The seasonal variation of Achilles tendon ruptures in Vancouver, Canada: a retrospective study

Recent developments in Achilles tendon risk-analyzing rupture factors for enhanced injury prevention and clinical guidance: Current implications of regenerative medicine

Background

In recent years, many countries have actively implemented programs and strategies to promote physical education and sports. Despite these efforts, the increase in physical activity has been accompanied by a significant rise in muscle and tendon-ligament injuries, with Achilles tendon rupture being the most prevalent, accounting for 47 % of such injuries. This review aims to summarize all significant factors determining the predisposition of the Achilles tendon to rupture, to develop effective personalized prevention measures.

Objective

To identify and evaluate the risk factors contributing to Achilles tendon rupture and to develop strategies for personalized prevention.

Methods

This review utilized data from several databases, including Elsevier, Global Health, PubMed-NCBI, Embase, Medline, Scopus, ResearchGate, RSCI, Cochrane Library, Google Scholar, eLibrary.ru, and CyberLeninka. Both non-modifiable and modifiable risk factors for Achilles tendon injuries and ruptures were analyzed.

Results

The analysis identified several non-modifiable risk factors, such as genetic predisposition, anatomical and functional features of the Achilles tendon, sex, and age. These factors should be considered when selecting sports activities and designing training programs. Modifiable risk factors included imbalanced nutrition, improper exercise regimens, and inadequate monitoring of Achilles tendon conditions in athletes. Early treatment of musculoskeletal injuries, Achilles tendon diseases, foot deformities, and metabolic disorders is crucial. Long-term drug use and its risk assessment were also highlighted as important considerations. Furthermore, recent clinical advancements in both conventional and surgical methods to treat Achilles tendon injuries were described. The efficacy of these therapies in enhancing functional outcomes in individuals with Achilles injuries was compared. Advancements in cell-based and scaffold-based therapies aimed at enhancing cell regeneration and repairing Achilles injuries were also discussed.

Discussion

The combination of several established factors significantly increases the risk of Achilles tendon rupture. Addressing these factors through personalized prevention strategies can effectively reduce the incidence of these injuries. Proper nutrition, regular monitoring, timely treatment, and the correction of metabolic disorders are essential components of a comprehensive prevention plan.

Conclusion

Early identification of Achilles tendon risk factors allows for the timely development of effective personalized prevention strategies. These measures can contribute significantly to public health preservation by reducing the incidence of Achilles tendon ruptures associated with physical activity and sports. Continued research and clinical advancements in treatment methods will further enhance the ability to prevent and manage Achilles tendon injuries.

The translational potential of this article

This study identifies key modifiable and non-modifiable risk factors for Achilles tendon injuries, paving the way for personalized prevention strategies. Emphasizing nutrition, exercise, and early treatment of musculoskeletal issues, along with advancements in cell-based therapies, offers promising avenues for improving recovery and outcomes. These findings can guide clinical practices in prevention and rehabilitation, ultimately reducing Achilles injuries and enhancing public health.

Hyperuricemia May Increase Risk of Achilles Tendon Rupture: A Case Control Study

It has been demonstrated in a number of studies that high levels of uric acid can cause crystal deposition in the tendons of the lower extremities, which in turn can impair the Achilles tendon. This study aimed to interpret whether hyperuricemia is relevant with Achilles tendon rupture. Patients diagnosed with Achilles tendon rupture at the same institution between 2013 and 2022 were included in the case group. Healthy subjects who had physical examinations during the same period were included in the control group. Propensity score matching was used to match in a 1:1 ratio. Demographic and clinical characteristics of patients in both groups were compared. Five hundred and fourteen patients were included in the study (ATR=257; Control group=257). The proportion of individuals with hyperuricemia varied significantly between the 2 groups (Achilles tendon rupture group=43.6%; control group=27.6%; p<0.001). The Achilles tendon rupture and hyperuricemia were linked by conditional logistic regression (p<0.001; OR=2.036; 95CI%=1.400-2.961). Compared with healthy subjects, patients with hyperuricemia have a higher risk of Achilles tendon rupture. Further studies are required to verify the effects of hyperuricemia and monosodium urate crystals on Achilles tendon structure.

Gender Differences in Achilles Tendon Ruptures-A Retrospective Study and a Review of the Literature

Achilles tendon ruptures are common injuries typically sustained during sport with higher incidence in men, though little is understood regarding sex-specific risk factors or outcomes following injury management. This cross-sectional clinical study and systematic review aimed to examine sex-specific Achilles tendon rupture incidence and outcomes following intervention. This study included patients who sustained a rupture between 2011-2021, were ≥18 years old, and who had a minimum follow-up of at least six months, and evaluated age, sex, sport involvement, mechanism of injury, and postoperative complications and revision. Separately, a systematic literature review in the PubMed, EMBASE, and Cochrane databases was performed. A total of 705 male and 158 female patients were included in this retrospective study. 71.1% of men and 52.5% of women sustained a sports-related rupture (p < .001), with sport involvement demonstrating a positive correlation with revision rate (coefficient = 0.09, p = .02). A total of 21 studies with 250,907 patients (87,514 male, 35,792 female) were included in the systematic review. All studies revealed an increased incidence of ATR in men. Functional outcomes were worse in women, and female sex was an independent risk factor for postoperative complications and need for revision surgery. This study demonstrated a higher incidence of sports-related ATR in men than women, likely related to their higher ball sport participation. Although the retrospective analysis did not find a significant difference in complication or revision rates, the systematic review demonstrates poorer functional outcomes, with increased likelihood for postoperative complication and revision surgery in women as compared to men.

Risk factors for Achilles tendon rupture: an updated systematic review

OBJECTIVE

Identifying risk factors for Achilles Tendon Rupture (ATR) is one of the first necessary steps for its prevention. This systematic review aimed to update the systematic review published in 2014 in ATR etiology.

METHODOLOGY

A systematic review was carried out using PubMed, EBSCO, and ScienceDirect databases. All types of research studies (Randomized Control Trials - RCTs, Cohort studies, Case-control studies and Cross-sectional studies) that considered ATR, were eligible. The inclusion criteria for eligibility of the studies were to be written in the English language, and to include populations of men and/or women, both athletes, and non-athletes, healthy individuals, and patients. Two independent reviewers used the assessment instrument Newcastle-Ottawa Scale independently, to evaluate the quality of each selected study. Further, two reviewers worked independently to extract the study characteristics, and the GRADE methodology was used to assess the level of certainty of each risk factor.

RESULTS

From 9526 studies initially identified, 19 studies were eligible for further analysis to identify risk factors for ATR. Seventeen studies were considered good quality, and two studies fair quality. Low to very low certainty of evidence was found for the following medications: steroids, quinolones, and oral bisphosphonate, as well as for other factors such as chronic tendon inflammation and Achilles' tendinopathy, spring season, diabetes, previous musculoskeletal injury, regular participation in athletic activity, hyperparathyroidism, renal failure, and genetic factors.

CONCLUSIONS

The risk factors found prove that ATR is a multifactorial injury. Appropriate methodologies and well-designed studies are needed to determine the factors and their significance in ATR risk. Finally, the role of biomechanical and psychological aspects in the ATR etiology may be of interest in future studies, as we could not extract relative data in our review.

Morphometric Analysis of Achilles Tendon Structure and Its Significance: A Cadaveric Study

INTRODUCTION

Achilles tendon is crucial for gait, and chronic Achilles tendinopathy can have a substantial impact on an individual's work and active involvement in physical or sports activity, and overall quality of life.

OBJECTIVES

This research was to determine the macroscopic and microscopic anatomy of Achilles tendons in cadavers.

MATERIALS AND METHODS

This experimental study was conducted in the Department of Anatomy, Saveetha Medical College, Thandalam, from March to August 2022. A total of 60 formalin-perfused cadavers (38 males and 22 females) were dissected to study their morphometry (length, width, thickness) and histology. The data was tabulated in MS excel and analyzed statistically using unpaired 't-test and one-way ANOVA in SPSS Software 17.0 (IBM Corp., Armonk, NY).

RESULTS

The mean length of the Achilles tendon was significantly higher in males than in females and similarly, the length on the right side was significantly higher than on the left side (p<0.005). The width and circumference were statistically higher in females than, males whereas, the histological features were similar in both males and females.

CONCLUSION

The better understanding of Achilles tendon morphometry in cadavers always aids in the diagnosis and surgical repair of tendinopathy, rupture, and degenerative change. The knowledge will be helpful for the surgeons during the repair and reconstruction of the injured tendon.

The influence of the COVID pandemic on the epidemiology of Achilles tendon ruptures in east Shropshire, United Kingdom

OBJECTIVES

Management strategies of the COVID pandemic included isolation to prevent transmission. This study aimed to determine if the pandemic of 2020 influenced the epidemiology of Achilles tendon rupture (ATR).

METHODS

The demographics of presentations from the local population to Princess Royal Hospital, Shrewsbury & Telford Hospital NHS Trust hospital, Shropshire, United Kingdom, with an ATR were analysed and compared together with the season, month, and year of the injury.

RESULTS

From 2009 to 2019, there was no significant change in the incidence of ATR over time with a mean (SD) incidence of 13.3 per 100,000. In 2020, there was a decrease in injuries with an incidence of 8.4 per 100,000, with an increase in 2021 to 22.4 per 100,000. In 2021, there was an increase in injuries from March with numbers maintained until October. The most common activity of ATR was team sport (36.2%), followed by the activities of daily living (28.9%), other physical activities (21.0%), and racket sports (13.9%). In 2020, there was the lowest number of injuries sustained in team and racket sports; however, in 2021, they accounted for over half of injuries.

CONCLUSIONS

There were significantly more patients sustaining ATR in 2021, the year after the COVID pandemic and mandatory isolation. This was considered to be related to altered activity and team and racket sports during 2020.

LEVELS OF EVIDENCE

IV case series.

Achilles Tendon Rupture and Dysmetabolic Diseases: A Multicentric, Epidemiologic Study

Introduction: Achilles tendon ruptures are common. Metabolic disorders, such as diabetes mellitus, hypercholesterolemia, thyroid disorders, and obesity, impair tendons health, leading to Achilles tendinopathy and likely predisposing patients to Achilles tendon ruptures. Materials and methods: Patients who visited the Orthopedic Outpatient Clinics and the Accident and Emergency Departments of five different hospitals in Italy were recruited. Through telephone interviews, we administered a questionnaire to all the patients who had undergone surgical ATR repair, evaluating their past medical history, sport- and work-related activities, drug use, and post-operative rehabilitation outcomes. Results: “Return to work activities/sport” was negatively predicted by the presence of a metabolic disorder (β = −0.451; OR = 0.637) and ‘open’ surgery technique (β = −0.389; OR = 0.678). “Medical complications” were significantly predicted by metabolic disorders (β = 0.600 (0.198); OR = 1.822) and was negatively related to ‘mini-invasive’ surgery (i.e., not ‘open’ nor ‘percutaneous’) (β = −0.621; OR = 0.537). “Immediate weightbearing” and “immediate walking without assistance” were negatively predicted by ‘open’ technique (β = −0.691; OR = 0.501 and β = −0.359 (0.174; OR = 0.698)). Conclusions: Metabolic conditions can strongly affect post-operative outcomes following surgical repair of acute Achilles tendon tears.

Epidemiological Characteristics of Patients Operated for Achilles Tendon Rupture in Shanghai

Objective

To reflect the potential epidemiological characteristics of Achilles tendon (AT) rupture in Shanghai, China, which has been rarely reported before.

Methods

This work is a descriptive epidemiology study. A total of 302 cases of AT rupture admitted to our department between 01/2013 and 02/2020 are analyzed according to telephone follow‐up and medical records. Male to female ratio is 10.3 and the average age is 37.5 years. The record of each case includes age, gender, Body mass index (BMI), quinolone use, corticoid exposure and related medical history/comorbidities. If the case is sports‐related (SR), details including kind of sports, intensity of exercise, exercise time before rupture, specific action that causes rupture and situation of warm‐up are collected. Two independent sample t‐tests and Pearson chi‐square tests are used for statistical analysis.

Results

A total of 252 ruptures are SR. Male to female ratio is 15.6 in SR cases. Most SR ruptures occur in patients aged 25–39 years. Ball games are major sports responsible for rupture: basketball in 95 (37.7%), badminton in 68 (27.0%) and soccer in 62 (24.6%). Acceleration and running start is the specific action that cause most (37.7%) ruptures. AT cases are observed in 91 patients with warm‐up and 161 without preparation before exercise. As a result, more ruptures happened within 10 min' sports in 161 unprepared (22.4%) than in 91 prepared (5.5%) cases. In SR cases, 107 and 145 cases are observed on weekends and weekdays. Of the 302 total cases, 64 are associated with Achilles tendinopathy. Frequently reported factors such as quinolone use and corticoid exposure are found only in two and 11 of all cases, respectively.

Conclusion

Middle‐aged males are common victims of AT rupture in Shanghai. Sports including basketball, badminton, soccer and actions involving in sudden and severe contraction of AT cause most ruptures. Warm‐up before exercise reduces rupture in short time. Factors such as quinolone, corticoid and Achilles tendonitis still need attention.

Association between outdoor temperature and achilles tendon repair: A 14-years nationwide population-based cohort study

The incidence of achilles tendon rupture varies by gender, age, and seasonal variation. However, there has been no study as yet linking achilles tendon rupture to daily fluctuations in outdoor temperature. The purpose of this study was to investigate the association between outdoor temperature and achilles tendon rupture using a Korea Meteorological Administration database and a Korean National Health Insurance Service-National Sample Cohort database. Between 2002 and 2015, all instances of achilles tendon repair were retrieved from the National Health Insurance Service-National Sample Cohort database to examine sociodemographic factors, specifically sex, age, residential area, and income level. Minimum age requirement was 20 years. Outdoor temperatures recorded at 16 observation points in South Korea were also acquired from the Korea Meteorological Administration data center for analysis. Overall, 850 (0.119%) of 713,456 individuals in the National Health Insurance Service-National Sample Cohort database underwent achilles tendon repair between 2002 and 2015. Yearly procedural totals increased with advancing age, peaking at ages 30–39 years (14.6 per 100,000 persons) and declining thereafter. Minimum, median, and maximum outdoor temperatures were associated with achilles tendon repair (p<0.05), as did household income. In multivariate logistic regression analysis, outdoor temperatures, sex, age, and household income emerged as factors significantly associated with achilles tendon repair. Outcomes of this study confirm an association between incidence of achilles tendon repair and outdoor temperature, the latter denoting a novel index and likely surrogate measure of vigorous physical activity afforded by warmer weather.

Achilles tendon ruptures during summer show the lowest incidence, but exhibit an increased risk of re-rupture

PURPOSE

Achilles tendon rupture (ATR) is a common injury. The knowledge of seasonal factors´ impact is incomplete, but may provide means for preventive approaches for Achilles tendon related morbidity. The aim of this study was to investigate seasonal variations in ATR incidence in relation to injury mechanism, adverse events including risk of re-rupture, and patient-reported outcome in adults in Stockholm, Sweden.

METHODS

In total, 349 patients with unilateral acute Achilles tendon rupture, prospectively treated with standardized surgical techniques, were retrospectively assessed. Date of injury was assigned to one of the four internationally defined meteorological seasons in the northern hemisphere. Injury mechanism and the rate of adverse events; deep venous thrombosis, infection and re-rupture in relation to per-operative complications. Patient-reported outcome at 1 year was assessed with the validated Achilles tendon Total Rupture Score.

RESULTS

ATR incidence was significantly highest during winter and spring, and lowest during summer (p < 0.05). The most common sporting activities associated with ATR were badminton, floorball and soccer (> 50%). The rate of soccer-related ATR was highest during summer (p < 0.05). Patients sustaining an ATR during summer, compared to other seasons, exhibited more per-operative complications (p < 0.05), a significantly higher risk of re-rupture (p < 0.05) and a lower rate of good outcome (n.s.). The risk of other adverse events after ATR did not differ between the seasons.

CONCLUSION

Winter and spring are the high risk seasons for sports-related ATR and the risk sports are badminton, soccer and floorball. The reason for the higher risk of re-rupture after ATR repair during summer should be further investigated.

LEVEL OF EVIDENCE

III.

Drug treatments associated with Achilles tendon rupture. A case-control study involving 1118 Achilles tendon ruptures

The incidence of Achilles tendon (AT) rupture, especially nonsport-related rupture, is increasing, while the reasons for this increase are largely unknown. The association between the AT rupture and the use of various drug treatments was studied. We collected AT rupture patients from the Finnish Hospital Discharge Register. We also acquired information about all the doctor-prescribed drugs they had purchased within 1 year before the rupture. For comparison, we randomly selected age- and sex-matched controls from the Finnish Population Register. There were 1118 AT rupture patients. Several drug groups had a statistically significant association with the AT rupture. Our study confirmed an association between fluoroquinolone antibiotics and AT rupture (OR 2.20, P = 0.005). A statistically significant association of renin-angiotensin II receptor antagonists with tendon rupture (OR 7.59, P = 0.003) was a previously unreported finding. The increasing incidence of AT rupture, especially in middle-aged and elderly patients, might partially be a consequence of the increased use of certain drug treatments. Some associations are probably explained by the symptomatic treatment of the painful tendon before the rupture.

Seasonal Variation of Achilles Tendon Injury

Background:

Achilles tendon rupture (ATR) is a common injury with increasing incidence. Several risk factors have been identified; however, little is known about seasonal variations in injury prevalence. Previous reports have generated mixed results, with no clear consensus in the literature. The purpose of this investigation was to retrospectively review ATRs seen at a major academic orthopaedic surgery department in New York City to determine whether a statistically significant seasonal pattern of ATRs exists.

Methods:

A retrospective chart review was conducted, identifying patients with an acute ATR. Patients were excluded if they had a chronic rupture, laceration, débridement for tendinitis, Haglund deformity, or other nonacute indications for surgery. Date and mechanism of injury were determined from the clinical record.

Results:

The highest rate of injury was seen in spring (P = 0.015) and the lowest in fall (P < 0.001), both of which were statistically significant. Overall, no statistically significant difference was noted in summer or winter, although more injuries were seen in summer. When only sports-related injuries are considered, a similar trend is seen, with most injuries occurring in spring (n = 48, P = 0.076) and fewest in fall (n = 25, P = 0.012); however, only the lower number in fall reaches statistical significance. No statistically significant difference was noted between seasons when only non–sports-related injuries were considered.

Conclusion:

A statistically significant increase was noted in the incidence of ATRs in spring and a statistically significant decrease in fall. The need for recognition of risk factors and preventive education is increasingly important in the orthopaedic surgery community and for primary care physicians, athletic trainers, coaches, and athletes.

Level of Evidence:

Prognostic level IV

Risk factors for complications after primary repair of Achilles tendon ruptures

Purpose

To identify patient characteristics associated with adverse events in Achilles tendon rupture (ATR) surgical repair cases.

Methods

A high risk (HR) cohort group of ATR patients were compared to healthy controls in the ACSNSQIP database with multivariate regression analysis.

Results

Overall, 2% (n = 23) of the group sustained an AE postoperatively, most commonly superficial SSI (0.9%, n = 10). Multivariate analysis did not reveal any patient characteristics to be significantly associated with the occurrence of an AE or superficial SSI.

Conclusions

Obesity, diabetes and a history of smoking did not predispose patients to significantly more AEs in the 30 day postoperative period following ATR repair in this study.

The epidemiology and trends in management of acute Achilles tendon ruptures in Ontario, Canada: a population-based study of 27 607 patients

AIMS

The aims of this study were to establish the incidence of acute Achilles tendon rupture (AATR) in a North American population, to select demographic subgroups and to examine trends in the management of this injury in the province of Ontario, Canada.

PATIENTS AND METHODS

Patients ≥ 18 years of age who presented with an AATR to an emergency department in Ontario, Canada between 1 January 2003 and 31 December 2013 were identified using administrative databases. The overall and annual incidence density rate (IDR) of AATR were calculated for all demographic subgroups. The annual rate of surgical repair was also calculated and compared between demographic subgroups.

RESULTS

A total of 27 607 patients (median age, 44 years; interquartile range 26 to 62; 66.5% male) sustained an AATR. The annual IDR increased from 18.0 to 29.3 per 100 000 person-years between 2003 and 2013. The mean IDR was highest among men between the ages of 40 and 49 years (46.0/100 000 person-years). The annual rate of surgical repair dropped from 20.1 in 2003 to 9.2 per 100 AATRs in 2013. There was a noticeable decline after 2009.

CONCLUSION

The incidence of AATR is increasing in Ontario, while the annual rate of surgical repair is decreasing. A sharp decline in the rate of surgical repair was noted after 2009. This coincided with the publication of several high-quality RCTs which showed similar outcomes for the 'functional' non-operative management and surgical repair. Cite this article: Bone Joint J 2017;99-B:78-86.

Increasing incidence of acute Achilles tendon rupture and a noticeable decline in surgical treatment from 1994 to 2013. A nationwide registry study of 33,160 patients

PURPOSE

The purpose of this study is to investigate the incidence of acute Achilles tendon rupture in Denmark from 1994 to 2013 with focus on sex, age, geographical areas, seasonal variation and choice of treatment.

METHODS

The National Patient Registry was retrospectively searched to find the number of acute Achilles tendon rupture in Denmark during the time period of 1994-2013. Regional population data were retrieved from the services of Statistics Denmark.

RESULTS

During the 20-year period, 33,160 ruptures occurred revealing a statistically significant increase in the incidence (p < 0.001, range = 26.95-31.17/100,000/year). Male-to-female ratio was 3:1 and average age 45 years for men and 44 years for women. There was a statistically significant increasing incidence for people over 50 years. A higher incidence in rural compared with urban geographical areas was found, but this was not statistically significant. There was a statistically significant decreasing incidence of patients treated with surgery from 16.9/10⁵ in 1994 to 6.3/10⁵ in 2013.

CONCLUSIONS

The incidence of acute Achilles tendon rupture increased from 1994 to 2013 based on increasing incidence in the older population. There was no difference in incidence of acute Achilles tendon rupture in the rural compared with urban geographical areas. A steady decline in surgical treatment was found over the whole period, with a noticeable decline from 2009 to 2013, possibly reflecting a rapid change in clinical practice following a range of high-quality randomized clinical trials (RCT).

LEVEL OF EVIDENCE

IV.

The Gift Box Open Achilles Tendon Repair Method: A Retrospective Clinical Series

Previous biomechanical studies have shown that the gift box technique for open Achilles tendon repair is twice as strong as a Krackow repair. The technique incorporates a paramedian skin incision with a midline paratenon incision, and a modification of the Krackow stitch is used to reinforce the repair. The wound is closed in layers such that the paratenon repair is offset from paramedian skin incision, further protecting the repair. The present study retrospectively reviews the clinical results for a series of patients who underwent the gift box technique for treatment of acute Achilles tendon ruptures from March 2002 to April 2007. The patients completed the Foot Function Index and the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale. The tendon width and calf circumference were measured bilaterally and compared using paired t tests with a 5% α level. A total of 44 subjects, mean age 37.5 ± 8.6 years, underwent surgery approximately 10.8 ± 6.5 days after injury. The response rate was 35 (79.54%) patients for the questionnaire and 20 (45.45%) for the examination. The mean follow-up period was 35.7 ± 20.1 months. The complications included one stitch abscess, persistent pain, and keloid formation. One (2.86%) respondent reported significant weakness. Five (14.29%) respondents indicated persistent peri-incisional numbness. The range of motion was full or adequate. The mean American Orthopaedic Foot and Ankle Society ankle-hindfoot scale score was 93.2 ± 6.8) and the mean Foot Function Index score was 7.0 ± 10.5. The calf girth and tendon width differences were statistically significantly between the limbs. The patients reported no repeat ruptures, sural nerve injuries, dehiscence, or infections. We present the outcomes data from patients who had undergone this alternative technique for Achilles tendon repair. The technique is reproducible, with good patient satisfaction and return to activity. The results compared well with the historical repeat rupture rates and incidence of nerve injury and dehiscence for open and percutaneous Achilles tendon repairs.