Raiyyan Tahsan

Raiyyan Tahsan
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TC(1003).(05).Orthopedics Case No 81:- Achilles Tendon Rupture

Achilles Tendon Rupture — বাংলা Clinical Note

Important: Achilles tendon rupture-এ ওষুধ tendon জোড়া লাগায় না। Main treatment হলো immobilization / functional rehabilitation ± surgery। নিচের drug list adult patient, normal renal/liver function ধরে দেওয়া; anticoagulant/antibiotic/opioid অবশ্যই physician/orthopedic surgeon-এর decision অনুযায়ী।

1. Definition

Achilles tendon rupture হলো calf muscle-এর gastrocnemius + soleus tendon বা tendo-Achilles-এর partial/complete tear, যা calcaneus bone-এর পেছনে insert করে। সাধারণত rupture হয় calcaneal insertion থেকে 2–6 cm proximal watershed area-তে। রোগী অনেক সময় বলে: “পেছন থেকে কেউ লাথি মারলো / pop sound হলো।” Clinical diagnosis মূলত history + examination দিয়ে হয়; ultrasound/MRI supportive।

2. Etiology / Cause & Risk Factors

Common cause / mechanism

  • Sudden push-off injury: দৌড় শুরু করা, jump করা, football/badminton/tennis/basketball খেলতে গিয়ে হঠাৎ acceleration।
  • Forced dorsiflexion: পা মাটিতে fixed, ankle হঠাৎ dorsiflexed হলে tendon ছিঁড়ে যায়।
  • Non-contact sports injury: অনেক সময় direct trauma ছাড়াই rupture হয়।

Risk factors

  • Age 30–50 years, male sex: middle-aged male “weekend athlete”-দের common।
  • Previous Achilles tendinopathy: আগে থেকেই tendon degeneration/ব্যথা থাকলে rupture risk বাড়ে।
  • Fluoroquinolone antibiotics: যেমন ciprofloxacin/levofloxacin tendon rupture risk বাড়াতে পারে।
  • Corticosteroid use: systemic steroid বা local steroid injection tendon দুর্বল করতে পারে।
  • Poor conditioning: হঠাৎ intense exercise, warm-up ছাড়া sports।
  • Metabolic/systemic factors: diabetes, obesity, renal disease, rheumatoid arthritis, hypercholesterolemia—tendon quality খারাপ করতে পারে।
  • Previous rupture or inadequate rehab: আগের injury ঠিকমতো heal না হলে re-rupture হতে পারে।

3. Pathophysiology — সহজ ভাষায়

Achilles tendon repeated microtrauma + poor blood supply area-তে degeneration হলে tendon দুর্বল হয়। হঠাৎ load পড়লে collagen fibers fail করে। Complete rupture হলে calf muscle contraction হলেও tendon force calcaneus-এ properly transmit করতে পারে না; তাই রোগী toe-off / tiptoe / push-off করতে পারে না।

4. Clinical Features / Symptoms

  • Sudden sharp pain ankle-এর পেছনে বা lower calf-এ।
  • Audible/feelable “pop” বা snap sensation।
  • রোগী মনে করে “কেউ পেছন থেকে লাথি মেরেছে”।
  • Walking difficulty: বিশেষ করে stairs ওঠা, দৌড়ানো, tiptoe দাঁড়ানো কঠিন।
  • Single heel raise করতে পারে না বা খুব দুর্বল।
  • Swelling + bruising ankle/calf-এর পেছনে।
  • Palpable gap: tendon-এর মধ্যে defect feel হতে পারে, বিশেষ করে acute swelling কম থাকলে।
  • Plantarflexion weakness: তবে active plantarflexion কিছুটা থাকতে পারে, কারণ অন্য flexor muscles কাজ করতে পারে—তাই plantarflexion থাকা মানেই rupture নেই, এমন নয়।

5. Clinical Diagnosis — Specific Examination

A. Inspection

  • Posterior ankle swelling, ecchymosis।
  • Resting foot position compare করুন: affected side কম plantarflexed থাকতে পারে।

B. Palpation

  • Achilles tendon course palpate করে gap/defect দেখুন।
  • Tenderness সাধারণত rupture site-এ।

C. Thompson / Simmonds calf squeeze test

  • Patient prone, foot edge থেকে ঝুলবে।
  • Calf squeeze করলে normal foot plantarflex হবে।
  • No plantarflexion / markedly reduced plantarflexion = positive test, rupture suggestive। Thompson test উচ্চ sensitivity/specificity সহ useful bedside test।

D. Matles test

  • Patient prone, knee 90° flexed।
  • Normal side foot slight plantarflexed থাকে।
  • Rupture side foot neutral/dorsiflexed হয়ে ঝুলে থাকে = positive।

E. Simmonds’ triad

  • Positive calf squeeze test
  • Altered angle of declination / resting tension loss
  • Palpable tendon gap
    এই triad clinically খুব useful।

6. Investigations — Specific

1. X-ray ankle, AP + lateral

Purpose: tendon দেখা যায় না, কিন্তু exclude করতে হয়:

  • calcaneal avulsion fracture
  • calcaneal fracture
  • posterior ankle bony injury
  • other traumatic pathology calcaneal fracture
  • posterior ankle bony injury
  • other traumatic pathology

2. Ultrasound / Dynamic ultrasound

Best first-line imaging when confirmation needed.
দেখায়:

  • partial vs complete rupture
  • rupture site
  • tendon gap size
  • plantarflexion করলে tendon ends approximate করছে কি না
  • hematoma / tendon retraction

Ultrasound gap measurement non-operative vs oper্য করতে পারে, তবে exact gap cut-off নিয়ে evidence limited। citeturn467307view3

3. MRI ankle

Routine acute obvious complete rupture-এ সবসময় দরকার হয় না। দরকার হয়:

  • diagnosis uncertain
  • partial rupture suspected
  • chronic rupture
  • re-rupture
  • surgical planning
  • atypical pain/swelling

4. Pre-operative investigations

Surgery planned হলে:

  • CBC
  • RBS / HbA1c
  • Serum creatinine, electrolytes
  • LFT
  • PT/INR, aPTT if anticoagulant/bleeding risk
  • ECG/CXR according to age/comorbidity

5. Doppler ultrasound

যদি calf swelling/pain disproportionate, immobilization, DVT risk থাকে—DVT exclude করার জন্য।

7. Differential Diagnosis

  • Gastrocnemius strain / “tennis leg”
  • Plantaris tendon rupture
  • Severe ankle sprain
  • Achilles tendinopathy / paratenonitis
  • Calcaneal avulsion fracture
  • Posterior ankle impingement
  • Deep vein thrombosis
  • Sural nerve injury
  • Retrocalcaneal bursitis

8. Complications of Disease — বাংলায়

  • Missed diagnosis → chronic rupture: প্রথমে diagnose না হলে tendon ends দূরে সরে যায়, পরে repair কঠিন হয়।
  • Tendon lengthening: tendon লম্বা হয়ে heal করলে push-off power কমে যায়; হাঁটায় limp থাকে।
  • Calf weakness & atrophy: দীর্ঘ immobilization/rupture-এর কারণে calf muscle শুকিয়ে যায়।
  • Re-rupture: non-operative treatment-এ historically re-rupture বেশি দেখা গেছে, তhab দিলে outcome ভালো হয়; surgery-তেও re-rupture হতে পারে। citeturn467307view3
  • Ankle stiffness: prolonged cast/immobilization-এর কারণে।
  • DVT / Pulmonary embolism: lower-limb immobilization ও surgery-এর কারণে clot risk।
  • Chronic pain / reduced sports performance: full strength ফিরে আসতে 6–12 মাস লাগতে পারে।
  • Surgical complications: wound infection, wound breakdown, scar tenderness, sural nerve injury, adhesions। Surgery-তে r কিন্তু wound/nerve/infection complications বেশি হতে পারে। citeturn467307view3

9. Management / Treatment

A. Immediate management — first aid

  • Stop activity immediately
  • RICE: Rest, Ice, Compression, Elevation
  • Non-weight bearing: crutch ব্যবহার
  • Ankle plantarflexion/equinus position-এ splint/boot
  • Urgent orthopedic referral: ideally early, কারণ early treatment outcome ভালো করে।
  • Analgesic দিন, কিন্তু NSAID/anticoagulant/antibiotic self-medication নয়।

B. Definitive treatment

1. Non-operative functional treatment

Suitable হতে পারে:

  • low/moderate demand patient
  • high surgical risk
  • early diagnosis
  • tendon ends plantarflexion-এ approximate করছে
  • patient rehab protocol follow করতে পারবে

Treatment:

  • Functional boot/cast with heel wedges
  • Protected weight-bearing
  • Early controlled ROM
  • Gradual wedge removal
  • Physiotherapy-guided strengthening

AOFAS অনুযায়ী selected patients-এ n effective, especially early functional rehabilitation সহ। citeturn467307view2

2. Operative repair

Consider করা হয়:

  • young/high-demand athlete
  • large tendon gap / poor tendon apposition
  • delayed presentation
  • re-rupture
  • high push-off strength needed occupation
  • chronic rupture

Options:

  • Open repair
  • Percutaneous/minimally invasive repair
  • Chronic rupture হলে tendon augmentation/transfer লাগতে পারে

AOFAS বলেছে acute Achilles rupture-এ **surgical and nonsurgical—দুই treatment-ই patient factors ও surgeon-patient shared decision অনুযায়ী। citeturn467307view1

3. Rehabilitation — practical outline

  • 0–2 weeks: splint/cast/boot in plantarflexion, swelling control।
  • 2–6 weeks: boot + heel wedges, protected weight-bearing, gentle ROM।
  • 6–12 weeks: wedge removal, progressive ROM, strengthening।
  • 3–6 months: jogging/functional training if strength adequate।
  • 6–12 months: sports return, depending on strength symmetry and functional testing।

10. Pharmacological Management — Bangladesh Brand + Dose + Purpose

Key rule

Achilles rupture prescription usually has supportive drugs:

  1. pain control
  2. inflammation control
  3. gastric protection if NSAID
  4. peri-operative antibiotic if surgery
  5. VTE prophylaxis if high risk/immobilized
  6. severe pain rescue opioid

10.1 Paracetamol

1. Generic name: Paracetamol / Acetaminophen
2. Therapeutic category: Analgesic + Antipyretic
3. Pharmacological class: Non-opioid analgesic; para-aminophenol derivative
4. Bangladesh available brand examples:

  • Napa 500 mg tablet, Napa Extend 665 mg, Napa One 1000 mg — Beximco
  • Ace 500 mg tablet — Square
  • Reset 500 mg, Reset ER 665 d strengths in Bangladesh. citeturn567500view0turn409567view0turn409567view1

5. Dose:

  • 500 mg–1 g orally every 6–8 hours PRN
  • Practical safe max: 3 g/day; absolute max 4 g/day in healthy adult
  • Duration: 3–7 days according to pain

6. কেন ব্যবহার হয়:

  • First-line pain control
  • NSAID contraindication থাকলে safer option

7. Side effects:

  • Nausea, rash rare
  • Overdose → severe hepatotoxicity

8. Interaction:

  • Alcohol + paracetamol → liver toxicity risk
  • Warfarin long-term/high-dose use → INR increase possible
  • Other cold/flu medicines containing paracetamol avoid করতে হবে।

10.2 NSAIDs — pain + inflammation control

একসাথে একটির বেশি NSAID নয়। খাবারের পরে দিতে হবে।

Option A: Ibuprofen

1. Generic name: Ibuprofen
2. Therapeutic category: Analgesic / Anti-inflammatory
3. Pharmacological class: NSAID; non-selective COX inhibitor
4. Bangladesh brand examples: Profen 400 mg, ReumafMedEx ibuprofen brands/dose list করে। citeturn980542search7turn980542search16
5. Dose: 400 mg orally every 8 hours after food PRN, 3–5 days
6. কেন ব্যবহার হয়: pain, swelling, inflammation কমাতে
7. Side effects: gastritis, dyspepsia, GI bleed, renal injury, BP rise, fluid retention, asthma exacerbation
8. Interaction: anticoagulant/antipl ACEI/ARB + diuretic-এর সাথে AKI risk। citeturn219323search0turn219323search1

Option B: Naproxen

1. Generic name: Naproxen / Naproxen sodium
2. Therapeutic category: Analgesic / Anti-inflammatory
3. Pharmacological class: NSAID
4. Bangladesh brand examples: Napro50/500 mg, Napryn 250/500 mg, Naspro 250 mg, Nasox 500 mg। citeturn388774view2
5. Dose: 250–500 mg orally twice daily after food, 3–7 days
6. কেন ব্যবহার হয়: longer acting NSAID; moderate pain/swelling
7. Side effects/interactions: NSAID class-এর মতো—GI bleed, renal injury, BP rise; anticoagulant/antiplatelet/other NSAID avoid।

Option C: Diclofenac sodium

1. Generic name: Diclofenac sodium
2. Therapeutic category: Analgesic / Anti-inflammatory
3. Pharmacological class: NSAID; phenylacetic acid derivative
4. Bangladesh brand examples: Diclovir 50 mg/SR 100 mg, Di mg/SR 100 mg, Rispain 50 mg/SR 100 mg, S-Fenac TR 100 mg। citeturn388774view1
5. Dose: 50 mg orally 2–3 times daily after food; max 150 mg/day; duration 3–5 days
6. কেন ব্যবহার হয়: acute musculoskeletal pain/inflammation
7. Caution: hypertension, ischemic heart disease, CKD, peptic ulcer, anticoagulant use থাকলে avoid/extra caution।

Option D: Etoricoxib

1. Generic name: Etoricoxib
2. Therapeutic category: Analgesic / Anti-inflammatory
3. Pharmacological class: Selective COX-2 inhibitor NSAID
**4. Bangladesh brand exa120 mg, Recox 60/90 mg, G-Cox 90/120 mg, Kingcox 60/90 mg। citeturn388774view3
5. Dose: 60–90 mg orally once daily after food, 3–5 days
6. কেন ব্যবহার হয়: gastric intolerance থাকলে selected patients-এ pain control
7. Caution: uncontrolled hypertension, ischemic heart disease, stroke risk, heart failure—avoid।

10.3 Pantoprazole — NSAID gastric protection

1. Generic name: Pantoprazole sodium
2. Therapeutic category: Anti-ulcerant / Gastroprotective
3. Pharmacological class: Proton Pump Inhibitor
4. Bangladesh brand examples: P-Gut 40 mg, P-Lock 20/40 mg, 20/40 mg, Pantogut 40 mg, Pantolok 20/40 mg, Pantonix IV। citeturn388774view4
5. Dose:

  • 40 mg orally once daily, breakfast-এর 30 মিনিট আগে
  • Duration: NSAID চলাকালীন 5–14 days; ulcer risk বেশি হলে longer physician decision

6. কেন ব্যবহার হয়:

  • NSAID-induced gastritis/ulcer/GI bleeding risk কমাতে
  • Age >60, dyspepsia, previous ulcer, steroid/anticoagulant use থাকলে useful

7. Side effects: headache, diarrhea/constipation, nausea; long-term use → hypomagnesemia, B12 deficiency, C. difficile risk।
8. Interaction: clopidogrel caution, high-dose methotrexate caution, ketoconazole/itraconazole/iron absorption কমতে পারে।

10.4 Tramadol — severe pain rescue

1. Generic name: Tramadol hydrochloride
2. Therapeutic category: Opioid analgesic / Centrally acting analgesic
3. Pharmacological class: μ-opioid agonist + serotonin/noradrenaline reuptake inhibition
4. Bangladesh brand examples: Dolonil 50 mg capsule/100 mg injection, Trado 50 mg, Tranal 50 mg/100 mg in00 mg injection/suppository, Retram 50 mg, Syndol 50 mg। citeturn113195search3
5. Dose:

  • 50 mg orally every 6–8 hours PRN severe pain
  • Max 400 mg/day
  • Duration: usually 1–3 days only

6. কেন ব্যবহার হয়:

  • Severe acute pain বা post-operative pain যখন paracetamol ± NSAID যথেষ্ট নয়

7. Side effects: nausea, vomiting, constipation, dizziness, sedation, respiratory depression, dependence।
8. Interaction: alcohol/benzodiazepine/sedative → respiratory depression; SSRI/SNRI/TCA/MAOI/linezisorder বা high dose-এ seizure risk। citeturn219323search11turn219323search20

10.5 Enoxaparin — DVT/PE prophylaxis

1. Generic name: Enoxaparin sodium
2. Therapeutic category: Anticoagulant / VTE prophylaxis
3. Pharmacological class: Low Molecular Weight Heparin; parenteral anticoagulant
4. Bangladesh brand examples: Cleven 4000/6000/8000 anti-Xa, Parinox 4000/6000/8000, Noxarin 2000/4000/6000/8000, Clotinex 4000/6000, Xaparin 4000/6000, Enoject 4000/6000/8000, Enoparin 4000/6000/8000। MedEx e class, dose, interactions and Bangladesh brands list করে। citeturn227633view0

5. Dose:

  • Common prophylaxis: 40 mg = 4000 anti-Xa IU SC once daily
  • Duration: 7–10 days; high-risk prolonged immobilization হলে 2–3 weeks or longer physician decision
  • Renal impairment থাকলে dose adjustment দরকার

6. কেন ব্যবহার হয়:

  • Achilles rupture surgery/immobilization-এ DVT/PE risk থাকলে clot prevention

7. Side effects: bleeding, injection-site hematoma, thrombocytopenia/HIT, raised liver enzymes, spinal/epidural hematoma risk।
8. Interaction: NSAID, aarfarin, DOAC, steroid, thrombolytic → bleeding risk বাড়ে। citeturn227633view0

10.6 Rivaroxaban — oral anticoagulant option

1. Generic name: Rivaroxaban
2. Therapeutic category: Oral anticoagulant / VTE prophylaxis
3. Pharmacological class: Direct Factor Xa inhibitor
4. Bangladesh brand examples: Kinexa 10/15/20/2.5 mg, RivaXa 10/2.5 mg, Rivarxarel 10/15/2.5 mg, Xarelta 10/15/20/2.5 mg, Oxaban 10 mg। citeturn760193view4

5. Dose:

  • Orthopedic prophylaxis label: 10 mg orally once daily after hip/knee replacement; Achilles immobilization-এ use individualized/off-label হতে পারে
  • Duration: high-risk immobilization period অনুযায়ী surgeon decision

6. কেন ব্যবহার হয়:

  • Injection avoid করতে চাইলে selected high-risk patient-এ DVT prophylaxis option

7. Side effects: bleeding, anemia, bruising; active bleeding থাকলে contraindicated।
8. Interaction: strong CYP3A4/P-gp iAID/antiplatelet/other anticoagulant → bleeding risk বাড়ে। citeturn760193view4

10.7 Cefazolin — peri-operative antibiotic

Closed Achilles rupture non-operative হলে antibiotic দরকার নেই। Surgery হলে prophylaxis হিসেবে দেওয়া হয়।

1. Generic name: Cefazolin sodium
2. Therapeutic category: Antibacterial / Surgical prophylaxis
3. Pharmacological class: 1st-generation cephalosporin; beta-lactam cell wall synthesis inhibitor
**4. Bangladesh brand examplesazoline Panpharma 1 g/5 mL, Zolibac 1 g। citeturn318583search0turn388774view7

5. Dose:

  • 2 g IV within 60 minutes before incision
  • ≥120 kg হলে 3 g IV
  • Long surgery হলে intra-op redose
  • Usually stop within 24 hours

Surgical prophylaxis guideline অনুযায়ী antiibiotic routine নয়। citeturn790318search0turn790318search1turn790318search11

6. কেন ব্যবহার হয়:

  • Surgical site infection prevention

7. Side effects: allergy, rash, diarrhea, C. difficile, injection-site reaction, rare anaphylaxis।
8. Interaction: warfarin-এর সাথে INR monitoring; nephrotoxic drugs caution।

10.8 Cefuroxime — only if infection/open wound/surgeon protocol

Routine closed clean Achilles repair-এর পরে long oral antibiotic evidence-based নয়। তবে open injury, wound infection, cellulitis, বা surgeon-specific protocol থাকলে ব্যবহার হতে পারে।

1. Generic name: Cefuroxime axetil
2. Therapeutic category: Antibacterial
3. Pharmacological class: 2nd-generation cephalosporin
4. Bangladesh brand examples: Turbocef 250/500 mg, Ximetil 250/500 mg and injection0 mg, Vexotil 500 mg, Winfax 250/500 mg। citeturn389223search2turn388774view6
5. Dose: 500 mg orally twice daily for 5–7 days, only if infection/open wound/surgeon indicates
6. কেন ব্যবহার হয়: soft-tissue infection/wound coverage
7. Side effects: diarrhea, rash, allergy, C. difficile
8. Interaction: warfarin INR monitoring; antacid/PPI absorption effect may occur for cefuroxime axetil।

11. Bangladesh Doctors Usually Prescribe — Practical List

Achilles tendon rupture prescription commonly includes:

  1. Paracetamol — pain control, first-line।
  2. One NSAID only — ibuprofen/naproxen/diclofenac/etoricoxib; pain + inflammation কমাতে।
  3. Pantoprazole — NSAID দিলে gastric protection।
  4. Tramadol — severe acute/post-op pain rescue, short course।
  5. Cefazolin IV — only operation-এর peri-operative prophylaxis।
  6. Enoxaparin or Rivaroxaban — immobilization/post-op high VTE risk থাকলে DVT/PE prevention।
  7. Cefuroxime — routine নয়; only wound/infection/open injury/surgeon protocol।

Avoid / caution: fluoroquinolone antibiotic unnecessary হলে avoid; steroid injection around Achilles avoid; multiple NSAID একসাথে নয়; NSAID + anticoagulant combination bleeding risk বাড়ায়।

12. Prevention

  • Exercise/shoe change-এর আগে gradual conditioning করুন।
  • Sports-এর আগে warm-up + calf stretching।
  • Calf strengthening: eccentric heel-drop, soleus/gastrocnemius strengthening।
  • Sudden high-intensity sports avoid, especially deconditioned হলে।
  • Previous Achilles pain থাকলে early treatment; pain ignore করে খেলবেন না।
  • Fluoroquinolone antibiotic + steroid use history থাকলে tendon pain হলে immediately stop high-load activity and review।
  • Proper footwear and heel support।
  • Diabetes/obesity/hyperlipidemia control।
  • Rehab incomplete থাকা অবস্থায় sports return করবেন না।
  • Return-to-sport decision: pain-free ROM, calf strength near symmetric, single heel raise ability, functional testing pass।

Overview / Summary

Achilles tendon rupture হলো calf muscle tendon-এর partial/complete tear, সাধারণত sudden push-off বা forced dorsiflexion injury-তে হয়। Diagnosis বেশিরভাগ ক্ষেত্রে clinical—pop sound, posterior ankle pain, walking difficulty, positive Thompson test, palpable gap। Ultrasound first-line confirmation; MRI selective। Treatment হলো functional immobilization/rehab ± surgical repair। Drug therapy শুধু pain control, gastric protection, infection prophylaxis, and DVT prophylaxis-এর জন্য—tendon heal করানোর primary treatment নয়।

Actionable Plan / Steps

  1. Suspected rupture হলে immediately sports বন্ধ করুন।
  2. Ankle plantarflexion position-এ splint/boot দিন, non-weight-bearing করুন।
  3. Thompson test + Matles test + palpable gap clinically assess করুন।
  4. X-ray দিয়ে fracture exclude করুন; ultrasound দিয়ে rupture confirm/gap assess করুন।
  5. Orthopedic referral করুন—operative vs non-operative decision patient demand, gap, chronicity, comorbidity অনুযায়ী।
  6. Pain: paracetamol first-line; NSAID short course if no contraindication; PPI if NSAID risk।
  7. Surgery হলে cefazolin peri-op; immobilization/high-risk হলে VTE prophylaxis consider।
  8. Rehab protocol strictly follow করুন; premature sports return করবেন না।

Reference List — Textbook + Guideline + DOI

Textbooks

  1. Apley & Solomon’s System of Orthopaedics and Trauma, 10th/11th ed., Foot & ankle tendon injury section.
  2. Maheshwari & Mhaskar, Essential Orthopaedics, latest ed., Injuries around ankle/foot and tendo-Achilles rupture chapter.
  3. Campbell’s Operative Orthopaedics, 14th ed., Foot and ankle surgery—Achilles tendon repair/reconstruction.

Guidelines / Position statements

  1. American Orthopaedic Foot & Ankle Soendon Ruptures*, Position Statement, 2024. citeturn467307view1turn467307view2
  2. AAOS Clinical Practice Guideline: Diagnosis and Treatment of Acute Achilles Tendon Rupture.
  3. WHO. he Prevention of Surgical Site Infection*, updated 2018. citeturn790318search1
  4. ASHP/IDSA/SIS/SHEArobial Prophylaxis in Surgery*, 2013. citeturn790318search0turn790318search11

Peer-reviewed journals with DOI

  1. Myhrvold SB, et al. Nonoperative or Surgical Treatment of Acute AchilJM*. 2022;386:1409–1420. DOI: 10.1056/NEJMoa2108447. citeturn346606search2
  2. Ochen Y, et al. Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systemasis. BMJ. 2019;364:k5120. DOI: 10.1136/bmj.k5120. citeturn346606search12
  3. Park SH, et al. Treatment of Acute Achilles Tendonrg*. 2020;12(1):1–8. DOI: 10.4055/cios.2020.12.1.1. citeturn553647search9

Md.Rafiqul Islam Lipu,Date:-14-06-2026 Sunday,Time:-12-21-12 Pm

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