Tendon Injuries
Achilles Tendon Tear / Rupture
Relevant anatomy
The Achilles tendon is formed by 3 co-joining tendons that insert into the posterior calcaneus:
- Gastronemius
- Popliteus
- Soleus
The primary function of the Achilles tendon is to perform ankle plantarflexion
Causes and Risk Factors
Common causes include:
- Sudden acceleration
- Jumping or landing awkwardly
- Sudden push-off during sports
- Unexpected dorsiflexion of the ankle
Risk factors:
- Advancing age
- Males
- Running / jumping sports
- Previous Achilles tendinopathy
- Fluoroquinolone antibiotic use
- Corticosteroid use
Clinical features
Typical symptoms include:
- Sudden posterior ankle or calf pain
- Sudden “pop” or snapping sensation
- Difficulty walking / standing on tiptoe
- Swelling or bruising around the posterior ankle/calf
Diagnosis
Achilles tendon tear / rupture is primarily a clinical diagnosis
The Simmonds triad is helpful:
| Triad component | Description / +ve test finding |
|---|---|
| Calf squeeze test (Simmonds-Thompson test) | Description: Patient lies prone with feet hanging over the bed. The examiner squeezes the calf
Positive test: absent or reduced passive plantarflexion on calf squeezing – suggests Achilles tendon rupture |
| Palpable tendon gap | Description: Patient lies prone with knees flexed or feet hanging freely. Compare the resting position of both feet.
Positive finding: the affected foot rests in a more dorsiflexed position because normal Achilles tendon tension is lost |
| Altered angle of declination | Description: Palpate along the Achilles tendon
Positive finding: palpable gap or defect in the tendon, suggesting tendon discontinuity |
Note that Simmonds’ triad is mainly for complete Achilles tendon ruptures. A minor or partial tear of the Achilles tendon would not result in the triad, as there are no true discontinuity of the tendon.
Imaging is NOT always necessary if the diagnosis is clear (e.g. compatible history with the Simmonds triad), it can be used if there is diagnostic uncertainty:
- 1st line: ultrasound
- MRI can be used for complex cases or pre-operative planning
Management
Initial management should involve PRICE self-care measures + analgesia
If a complete tear of the Achilles tendon is suspected → same day referral to specailist
Avoid corticosteroid injection into the Achilles tendon due to rupture risk
Achilles Tendon Partial Tear
Partial tears are usually managed conseratively, which typically include:
- Immobilisation in a cast / boot in plantarflexion (to bring the tendon closer to aid healing)
- Serial casting with gradual dorsiflexion may be performed
- Protected weight-bearing
- Physiotherapy-guided rehabilitation
Achilles Tendon Complete Tear
Complete Achilles tendon rupture may be treated either:
- Conservatively (immobilisation and rehabiliation – see above for more details), OR
- Surgically (surgical repair of the tendon followed by immobilisation and rehabilitation)
The choice between conservative vs operative management is somewhat controversial with no clear cut recommendations:
- Conservative treatment avoids surgical complications and can give good outcomes with modern functional rehabilitation
- Operative treatment may reduce re-rupture risk slightly, but introduces surgical risks
The decision is individualised and usually made by orthopaedics through shared decision-making
Biceps Tendon Rupture
Relevant Anatomy
The biceps brachii has two proximal tendons at the shoulder and one distal tendon at the elbow
| Tendon | Location |
|---|---|
| Proxiaml long head of biceps tendon | Attaches to the supraglenoid tubercle and run through the bicipital groove |
| Proximal short head of biceps tendon | Attaches to the coracoid process |
| Distal biceps tendon | Inserts onto the radial tuberosity |
Key function of the biceps brachii:
- Elbow flexion
- Forearm supination
Biceps tendon involvement:
- Proximal biceps tendon rupture is more common than distal biceps tendon rupture
- Within proximal biceps tendon ruptures, the long head tendon is much more commonly involved than the short head tendon
Therefore, the most common pattern of biceps tendon rupture is proximal rupture of the long head of biceps
Causes and Risk Factors
Biceps rupture classifcally occurs upon a sudden eccentric load on a contracted biceps, followed by a force that pulls the elbow into extension
Examples include:
- Lowering phase of a heavy biceps curl
- Descending phase of a pull-up
- Trying to catch or hold a falling heavy object
- Heavy lifting where the load suddenly drops
- Sudden forced extension of a flexed elbow
Risk factors include:
- Advancing age (due to degenerative changes)
- Males
- Smoking
- Heavy lifting / manual work
- Weight training
- Corticosteroid use
Clinical features
| Proximal biceps tendon rupture (more common) |
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| Distal biceps tendon rupture |
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Diagnosis
Biceps tendon rupture is primarily a clinical diagnosis
Some clinical tests can be helpful:
| Clinical test | Interpretation |
|---|---|
| Hook test | Description: The patient flexes the shoulder against resistance with the elbow extended and forearm supinated
Positive test finding: The examiner cannot hook the distal biceps tendon because it is absent or retracted. This suggests distal biceps tendon rupture |
| Speed test | Description: The patient flexes the shoulder against resistance with the elbow extended and forearm supinated
Positive test finding: Pain in the bicipital groove/anterior shoulder. This suggests more proximal biceps tendopathy |
Imaging is NOT always necessary if the diagnosis is clear, it can be used if there is diagnostic uncertainty:
- 1st line: ultrasound
- MRI can be used for complex cases or pre-operative planning
Management
Initial management should involve PRICE self-care measures + analgesia
Definitive management:
| Rupture type | Management |
|---|---|
| Proximal biceps tendon rupture (more common) | Conservative management
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| Distal biceps tendon rupture | Surgical management is often necessary, esp. in:
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Quadriceps and Patellar Tendon Injury
Both quadriceps and patellar tendons are involved in knee extension mediated by the quadriceps muscle
Quadriceps muscle → quadriceps tendon → patella → patellar tendon → tibial tuberosity
| Feature | Quadriceps tendon injury | Patellar tendon injury |
|---|---|---|
| Description | Injury to the tendon above the patella (connects the quadriceps muscle to the patella) | Injury to the tendon/ ligament below the patella (connects the patella to the tibial tuberosity) |
| Risk factors | More common in middle-aged or older patients, especially those with degenerative tendon change or comorbidities | More common in younger, active patients, especially those involved in jumping sports |
| Common causes |
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| Investigation and diagnosis | Primarily a clinical diagnosis
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| Management | Initial management: PRICE self-care measures + analgesia
Definitive management:
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