cm and progressive tendon loading at weeks 7–12. After 12 weeks, the heel lift can be removed if pain-free, and the patient can gradually start eccentric exercises lowering the heel below floor level and gradually returning to previous sport level. If conservative management has a poor effect, surgical exploration and the excision of the partial rupture and suturing is required. Augmentation procedures or anchor applications might be useful for partial ruptures in the Achilles insertion, but this depends on the size and exact location. After surgery, the 12 to 14-week rehabilitation program used in conservative management can be recommended before the patient’s return to full tendon loading activities.

Multimodal Ultrasound Versus MRI for the Diagnosis and Monitoring of Achilles Tendinopathy: A Prospective Longitudinal Study

“…Bmode might not adequately differentiate between partial tendon tears from local degenerative lesions, as has been shown previously. 16,34 However, we did not confirm the presence of partial ruptures by biopsies or intraoperative findings, and further research is required to assess the capacity of high-frequency ultrasound probes in detecting partial ruptures. 16 Interestingly, the quantitative MRI parameters CSA (79%) and AP diameter (59%) showed good to moderate diagnostic accuracy for insertional and midportion AT monitoring, respectively.…”

“… 16 , 34 However, we did not confirm the presence of partial ruptures by biopsies or intraoperative findings, and further research is required to assess the capacity of high-frequency ultrasound probes in detecting partial ruptures. 16 Interestingly, the quantitative MRI parameters CSA (79%) and AP diameter (59%) showed good to moderate diagnostic accuracy for insertional and midportion AT monitoring, respectively. This is in line with previous studies that showed a significant decrease of tendon volume and CSA after 24 weeks of eccentric exercises.…”

“… 17 Moreover, MRI is able to evaluate structures that lay beyond the possibilities of ultrasound, such as characterization of bone bruises or partial ruptures, which might have substantial influence on adequate treatment ( Table 1 ). 16 , 22 , 29 …”

“…17 Moreover, MRI is able to evaluate structures that lay beyond the possibilities of ultrasound, such as characterization of bone bruises or partial ruptures, which might have substantial influence on adequate treatment (Table 1). 16,22,29 Even though ultrasound techniques have improved over the years, MRI still detected the most partial ruptures. Bmode might not adequately differentiate between partial tendon tears from local degenerative lesions, as has been shown previously.…”

A retrospective audit of the timescales involved in the diagnosis and management of suspected Achilles tendon ruptures at a single National Health Service trust: A quality service improvement and redesign project

“…This suggests that ED clinicians and practitioners do possess expertise for assessment of these injuries and should not be considered "non-specialists". The fact that one partial thickness tear was initially discharged is unsurprising as these are known to be more problematic to diagnose clinically, with symptoms easily misinterpreted as aggravated Achilles tendinopathy [14]. Unfortunately, it was beyond the audit scope to determine if any of the patients who initially presented via other referral routes had their initial referral delayed for any reason.…”