Tendon Injuries

Diagnosis

• A thorough physical examination, including inspection for swelling, asymmetry, and erythema of involved tendons, range-of-motion testing, palpation for tenderness, and specific examination maneuvers, is necessary for diagnosis 1
• Plain radiographs (3 views) are always indicated as initial imaging to detect any associated fracture fragments, according to the American College of Radiology 2
• Examination maneuvers that simulate tendon loading to reproduce pain, plain radiography, and MRI (with 95% sensitivity and 95% specificity) are recommended for diagnosis, particularly when diagnosis remains unclear, by the American Academy of Family Physicians 1
• Diagnostic tests for Achilles tendon injuries include physical examination and imaging, such as ultrasound or MRI, to determine the type and severity of the injury, with the following diagnostic accuracy:

3, 4

• The Thompson/Simonds squeeze test, assessment of decreased ankle plantar flexion strength, presence of a palpable gap, and increased passive ankle dorsiflexion with gentle manipulation are recommended tests to establish the diagnosis of acute Achilles tendon rupture, with a combination approach yielding sensitivity values ranging from 73% to 84% and specificity values from 77% to 78%, as supported by the American Academy of Orthopaedic Surgeons 3

Treatment and Management

• Treatment should be initiated promptly, as delay can lead to functional impairment, according to the American College of Radiology 2
• Relative rest, reducing activities that exacerbate symptoms, and NSAIDs for acute pain relief are recommended, but NSAIDs are not recommended over other analgesics for long-term use, by the American Academy of Family Physicians 1
• Additional modalities such as low-level laser therapy, ultrasound therapy, and technique modification may be considered, and surgical treatment is reserved for patients who have failed conservative therapy, as suggested by the American Academy of Family Physicians 1
• Initial treatment should include relative rest, ice therapy, NSAIDs, heel lifts or orthoses, open-backed shoes, stretching and eccentric strengthening exercises, and weight loss if indicated, for a period of 6-8 weeks, as recommended by the American Academy of Family Physicians 5, 1
• Eccentric strengthening exercises are recommended as the most effective conservative treatment for Achilles tendinopathy, by the American Academy of Family Physicians 1
• Addressing biomechanical factors, such as foot pronation, pes planus, or heel varus, may contribute to the condition, as supported by the American Academy of Family Physicians 1
• Surgical treatment is recommended for chronic tendinopathy unresponsive to 2-3 months of conservative care, complete Achilles tendon ruptures in young, active patients and athletes, and persistent partial ruptures not responding to conservative treatment, as supported by the American Academy of Family Physicians and the American Academy of Orthopaedic Surgeons 5, 3
• Surgical options for Achilles tendon rupture include open repair, limited open repair, and percutaneous repair, with percutaneous repair showing higher physical and mental component scores on quality of life measures, and minimally invasive approaches may provide the best balance between rerupture prevention and complication avoidance 3

Prognosis and Recovery

• Most patients with properly treated tendon injuries can expect full recovery within 3-6 months, as reported by the American Academy of Family Physicians 1
• Most patients (80%) fully recover within 3-6 months with proper conservative care, according to the American Academy of Family Physicians 1
• Early protected weight-bearing and mobilization are recommended for both surgical and non-surgical treatments to prevent muscle atrophy and deconditioning, as supported by the American Academy of Family Physicians and the American Academy of Orthopaedic Surgeons 5, 3, 1
• Rehabilitation exercises, including tensile loading exercises to stimulate collagen production, eccentric strengthening exercises, and stretching exercises for the posterior thigh muscles, are essential for recovery 1
• Regular clinical assessment of pain and function, and progressive return to activities based on functional improvement, are crucial for optimal recovery, and avoiding corticosteroid injections directly into the tendon and prolonged immobilization are crucial to prevent rupture risk and muscle atrophy 1, 5
• Athletes with complete ruptures typically require surgical repair to minimize re-rupture risk and optimize return to sport, while bilateral tendon damage is common in Achilles tendon injuries, even when symptoms appear unilateral, highlighting the importance of addressing biomechanical factors and rehabilitation of both limbs to prevent future injury 5, 3
• Non-surgical management is often preferred by older, less active patients, and patients with significant comorbidities 5, 3, 1
• Involvement of more than one-third of the articular surface, palmar displacement of the distal phalanx, or an interfragmentary gap >3 mm usually requires operative fixation, as recommended by the American College of Radiology 2
• Potential complications of surgical treatment include wound infections, nerve injury, rerupture, and scar adhesions, and common pitfalls to avoid include misdiagnosis, inadequate imaging, overly aggressive early rehabilitation, injecting corticosteroids directly into the tendon substance, and prolonged immobilization leading to muscle atrophy and deconditioning 3, 1