Acute and Chronic
Ruptures in Athletes
Jonathan Thompson, DPMa,b,*, Bob Baravarian, DPMc,d
Achilles tendon injuries are one of the most common injuries in athletes. The Achilles
tendon is the largest and strongest tendon in the human body and is composed of the
gastrocnemius and the soleus muscles1to create a musculotendinous complex
(triceps surae) that crosses the knee, ankle, and subtalar joint. The Achilles tendon
is subjected to extensive static and dynamic loads and can be subjected to loads 2
to 3 times the body weight with walking and up to 10 times the body weight with
certain other athletic activities.2,3The Achilles tendon is the most injured tendon of
athletes in the lower extremities and has been noted to be the most common tendon
to rupture spontaneously.4
The Achilles tendon is in the superficial posterior compartment of the leg and is formed
from tendinous continuations of the 2 muscle bellies of the gastrocnemius and soleus
muscles, inserting primarily on the central middle portion of the posterior calcaneus as
well as providing fibers that extend around the heel to blend in with the plantar fascia.5
The plantaris tendon (absent in 7%–20% of individuals) is located medial to the
Achilles tendon apparatus and inserts medial and anterior to the Achilles complex.5,6
The Achilles tendon receives its main blood supply to the midportion of the tendon
from the paratenon, more proximally from the recurrent branch of the posterior tibial
artery and the local small muscular branches and distally from the rete arteriosum cal-
caneare supplied by the posterior and fibular arteries.5,7,8The Achilles tendon is
The author has nothing to disclose.
aUniversity Foot and Ankle Institute, Private Practice, 1101 Sepulveda Boulevard, Suite 104,
Manhattan Beach, CA, USA
bUniversity Foot and Ankle Institute, Private Practice, 2121 Wilshire Boulevard, Suite 101,
Santa Monica, CA 90403, USA
cUniversity Foot and Ankle Institute, Private Practice, 2121 Wilshire Boulevard, Suite 101, Santa
Monica, CA 90403, USA
dSanta Monica Orthopedic Hospital, 1250 Sixteenth Street, Santa Monica, CA 90404, USA
* Corresponding author. University Foot and Ankle Institute, Private Practice, 1101 Sepulveda
Boulevard, Suite 104, Manhattan Beach, CA.
E-mail address: firstname.lastname@example.org
? Achilles tendon rupture ? Athletes ? Rehabilitation
Clin Podiatr Med Surg 28 (2011) 117–135
0891-8422/11/$ – see front matter. Published by Elsevier Inc.
almost entirely composed of type I collagen and approximately rotates 11?to 90?in
a medial direction in that the medial fibers proximally come to lie in a posterior position
distally.1This anatomic construct provides potential energy and mechanical advan-
tage with rotational contraction; however, in doing so, it potentially “strangulates”
this portion of the tendon known as the watershed area, making it the most common
site of rupture.9,10This area of lowest vascularity is approximately 2 to 6 cm proximal
to the insertional area.9–11Lagergren and Lindholm10originally described this zone of
reduced vascularity in the midportion of the tendon1,7,11and subsequent studies have
supported their findings.7,9,12Although there remains some dispute regarding the
zone of least vascularity,1,11,13it is generally expected that the blood flow is dimin-
ished with increasing age, with gender (decreased in men), and during certain physical
loading conditions.11,13Astrom and Westlin11evaluated the blood flow of Achilles
tendons by comparing 35 patients, most of them competitive runner athletes, with
40 healthy volunteers using Doppler flowmetry and concluded the following: (1) blood
flow was evenly distributed throughout the Achilles tendon in both groups, (2) blood
flow values progressively declined when tension/contraction increased, (3) values
were significantly lower at the distal insertional areas, and (4) symptomatic Achilles
tendons had an increase in blood flow to the area. The Achilles tendon lacks a true
synovial sheath or lining like other tendons and is surrounded by a peritendinous struc-
ture called the paratenon. The paratenon is a multilayered structure that covers the
tendon and is composed of an outer layer of which the deep fascia is a portion, the
mesotenon, and a very thin and delicate epitenon layer that directly surrounds the
tendon.5The sural nerve and lesser saphenous vein course in the posterior midline
of the leg and need to be accounted for during surgical repair.
There is a paucity in the literature with few reported studies documenting the preva-
lence of Achilles tendon ruptures in the general population and let alone in the athletic
population. The incidence of ruptured or spontaneously ruptured Achilles tendons
seems to be growing; however, it cannot be determined if this incidence is from
a growing population or an increasing percentage of the population. Rates of Achilles
tendon rupture have been reported from 2 to 18 ruptures per 100,000.1,14,15A large
study in Scotland was published in 1999 of a total of 4201 Achilles tendon ruptures
between 1980 and 1995, which analyzed data on age- and gender-specific incidence
rates, and demonstrated similar rupture rates of 4.7 per 100,000 in 1981 and 6 per
100,000 in 1995.16The investigators also determined that the peak incidence in
men was from age 30 to 39 years but in women the risk increased after the age of
60 years, and the incidence after the age of 80 years was greater in women than in
men.16Most studies demonstrated thatAchilles tendon ruptures have occurred during
sporting-related activities. A study by Postacchini and Puddu17showed that in 44% or
12 of 27 cases the rupture occurred during athletic activities. Cetti and colleagues18
reported that 83% (92/111) of patients in a study injured their tendons during activities.
A Scandinavian study of badminton players demonstrated that 58 of 111 patients
(52%) with Achilles ruptures were playing badminton at the time of injury.1,19A
Hungarian study analyzed 749 patients from 1972 to 1985 who were diagnosed and
surgically treated for 832 acute tendon ruptures (both upper and lower extremity
ruptures).20Of the 292 cases, 59% Achilles tendon ruptures occurred during sport-
related activities in contrast to 2% of other tendon ruptures.20There were no profes-
sional athletes included in this study; however, the ruptures occurred most often in
participants of recreational soccer (33.5%), track and field (16.2%), and basketball
Thompson & Baravarian
(13.3%). Furthermore, the investigators also demonstrated that (1) there was a higher
prevalence of Achilles tendon ruptures (53.7%) and reruptures (71%) in those with
blood group O, (2) most patients commonly ruptured their left Achilles tendon, and
(3) most ruptures demonstrated histopathologic alterations on examination.20Parekh
and colleagues21documented 31 cases of Achilles tendon ruptures in the National
Football League (NFL) between 1997 and 2002. The average age and time in the
league was 29 years (average age of NFL players is 26 years) and 6 years, respec-
tively.21About 32% of players (10/31) never played in the NFL again, and those who
returned showed a reduction in their performance of more than 50%.21There was
no study that compared Achilles tendon rupture occurrence rates between profes-
sional and recreational athletes. Most studies demonstrated that recreational athletes
and furthermore the “weekend warrior” athletes are more prone to ruptures and have
increasing rupture rates secondary to a partial sedentary life combined with intermit-
tent activities compared with professional athletes who are consistently exercising. It
is postulated that regular exercise allows the tendon diameter to thicken and the
tendon to become stronger and, in theory, decreases the chance of rupture compared
with inactivity, which results in an atrophied Achilles tendon.22Other factors that
potentially differentiated the 2 groups of athletes are that the professional athletes
are generally younger, are healthier with less associated comorbidities, have poten-
tially lower body mass indexes, and have regular access to physical therapy and
a controlled athletic training program.
described to be associated with multiple disorders, including, but limited to, inflamma-
tory conditions, autoimmune disorders, collagen abnormalities,1,23–26infectious
process, exposure to antibiotics (fluoroquinolones),27,28systemic or injectable steroid
use,29–32repetitive microtrauma, tendon variations, decreased blood flow with
advanced age,33,34abnormal pronation and mechanics, ankle equinus, and Achilles
calcification.35Some investigators have proposed a possible mechanical theory,
whereby injury to the tendon leads to weakening and incomplete regeneration, versus
a vascular theory, whereby decreased tendon vascularity secondary to age and/or
trauma leading to chronic tendon degeneration.34,36It has been debated if a previous
history or current symptomatic Achilles tendon increases the risk of Achilles rupture or
if most cases are truly spontaneous. Achilles tendon disorders are more prominent in
participants of running sports and has been noted to be symptomatic in 7% to 11% of
in other studies. One of the larger studies by Kvist39demonstrated that approximately
53% of 455 athletes who developed Achilles tendon disorders were involved in running
sports.40Because the Achilles tendon is unique compared with other tendons in the
body in that it lacks a true synovial sheath it can be a potential for somewhat confusing
terminology. Achilles tendon disordersare nowgrouped togetherinto what is known as
Tendinosis is differentiated from tendonitis in that there is degeneration of the tendon
without inflammation or evidence of intratendinous inflammatory cells.1,42This distinc-
tion is important not only to understand the pathologic condition but also to dictate
the proper and appropriate treatment. Puddu and colleagues44in 1976 defined this
terminology and classified Achilles tendon disease into 3 categories: (1) pure peritendi-
nitis or inflammation of peritendinous tissue with normal tendon, (2) peritendinitis with
tendinosis or inflamed peritendinous tissue and degenerative changes of the tendon
Achilles Tendon Ruptures in Athletes
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Achilles Tendon Ruptures in Athletes