Achilles Tendon Rupture

M.Mazloumi MD

Anatomy

Largest tendon in the body

Origin from gastrocnemius and soleus muscles

Insertion on calcaneal tuberosity

Anatomy

Lacks a true synovial sheathParatenon has visceral and parietal layersAllows for 1.5cm of tendon glide

Anatomy

ParatenonAnterior – richly vascularizedThe remainder – multiple thin membranes

Anatomy

Blood supply1) Musculotendinous junction

2) Osseous insertion on calcaneus

3) Multiple mesotenal vessels on anterior surface of paratenon (in adipose)

– Anterior mesentery Hypovascular area at 2 to 6 cm proximal to osseous

insertion

Physiology

Remarkable response to stressExercise induces tendon diameter increase Inactivity or immobilization causes rapid

atrophyAge-related decreases in cell density,

collagen fibril diameter and densityOlder athletes have higher injury

susceptibility

Biomechanics

Gastrocnemius-soleus-Achilles complexSpans 3 joints

Flex kneePlantar flex tibiotalar jointSupinate subtalar joint

Up to 10 times body weight through tendon when running

Achilles Tendon Rupture

Pathophysiology Repetitive

microtrauma in a relatively hypovascular area.

Reparative process unable to keep up

Achilles Tendon Rupture

May be on the background of a degenerative tendon

Achilles Tendon Rupture

Antecedent tendinitis/tendinosis in 11%

75% of sports-related ruptures happen in patients between 30-40 years of age.

Most ruptures occur in 4cm proximal to the calcaneal insertion.

Achilles tendon disorders

Achilles Tendon Rupture

History

Case reports of fluoroquinolone use, steroid injections

Mechanism Eccentric loading (running backwards in tennis) Sudden unexpected dorsiflexion of ankle Direct blow or laceration Fall from a hight

Achilles Tendon Rupture

PhysicalPartial

Localized tenderness +/- nodularityComplete

DefectCan not heel raisePositive Thompson test

Imaging

Ultrasound Inexpensive , dynamic

examination possible

Good screening test for complete rupture

Imaging

MRIExpensiveBetter at detecting

1-partial ruptures

2- staging degenerative changes

3- monitor healing

Management Goals

Restore musculotendinous length and tension.

Optimize gastro-soleous strength and function

Avoid ankle stiffness

Conservative Management

Cast in Plantarflexion CAM Walker or cast with plantarflexion q 2 wks

2 wks

Allow progressive weight-bearing in removable cast

Remove cast and walk with shoe lift. Start with 2cm x 1 month, then 1cm x1 month then D/C

4 weeks

Start physio for ROM exercises

When WBAT and foot is plantigrade

Start a strengthening program

2- 4 weeks

Functional Bracing

Surgical Management

Preserve anterior paratenon blood supply

Beware of sural nerveDebride and approximate tendon endsUse 2-4 stranded locked suture

techniqueMay augment with absorbable sutureClose paratenon separately

Surgical Management

Kerachow suture technique Dynamic loop suture of Peroneus brevis

Surgical Management

Lynn technique Percutaneous repaire

Old rupture

Bosworth technique for repairing old ruptures of Achilles tendon

Wapner technique with FHL tendon

Percutaneous versus open repair

Percutaneous repair Open repair

Surgical Management : Post– op Care

Assess strength of repair, tension and ROM intra-op.

Apply cast with ankle in the least amount of plantarflexion that can be safely attained.

Patient returns to fracture clinic 2 weeks post-op.

Conservative vs Surgical

Acute rupture of tendon Achillis. A prospective randomised study of comparison between surgical and non-surgical treatment.Moller M, et al. J Bone Joint Surg Br. 2001 Aug;83(5):863-8

112 patients

Surgery +

Early functional rehab in brace

Casted x 8 wks

21 % re-rupture 1.7% re-rupture

5% infection

2% Sural nerve inj.No difference in functional outcome

Conservative vs Surgical

Acute Achilles tendon rupture: minimally invasive surgery versus nonoperative treatment with immediate full weightbearing--a randomized controlled trial.

Am J Sports Med. 2008 Sep;36(9):1688-94. Epub 2008 Jul 21.

83 patients

Surgery +

Early functional rehab in brace

Casted x 8 wks

5 \ 41 re-rupture 3 \ 42 re-rupture

0.5% infection

0.1% Sural nerve inNo difference in functional outcome

Limited open technique

1. Outcome of achilles tendon ruptures treated by a limited open technique. Jung HG, Lee KB, Cho SG, Yoon Foot Ankle Int. 2008 Aug;29(8):803-7.

2. Repair of achilles tendon rupture under endoscopic control. Fortis AP, Dimas A, Lam Arthroscopy. 2008 Jun;24(6):683-8.

3. Minimally invasive repair of ruptured Achilles tendon. Chan SK, Chu Hong Kong Med J. 2008 Aug;14(4):255-8.

Summary of Pooled Outcome Measures

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