Complete Rupture of The Achilles Tendon

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Complete Ruptures of the Achilles Tendon

,
Medscape Orthopedics. 2001;5(3)
Abstract
Although Achilles tendon ruptures may occur in young athletes, they generally occur in 30- to 40-year-old sedentary
males who overexert themselves, usually on weekends. The patient typically presents with pain, ecchymosis, and a
history of an audible "pop" in the calf. Usually in these cases, a gap is palpable 2 cm to 6 cm above the insertion of
the Achilles tendon; the patient is unable to perform repetitive heel rises; and Thompson, Copeland, and O'Brien
tests scores are positive. Usually the diagnosis is made on clinical grounds, but MRI and ultrasound can be useful
when the diagnosis is uncertain. During the late 1980s and 1990s, surgical treatment was favored in young active
patients and in those with chronic tears. Although simple end-to-end repair achieves good results in acute tears,
chronic tears usually require some type of augmentation. The trend in postoperative rehabilitation is moving toward
progressive functional protocols.
Background
Although the Achilles tendon is the thickest, strongest, most powerful tendon in the human body, it can be
vulnerable to injury. One of the best known descriptions of an Achilles tendon injury occurred in Homer's, The Iliad.
After learning of the prophecy that her son would die in battle, Thetis immersed Achilles into the river, Styx, to render
him invulnerable to injury. Unfortunately, in holding Achilles by the ankles, the magic water failed to touch his heels,
which later left him victim to a poisonous arrow.[1]
Achilles tendon ruptures are often in the media spotlight as because they have incapacitated many famed athletes,
such as football quarterbacks Dan Marino and Vinny Testaverde. About 75% of all Achilles tendon ruptures occur
during sporting events.[2] However, the average victim of a complete Achilles tendon rupture does not engage in
highly competitive professional athletics. Rather, the victim is usually the so-called "weekend warrior." This weekend
warrior is typically a 30- to 40-year-old, sedentary, male, white-collar worker, who over-exerts himself while playing
sports on the occasional weekend. This overexertion most commonly occurs while playing basketball (United
States), badminton (Sweden), and soccer (Germany).[3]
With the increased popularity in recreational athletics, Western countries have watched the weekend warrior, and
his associated injuries, flourish. Prior to 1929, fewer than 66 cases of Achilles tendon ruptures were reported in the
literature.[2] In 1956, the Achilles tendon became the third most frequent tendon torn, following the finger and knee
extensors.[4] Then, in 1989, it became the most frequently torn tendon and constituted 40% of all operated tendon
ruptures.[2] According to a report from the University of Aberdeen Hospital in Scotland, Achilles tendon repairs are
performed roughly every 7 to 10 days.[5]
In contrast, the incidence remains very low in underdeveloped countries, for example, those of Africa and East Asia.
[6]
Although inhabitants of these countries may be less physically vigorous on intermittent weekends, they are likely
to be more active during the week than Western weekend warriors. The typical weekend warrior spends the work
day in an air-conditioned office 5 or 6 days a week, those in less developed countries typically exercise their tendons
and muscles during their daily routine.
Mechanism of Injury
The weekend warrior ruptures the Achilles tendon in 1 of 3 ways. Most often, they occur when pushing off the
weight-bearing foot while extending the knee joint, which occurs during sprinting or jumping. Because the right-
handed warrior is apt to push off with the left leg, left Achilles tendon rupture is more prevalent in this population.
Approximately 17% of ruptures occur when the warrior suddenly and unexpectedly dorsiflexes his ankle when
stepping into a hole, falling forward, or slipping on a ladder.[7] Approximately, 10% of ruptures result from
jumping/falling from a height and violently dorsiflexing the plantarflexed foot.[7]
http://www.medscape.com/viewarticle/408535_print 6/29/2017
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Although previous studies have reported male to female rupture ratios between 2:1 and 19:1, recent experiences at
Union Memorial Hospital in Baltimore, Maryland, reflect a 30:1 ratio.[6] It is not known whether these widely varying
ratios merely reflect a larger number of male vs female weekend warriors in the regions studied or whether the male
tendon is somehow more susceptible.
Drug- and Disease-Related Risk Factors
Both corticosteroids and anabolic steroids as well as fluoroquinolones have been implicated in playing a role in
Achilles tendon ruptures. The injection of corticosteroids into the tendons of rats has been shown to cause tendons
necrosis.[1] Although injection into peritendinous areas is less detrimental, corticosteroids, nonetheless, inhibit
healing. In addition, corticosteroids may mask painful symptoms, causing the individual to overexert a weakened
tendon. Furthermore, both anabolic steroids[3] and fluoroquinolones[6] cause dysplasia of collagen fibrils, which, in
turn, decrease tendon tensile strength. A recent study showed that animals administered fluoroquinolones at doses
comparable to those given to humans had disruption of their extracellular cartilage matrix and a depletion of
collagen.[1] Other reported causes of Achilles tendon ruptures include gout, hyperthyroid, renal insufficiency, and
arteriosclerosis.[6]
Physical Examination
Along with gathering a detailed history, a careful physical exam is critical to diagnosing an Achilles tendon rupture.
The classic findings are a palpable and painful defect 2 cm to 6 cm proximal to the tendo-calcaneal insertion. The
reason for this distribution of injuries is not entirely clear, although some studies suggest that the blood flow in this
vicinity is relatively poor.[3] Also, the leg bruises in the area of the tear and the patient has weak plantarflexion.
Despite the seemingly straightforward history and physical, about 25% of Achilles tendon ruptures are missed during
the patient's first visit.[8] Although the patient initially feels the pain of a violent kick, or even a "gunshot," pain may
not be present on palpation. In addition, the typical ecchymosis and edema may not be present early. If swelling is
present, it can obliterate any palpable defect. The physician may incorrectly diagnose a "partial tear" if the patient
can still plantarflex his ankle. This paradox is due to the functional flexor hallucis longus, flexor digitorum longus,
posterior tibial, and peroneal tendons.
These pitfalls can be avoided by using a few simple tests. First, the patient should be instructed to perform repetitive
heel rises. Despite the other functioning plantarflexors, the patient with a torn Achilles tendon will be unsuccessful in
this attempt. The well-known Thompson test can aid in the diagnosis. This is done by simply squeezing the midcalf
of the affected leg, which is kneeling (90-degree angle) on a chair while the opposite leg remains standing. The
absence of ankle plantarflexion is suggestive of a complete Achilles tendon rupture and is termed a "positive"
Thompson test (Figure 1).
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Figure 1.
Ruptured Achilles tendon, as indicated by absence of plantarflexion motion on Thompson testing.
Although relatively reliable, the Thompson test can be equivocal. In such cases, one or both of the following tests
can be used. The Copeland test involves having the patient lie prone while flexing his knee to ninety degrees. A
sphygmomanometer cuff is then placed around the bulk of the calf and inflated to 100 mm Hg with the ankle
plantarflexed. When the ankle is dorsiflexed, the calf pressure in normal controls increases to about 140 mm Hg. In
contrast, the pressure in those with a torn Achilles tendon will change by merely a flicker. It should be noted that the
opposite leg may be used as a control for comparison purposes.[9]
Recently, O'Brien[8] described a test in which a 25-gauge needle is placed 10 cm proximal to the superior border of
the calcaneus such that it penetrates the Achilles tendon. The ankle is then alternated with passive dorsiflexion and
plantarflexion movements. If the needle end tilts such that it points in the direction opposite the movement, then the
Achilles tendon is noted to be intact. However, if it remains relatively still, a rupture is the diagnosis.
Ultrasonography and MRI
A careful history and physical examination as described above should result in an accurate diagnosis in more than
90% of patients. However, some patients and physicians may opt to forego the Copeland and O'Brien tests due to
the pain involved and possible inaccurate results due to inexperience. If the diagnosis remains questionable, either
ultrasound or MRI can be helpful.
Ultrasound scanning will show an intact Achilles tendon as a hypoechogenic ribbon-like image contained within 2
hyperechoic bands (Figure 2).[10] When torn, the distal stump will be grossly thickened and contain an irregular
echogenic pattern. This correlates with the operative findings of a degenerative stump surrounded by inflammatory
cells. The site of the tear will also show a hyperechogenic area consistent with a partially organized hematoma
(Figure 3).[10] Ultrasound is noninvasive, inexpensive, nonionizing, and fast. Unfortunately, it may not be sensitive in
differentiating between partial and complete tears and its interpretation often requires a steep learning curve.
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Figure 2.
Ultrasonographic appearance of a normal Achilles tendon -- a hypoechogenic ribbon with well-defined anterior
border. Large arrow shows posterior subcutaneous fat; small arrow shows anterior border of the tendon; triangle
placed at Kager's triangle. TE = tendon; TI = tibia; CA = calcaneus; K = Kager's triangle; H = hematoma; SF =
subcutaneous fat. Reprinted with permission from Maffulli N, et al. J Sports Med. 1989:29:365-368.[10]
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Figure 3.
Ultrasonographic appearance of a ruptured Achilles tendon. Smaller arrow shows rupture site; 2 larger arrows
show swollen tendon distal to rupture site; hollow arrow shows hyperechogenic hematoma which obscures anterior
wall of tendon. TE = tendon; TI = tibia; CA = calcaneus; K = Kager's triangle; H = hematoma; SF = subcutaneous fat.
Reprinted with permission from Maffulli N, et al. J Sports Med. 1989:29:365-368.[10]
On MRI, an intact Achilles tendon will have low signal intensity on all pulse sequences; any increased signal
intensity within the tendon is viewed as abnormal. The sagittal T1 images can differentiate fat from hemorrhage. It
will show high signal intensity at a rupture site filled with edema and hemorrhage. In contrast, sagittal T2 images are
best for delineating the size of the gap and the condition/orientation of the torn fibers (Figures 4A and 4B).[11]
Although more time consuming and expensive, MRI is generally superior to ultrasound in differentiating hemorrhage
from tendon at the rupture site as well as differentiating partial from complete tears.
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Figure 4.
(A) T1-weighted (TR 600, TE 20) sagittal image showing Achilles tendon tear between black arrowheads via
obliteration of normally high signal pre-Achilles fat. soft tissue components not identifiable because this imaging
sequence cannot differentiate between blood from tendon. (B) T2-weighted (TR 2000, TE 90) sagittal image shows
2-cm gap composed of high signal blood and fragments of low signal unopposed tendon (arrowheads). Arrow
shows distal end of tendon has high signal intensity representing intratendinous hemorrhage. Reprinted with
permission from Keene JS, et al. Am J Sp Med. 1989:17:333-337.[10]
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Figure 4.
(A) T1-weighted (TR 600, TE 20) sagittal image showing Achilles tendon tear between black arrowheads via
obliteration of normally high signal pre-Achilles fat. soft tissue components not identifiable because this imaging
sequence cannot differentiate between blood from tendon. (B) T2-weighted (TR 2000, TE 90) sagittal image shows
2-cm gap composed of high signal blood and fragments of low signal unopposed tendon (arrowheads). Arrow
shows distal end of tendon has high signal intensity representing intratendinous hemorrhage. Reprinted with
permission from Keene JS, et al. Am J Sp Med. 1989:17:333-337.[10]
In addition to aiding in the diagnosis, ultrasound and MRI can help the surgeon determine (1) whether to operate
and (2) which operation is best. For example, if the test shows the intertendinous gap to be small with well-oriented
fibers, the chances of the tendon healing with conservative treatment are likely to be greater. Some physicians use
serial ultrasounds in patients who have received nonsurgical treatment to detect an increased gap that may lead to
poor healing and is at increased risk for re-rupture.
Treatment of Acute Achilles Tendon Ruptures

Nonsurgical Treatment
The choice of treatment for acute ruptures of the Achilles tendon continues to be controversial. Nonsurgical
treatment was favored prior to the turn of the century and regained favor during the 1970s. The conservative camp
argues that equally good results can be obtained with cast immobilization without the complications associated with
surgery. In 1972, Lea and Smith[12] reported on 66 patients who underwent 8 weeks of below-the-knee cast
immobilization with the foot in gravity equinus. The patients gradually increased their weight bearing and used a
2.5-cm heel lift for 4 weeks after cast removal. Although 11% re-ruptured their tendon, 52 out of 55 patients stated
they were satisfied with their result. One year later, The Lancet published an editorial stating, "... in view of the
excellent results obtainable by conservative treatment it is doubtful whether surgical repair in closed rupture of the
Achilles tendon can be justified."[13] In the late 1970s Lildholt[14] and Termansen[15] used similar protocols; Lildholt's
series showed 11 of 14 patients to be satisfied, and Termansen's series showed 10 of 12 patients to be satisfied.
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In 1981, Nistor[16] published the first prospective randomized trial comparing surgical versus nonsurgical treatment of
Achilles tendon ruptures. He found that the rate of re-rupture in the surgical group was 4% vs 8% in the nonsurgical
group. However, because the nonsurgical patients had a shorter hospital stay, less absenteeism from work, ,
regained levels of strength similar to those seen in surgical patients, and a had a lower rate of complications, he
favored conservative treatment.[16]
In the largest study of 775 patients, the overall complication rate of surgically treated Achilles tendon ruptures was
20%.[6] These complications include skin necrosis, wound infection, sural neuromas, adhesions of the scar to the
skin, and the usual anesthesia risks. Problems with wound healing remain the most common and most difficult to
manage given the degree of avascularization around the heel cord. Members of the conservative camp point out
that the options for soft tissue coverage over the Achilles tendon are limited. Unfortunately, skin grafts will not
adhere to an exposed tendon and local flaps may result in an unsightly donor site and an unacceptable scar.
Therefore, these large defects often require a microvascular free flap from the forearm, groin, tensor fascia lata, or
the latissimus dorsi.
Studies regarding conservative management of Achilles tendon ruptures have been based on protocols involving
extended periods of rigid immobilization. Many authors used below-knee casts for 6 to 12 weeks with the casts first
being set with the feet in gravity equinus. The cast was then changed at various intervals, placing the foot in greater
dorsiflexion at each change. The last change brought the foot to a plantigrade position (Figures 5A and B). Patients
eventually were allowed to bear weight with crutches while in the cast and were instructed to work toward full weight
bearing at a gradual pace.[5,12,17-19] Many authors also used a heel lift for 6 weeks after cast removal.[5,12,16-18]
Figure 5.
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Casting for nonsurgical treatment of ruptured Achilles tendon. (A) Patient is seated and foot placed in gravity
equinus. (B) Below-knee or above-knee cast is placed with foot in gravity equinus. Reprinted with permission from
Coughlin, MJ. Disorders of tendons. In: Coughlin MJ, Mann RA, eds. Surgery of the Foot and Ankle, Vol. 2, 7th ed
St. Louis, Missouri: Mosby, Inc; 1999:826-861.[38]
Figure 5.
Casting for nonsurgical treatment of ruptured Achilles tendon. (A) Patient is seated and foot placed in gravity
equinus. (B) Below-knee or above-knee cast is placed with foot in gravity equinus. Reprinted with permission from
Coughlin, MJ. Disorders of tendons. In: Coughlin MJ, Mann RA, eds. Surgery of the Foot and Ankle, Vol. 2, 7th ed
St. Louis, Missouri: Mosby, Inc; 1999:826-861.[38]
Recently, a more functional protocol has been used. Saleh and colleagues[20] compared a group of patients who
were placed in a rigid cast for 8 weeks with a group that was placed in a rigid cast for 3 weeks followed by a
Sheffield splint for 6 to 8 weeks. This splint is an ankle-foot orthosis that holds the ankle at 15 degrees of plantar
flexion and allows controlled motion with physical therapy. The group with the splint gained dorsiflexion motion more
rapidly, returned to normal activities quicker, and preferred the splint to the cast. In addition, there was no increased
rate of re-rupture. Whether this protocol will influence more surgeons to opt for non-operative treatment remains to
be seen.
Surgical Treatment
Despite the resurgence of the conservative camp in the 1970s, surgery has been the first choice of treatment for
Achilles tendon ruptures in young fit individuals since the late 1980s. Advances in surgical techniques and new
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postoperative
[6,17,18,19,21]
rehabilitation protocols have resulted in studies showing the advantages of direct tendon repair.
With conservative treatment, extensive scarring often fills the gap between the torn tendons. This leads to a
lengthened tendon, which, in turn, leads to decreased push-off strength. In separate studies, Helgeland[22] and Inglis
[17]
and colleagues showed that surgical treatment of Achilles tendon rupture resulted in increased strength. Cetti
and colleagues[18] and Haggemark[23] independently showed that direct repair resulted in less calf atrophy when
compared with non-surgical treatment. Mendelbaum and colleagues[19] showed that those undergoing direct repair
lost only 2.6% of their strength when undergoing isokinetic testing and that 92% of athletes were able to return to
their respective sports at a similar level at 6 months postoperatively. Cetti and colleagues[18] also showed a higher
number of patients returning to their pre-injury athletic level. In addition, surgical repair appears to significantly
increase the strength in those suffering re-ruptures. Those treated surgically for the second time increased their
level of strength by 85% compared with a 51% strength gain in those treated conservatively.[3]
Perhaps the most well known benefit of surgical repair is the decreased re-rupture rate. Despite favoring nonsurgical
treatment, Nistor[16] noted that those treated conservatively had an 8% re-rupture rate while those treated surgically
had a 4% rate. Recent studies show an even greater difference. Cetti and colleagues[18] reported re-rupture rates of
1.4% 13.4% for surgical and conservative repair, respectively. In a meta-analysis by Kellam and coworkers,[21] re-
rupture rates were found to be 1% and 18% for surgical and conservative repair, respectively. Even more impressive
is a study by Inglis and colleagues[16] who reported that none of the 44 patients receiving direct repair re-ruptured,
whereas 9 of 24 patients treated nonsurgically did re-rupture.
In contrast to Nistor's 1981 study,[16] more recent studies[18,24] show an increased complication rate in those treated
conservatively. One prospective randomized study reported complication rates of 11.8% in patients treated
surgically vs 18% for those treated nonsurgically;[18] 96.6% of the complications in the surgical group were
considered minor. Leppilehti and coworkers[24] noted that complications related to surgery did not significantly
influence the long term outcome as most of them were minor wound healing problems which eventually healed.
Increased operative treatment also leads to more experience in treating complications effectively. For example, it is
now shown that physical therapy can overcome many of the problems associated with adhesions between the repair
site and the skin.[6] Moreover, the vast majority of superficial wound infections can be treated effectively with limited
weight bearing, oral antibiotics, and silver sulfadiazine (Silvadene).[6] Once the tissue granulates, the wound can
simply be treated with wet to dry dressing changes; only in rare circumstances is a local or a free flap necessary.
Those favoring surgical treatment also point out the relatively uncomplicated nature of the procedure. There is no
evidence showing that primary augmentation is more effective than simple end-to-end repair in acute tears.
Therefore, more extensive procedures using tendon transfers, flaps, or mesh are best left for use with delayed tears,
in which the repair will be under tension due to the chronically retracted ends.
Surgical Technique
The patient is placed in the prone position with both prepped feet dangling from the end of the table. By placing the
table in Trendelenburg, the feet receive less blood flow. An 8-cm to 10-cm longitudinal incision is made just medial
to the Achilles tendon. A posterior lateral incision would place the sural nerve at risk and a mid-posterior incision can
result in suture interference from the tendon repair site. After dissecting through the subcutaneous tissues, the
paratenon is cut longitudinally with Mayo scissors. As the ruptured ends often have a "mop-end" appearance
(Figures 6A-6C), some surgeons will wait one week before repair in order to allow the ends to better consolidate.
After juxtaposing the ends, the tendon is sewn together with non-absorbable suture via a Krackow (Figure 7) or
Bunnell stitch. Prior to tying the suture ends, the tendon's dynamic resting tension is optimized by comparing it with
the control side. A circumferential stitch is used to further strengthen the repair site. After closing the paratenon, the
plantaris fascia can be fanned out over the repair site to help prevent adhesions with the undersurface of the skin.
The subcutaneous tissue is then approximated with absorbable suture and the skin sewn together in a nylon
mattress fashion. A fasciotomy of the deep posterior compartment can facilitate closure in cases with excessive skin
tension.[6] This allows for improved closure of the paratenon as well.
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Figure 6.
Acute Achilles tendon ruptures. (A) Separation of fragments with lack of tendon fraying. (B) Rupture with marked
tendon fraying. Reprinted with permission from Coughlin, MJ. Disorders of tendons. In: Coughlin MJ, Mann RA, eds.
Surgery of the Foot and Ankle, Vol. 2, 7th ed. St. Louis, Missouri: Mosby, Inc; 1999: 826-861.[38]
Figure 6.
Acute Achilles tendon ruptures. (A) Separation of fragments with lack of tendon fraying. (B) Rupture with marked
tendon fraying. Reprinted with permission from Coughlin, MJ. Disorders of tendons. In: Coughlin MJ, Mann RA, eds.
Surgery of the Foot and Ankle, Vol. 2, 7th ed. St. Louis, Missouri: Mosby, Inc; 1999: 826-861.[38]
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Figure 7.
Krackow technique of double-lock suture used in the repair of ruptured Achilles tendon. Reprinted with permission
from Coughlin, MJ. Disorders of tendons. In: Coughlin MJ, Mann RA, eds. Surgery of the Foot and Ankle, Vol. 2, 7th
ed. St. Louis, Missouri: Mosby, Inc; 1999: 826-861.[38]
Percutaneous repair. In 1977, Ma and Griffith[25] described a technique of repair that does not require the healing
of a large incision. By placing 6 small stab incisions on the medial and lateral sides of the Achilles tendon, they
showed that the tendon could be repaired. Only 2 of the 18 patients experienced minor noninfectious skin
complications and none of the patients re-ruptured. Using a similar technique, Fitzgibbons noted good results in all
14 of his patients.[26] In Rowley and Scotland's series, those with percutaneous repair had increased plantarflexion
strength and returned to their usual level of activity sooner than did those treated non-operatively with a cast.[27]
Unfortunately, most studies of percutaneous repair report inferior results when compared with open repair. Rowley
and Scotland[27] noted a 10% rate of sural nerve entrapment and Klein and colleagues[28] noted a 13% rate.
Hockenbury and Johns[29] performed the procedure on cadavers and noted that 60% of the patients had an
entrapped sural nerve. They also found that 80% had malaligned stumps. This may account for their further finding
that these cadavers had only one half the strength at the repaired site as did those repaired in an open manner. This
may explain why the re-rupture rate is higher after percutaneous repair than after open repair.
Currently, percutaneous repair is favored over open operative repair only in patients who have minimal requirements
for playing sports, accept a higher risk of re-rupture, desire a re-approximated tendon, and place a high value on
their cosmetic appearance. Given the current guidelines, the procedure likely will continue to be performed less
frequently then open repair. Therefore, improvements in the technique will also most likely continue to lag.
Treatment of Chronic Achilles Tendon Ruptures
Because some Achilles tendon ruptures are missed on the initial physical exam, many patients will present late.
Although there is no consensus regarding when an acute rupture becomes a chronic or neglected rupture, 4 weeks
appears to be the most quoted time frame.[30] During this time lapse, disorganized scar tissue fills the gap between
the retracted proximal stump and the distal stump. This nonlongitudinally oriented fibrous tissue lacks the contractile
strength of normal tendon and contributes to a strength deficit.[31] In addition, it results in a lengthened tendinous
unit, which, as mentioned, leads to a significant decrease in plantar flexion strength. If the patient (1) experiences a
functional deficit as a result of his decreased push off strength and/or (2) does not have preexisting wound healing
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problems (eg, heavy smoker, chronic swelling, venous stasis, diabetic ulcers), then a delayed repair should be
performed.[6] Since the proximal tendon tends to retract, the repair often requires some type of augmentation. These
options include free fascial tendon grafts, synthetic bridges, fascial advancements, and local tendon transfers.
Bugg and Boyd[32] describe a technique in which they harvest a 7.5 cm by 15 cm fascia lata graft via an ipsilateral
thigh incision. Three 1-cm-wide strips are cut from the end of the graft and then placed obliquely across the Achilles
tendon defect. After suturing the strips to the proximal and distal tendon stumps, the remaining sheet of fascia lata is
wrapped around the defect in a tube-like fashion. This is then sutured to the 2 tendon stumps with the serosal
surface facing external (Figures 8A-8C). Despite the obvious disadvantage of requiring a second surgical site, Bugg
and Boyd reported a satisfactory result in all 10 of their patients.
Figure 8.
Achilles tendon repair using fascia lata. (A) Repair using fascia lata strips. (B) Three fascial strips bridge gap. (C)
Fascia lata sheet used to cover and reinforce repair. Reprinted with permission from Bugg EI Jr, Boyd BM. Clin
Ortho R & R. 1968;56:73-75.[32]
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Figure 8.
Ortho R & R. 1968;56:73-75.[32]
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Figure 8.
Ortho R & R. 1968;56:73-75.[32]
Carbon fiber, Marlex mesh, and Dacron have also been used to bridge the gap between torn tendons. These
procedures avoid the need for a second incision as well as the sacrifice of another tendon. However, Amis and
Campbell[33] showed that they initiate a significant foreign body response in the early stage of collagen scaffolding.
They noted large edematous areas within the neotendon within 6 months. Although Ozaki[34] reported good results
with Marlex mesh in 6 patients (average 6-year follow-up), many surgeons are reticent to place a foreign body into a
area that is notorious for tenuous wound healing.
Bosworth[35] describes a technique in which a 20-cm strip of aponeurosis is dissected from the central portion of the
gastrocnemius-soleus fascia. Leaving the distal end of the proximal segment attached, the flap is turned downward
to bridge the Achilles tendon defect. The fascia is woven transversely through the proximal and distal tendon
stumps. The augmentation is then reinforced by weaving the fascia through the stumps in an anterior and posterior
direction at 90 degrees to the initial transfer. Bosworth[35] reported good results with this technique in 6 adults at 1 to
14 months postrupture.
Abraham and Pankovich[36] showed that a V-Y myotendinous lengthening procedure corrected the strength deficit in
3 of 4 patients. This technique involves a long incision that begins proximal to the myotendinous junction in the
midline and curves postero-medially to the Achilles tendon and ends distal to the tendon insertion. An inverted V of
gastrocnemius fascia is cut free from the muscle with the arms of the V being about 2 times the length of the
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Achilles tendon gap. The flap is then advanced and the proximal fascia repaired side to side. The Achilles tendon is
then repaired end to end after adequate resection of the scar (Figures 9A and 9B ). Kann and Myerson[31] prefer to
combine an FHL transfer with this procedure in gaps longer than 5-cm. Their experience showed that without an
FHL transfer, the V-Y lengthening did not allow for early range of motion and compromised their aggressive
rehabilitation protocol.
Figure 9.
V-Y myotendinous lengthening procedure for Achilles tendon repair. (A) After exposure, incision is made into the
fascia of the gastrocnemius. the arms of the inverted V should be twice the length of the defect. (B) The inverted V
is then advanced and end-to-end repair is performed, with the Y being closed with a 2-0 nonabsorbable suture.
Reprinted with permission from Kann JN, Myerson MS: Surgical management of chronic ruptures of the Achilles
tendon. In: Myerson MS, Mandelbaum BR, eds: Foot and Ankle Clinics. Philadelphia, Pennsylvania: WB Saunders
Company; 1997;2:535-545.[31]
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Figure 9.
V-Y myotendinous lengthening procedure for Achilles tendon repair. (A) After exposure, incision is made into the
fascia of the gastrocnemius. the arms of the inverted V should be twice the length of the defect. (B) The inverted V
is then advanced and end-to-end repair is performed, with the Y being closed with a 2-0 nonabsorbable suture.
Reprinted with permission from Kann JN, Myerson MS: Surgical management of chronic ruptures of the Achilles
Company; 1997;2:535-545.[31]
The plantaris, peroneal, flexor digitorum longus (FDL) and flexor hallucis longus (FHL) tendons have all been used
to augment an Achilles tendon repair. Lynn[37] fanned out the plantaris tendon to cover the Achilles tendon defect
with a 2.5-cm wide membrane. Although this adds little strength to the repair, some surgeons continue to use this
technique in acute repairs to decrease adhesions between the repair site and the skin. Others will weave the
plantaris tendon through the Achilles tendon rupture site to add strength to the repair. Unfortunately, the plantaris
tendon is absent in up to one third of patients and, when present, it is often incorporated into the scar tissue of long-
standing ruptures.[38]
Teuffer[39] noted 28 excellent and 2 good results when transferring the peroneus brevis through a hole in the
calcaneus although they did not differentiate between acute and delayed repairs. Turco and Spinella[40] later also
used this approach and, like Teuffer, did not report any functional deficit. However, as this technique involves
sacrificing an important lateral ankle stabilizer, it remains less appealing than the FHL and flexor digitorum longus
(FDL) tendon transfers.
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Mann[41] transected the FDL just proximal to the division of the individual tendons to supplement his repair. The
distal stump of the FDL was sutured to the FHL at the site of the release. The tendon was then pulled through a drill
hole in the calcaneus before using it to bridge the Achilles tendon stumps. No lesser toe dysfunction was reported.
Kann and Myerson[31] state that the FHL is the most optimal tendon to transfer and they use this technique for 2- to
5-cm gaps. In addition to being the second strongest plantar flexor (after the gastrocnemius-soleus complex) and
twice as strong as the FDL, its excursion is compatible with its function as a transfer tendon. The advantages of
using the FHL over the peroneus brevis also include its proximity to the Achilles tendon and its ability to maintain
better ankle balance because it substitutes for another plantar flexor. An incision is made at the talo-navicular joint
proximally and the midportion of the first metatarsal distally. The FHL is identified after dissection deep to the
abductor hallucis and flexor hallucis brevis. After retracting the medial plantar branch of the medial plantar nerve, the
FHL is cut and its distal end tenodesed to the FDL. The fibrous connections between the FHL and FDL at the Knot
of Henry are released to further free the FHL. An incision is made medial to the Achilles tendon from the
myotendinous junction to 2 cm distal to the Achilles tendon insertion. After opening the deep posterior compartment,
the FHL is pulled into the proximal incision. A hole is then made in the calcaneus with a 4.5 mm drill (Figures 10A
and 10B). Next, a 1-cm incision is made on the lateral side of the calcaneus at the drill hole site and the FHL tendon
is pulled through the hole from medial to lateral. The FHL tendon is then woven through both the Achilles tendon
stumps from distal to proximal. Finally, the FHL tendon and muscle are sutured to the Achilles tendon.
Figure 10.
Flexor hallucis longus (FHL) tendon to transfer for Achilles tendon repair. (A) The FHL is mobilized into proximal
wound, then a 4.5-mm hole is drilled 1 cm distal to the insertion of the Achilles tendon and 1.5 cm anterior to the
posterior calcaneal cortex (medial to lateral). (B) The FHL is pulled from medial to lateral through drill hole. A
Page 19 of 23
subcutaneous tunnel is made over the dorsal cortex of the calcaneus then the length of FHL is woven from distal to
proximal through the Achilles tendon. The FHL tendon and muscle are then sutured to the Achilles tendon.
Reprinted with permission from Kann JN, Myerson MS. Surgical management of chronic ruptures of the Achilles
Company; 1997;2:535-545.[31]
Figure 10.
Flexor hallucis longus (FHL) tendon to transfer for Achilles tendon repair. (A) The FHL is mobilized into proximal
wound, then a 4.5-mm hole is drilled 1 cm distal to the insertion of the Achilles tendon and 1.5 cm anterior to the
posterior calcaneal cortex (medial to lateral). (B) The FHL is pulled from medial to lateral through drill hole. A
subcutaneous tunnel is made over the dorsal cortex of the calcaneus then the length of FHL is woven from distal to
proximal through the Achilles tendon. The FHL tendon and muscle are then sutured to the Achilles tendon.
Reprinted with permission from Kann JN, Myerson MS. Surgical management of chronic ruptures of the Achilles
Company; 1997;2:535-545.[31]
Wapner and Hecht[42] used a similar technique when describing the FHL transfer. After a mean of 17 months, none
of their 7 patients had postoperative infections, loss of skin, or repeat ruptures. Although all 7 patients had some
loss in the range of motion in the great toe and ankle, it was not of functional importance and all were satisfied with
their results.
Page 20 of 23
Postoperative Rehabilitation
Traditionally, postoperative rehabilitation involved wearing a splint with the ankle in equinus during the immediate
postoperative period. A cast is then placed within a few days and continued for 6 weeks. The patient is seen in the
clinic at 2-week intervals during which the cast is changed and placed in an increasingly more dorsiflexed position.
After 4 to 6 weeks in the cast, it is advanced to a plantigrade position. With the cast in place, the patient is instructed
to begin isometric gastrocnemius-soleus complex exercises once weight bearing is tolerated. Following cast
removal, the ankle is mobilized with supervision of a physical therapist. Two weeks later, the patient is encouraged
to swim and bicycle, and can usually return to sports within 3 to 6 months.
Although popular, the above protocol can have detrimental effects. The long period of immobilization increases the
likelihood of muscle atrophy, joint stiffness, cartilage atrophy, degenerative arthritis, adhesions, and deep venous
thrombosis. In contrast, early mobilization limits atrophy, promotes fiber polymerization to collagen, and increases
the organization of collagen at the repair site, which ultimately increases muscle and tendon strength.[6]
A recent trend toward a more functional rehabilitation program is gaining popularity. These protocols use an anterior
plaster slab or an orthosis/walking boot (Figure 11) for 6 weeks allowing full range of motion with the exception of
dorsiflexion beyond neutral. The patient performs progressive exercises and is allowed to bear weight, as tolerated
with crutches. Myerson's[6] program involves use of the bicycle at 3 weeks, the pool at 4 weeks, and push off
strengthening exercises with a stair climbing device at 8 weeks. At 2 months, the patient can perform heel rises, jog,
and increase push-off strengthening activities. In comparing the traditional with a more functional rehabilitation
protocol, Cetti and colleagues[18] found that those in the latter group had a 1% plantarflexion deficit compared with
9% in the traditional rehabilitation group. In addition, 80% of those in the functional rehabilitation group resumed
sports activities at the same level and 7% at a diminished level. In contrast, only 50% of those treated with a rigid
cast resumed at the same level of sports activity and 13% a diminished level. Mandelbaum and colleagues[19] have
also shown that functional protocols are effective in the compliant well-motivated athlete. Whether superior results
can be obtained in the general population is not yet known.
Page 21 of 23
Figure 11.
Mobile Achilles tendon cast which allows immediate protected postoperative ankle movements. Reprinted with
permission from Cetti R. Operative versus nonoperative options. In: Myerson MS, Mandelbaum BR, eds: Foot and
Ankle Clinics. Philadelphia, Pennsylvania: WB Saunders Company; 1997;2:511.[43]
Summary
Accompanying the increased popularity of weekend recreational sporting contests is an increased incidence of
Achilles tendon ruptures. These usually occur in otherwise sedentary males who are in their 30s or 40s. Although
the history and physical remain the most accurate way to diagnose the injury, MRI and ultrasonography can prove
helpful in select circumstances. The current preferred treatment in young and otherwise healthy patients and in
virtually all chronic ruptures is surgical repair. Conservative treatment remains an acceptable alternative in older
patients who have fewer physical demands. Improved rehabilitation protocols have enhanced recovery for patients
who receive either nonsurgical or surgical treatment. However, more studies comparing patients treated
nonsurgically with follow-up functional rehabilitation vs those treated surgically with follow-up functional rehabilitation
are needed. MRI and ultrasonography may prove useful in studies comparing surgical and nonsurgical treatment in
patients whose tendons have similar conditions, orientations, and gap sizes.
References
1. Maffulli N. Rupture of the Achilles tendon. J Bone Joint Surg Am. 1999;81:1019-1036.
Page 22 of 23
2. Jozsa L, Kvist M, Balint BJ, et al. The role of recreational sports activity in Achilles tendon rupture. A clinical,
pathoanatomical, and sociological study of 292 cases. Am J Sports Med. 1989;17:338-343.
3. Leppilahti J, Orava S. Total Achilles tendon rupture. Sports Med. 1998;2:79-100.
4. Weiner AD, Lipscomb RR. Rupture of muscles and tendons. Minn Med. 1956;39:731-736.
5. Maffulli N. Current Concepts in the management of subcutaneous tears of the Achilles tendon. Bull Hosp Jt
Dis. 57:152-158, 1998
6. Myerson M. Achilles tendon ruptures. Instr Course Lect. 1999;48:219-230.
7. Arner O, Lindholm AS. Subcutaneous rupture of the Achilles tendon. A study of 92 cases. Acta Chir
Scandinavica. 1959;(suppl 239).
8. O'Brien T. The needle test for complete rupture of the Achilles tendon. J Bone Joint Surg Am. 1984;66:1099-
1101.
9. Copeland SA. Rupture of the Achilles tendon: a new clinical test. Ann R Coll Surg Engl. 1990;72:270-271.
10. Maffulli N, Dymond NP, Capasso G. Ultrasonographic findings in subcutaneous rupture of Achilles tendon. J
Sports Med. 1989;29:365-368.
11. Keene JS, Lash EG, Fisher DR, DeSmet AA. Magnetic resonance imaging of Achilles tendon ruptures. Am J
Sports Med. 1989;17:333-337.
12. Lea RB, Smith L: Non-surgical treatment of tendo achillis rupture. J Bone Joint Surg Am. 1972;54:1398-1407.
13. Achilles tendon rupture. Lancet. 1973;1(7796):189-190.
14. Lildholt T, Munch, Jorgenson T. Conservative treatment of Achilles tendon rupture. Acta Orthop Scand.
1976;47:454-458.
15. Termansen NB, Damholt V. Konservativ behandling of subcutan achillesenruptur. Ugeske Laeger.
1979;141:1843-1845.
16. Nistor L. Surgical and non-surgical treatment of Achilles tendon rupture: a prospective randomized study. J
Bone Joint Surg Am. 1981;63:394-399.
17. Inglis AE, Scott WN, Sculco TP, et al. Ruptures of the tendo achillis: an objective assessment of surgical and
non-surgical treatment. J Bone Joint Surg Am.1976;58:990-993.
18. Cetti R, Christensen S-E, Ejsted, Jensen R. Operative versus nonoperative treatment of Achilles tendon
rupture. A prospective randomized study and review of the literature. Am J Sports Med. 1993;21:791-799.
19. Mandelbaum BR, Myerson MS, Forster R. Achilles tendon ruptures: A new method of repair, early range of
motion, and functional rehabilitation. Am J Sports Med. 1995;23:392-395.
20. Saleh M, Marshall PD, Senior R, et al. The Sheffield splint for controlled early mobilisation after rupture of the
calcaneal tendon: a prospective, randomised comparison with plaster treatment. J Bone Joint Surg Br.
1992;74:206-209.
21. Kellam J, Hunter GA, McElwain JP. Review of the operative treatment of Achilles tendon rupture. Clin
Orthop. 1985;201:80-83.
22. Helgeland J, Odland P, Howe LM. Achilles tendon rupture: surgical or nonsurgical treatment. Tiddskr Nor
Laegeforen. 1997;117:1763-1766.
23. Haggemark T, Liedberg H, Eriksson E, Wredmark T. Calf muscle atrophy and muscle function after
nonoperative vs operative treatment of Achilles tendon ruptures. Orthopedics. 1986;9:160-164.
24. Leppilahti J, Kaarela O, Teerikangas H, Raatikainen T, Orava S, Waris T. Free tissue coverage of wound
complications following Achilles tendon rupture surgery. Clin Orthop. 1996:328:171-176.
Page 23 of 23
25. Ma GWC, Griffith TG: Percutaneous repair of acute closed ruptured Achilles tendon. A new technique. Clin
Orthop. 1977;128:247-255.
26. Fitzgibbons RE, Hefferon J, Hill J. Percutaneous Achilles tendon repair. Am J Sports Med. 1993;21:724-727.
27. Rowley DI, Scotland TR. Rupture of the Achilles tendon treated by a simple operative procedure. Injury.
1982;14:252-254.
28. Klein W, Lang DM, Saleh M: The use of the Ma-Griffith technique for percutaneous repair of fresh ruptured
tendo Achillis. Chir Organi Mov. 1991;76:223-228.
29. Hockenbury RT, Johns JC. A biomechanical in vitro comparison of open versus percutaneous repair of
tendon Achilles. Foot Ankle Int. 1990;11:67-72.
30. Gabel S, Manoli A. Neglected rupture of the Achilles tendon. Foot Ankle Int. 1994;15:512-517.
31. Kann JN, Myerson MS. Surgical management of chronic ruptures of the Achilles tendon. In: Myerson MS,
Mandelbaum BR, eds. Foot and Ankle Clinics. Philadelphia, Pennsylvania: WB Saunders Company;
1997;2:535-545.
32. Bugg EI Jr, Boyd BM. Repair of neglected rupture or laceration of the Achilles tendon. Clin Orthop.
1968;56:73-75.
33. Amis AA, Campbell JR. Comparison of the strength of neotendons induced by implantation of carbon or
polyester fiber. J Bone Joint Surg Br. 1984;66:131-139.
34. Ozaki J, Fujiki J, Sugimato K, et al. Reconstruction of neglected Achilles tendon rupture with Marlex mesh.
Clin Orthop. 1989;238:204-208.
35. Bosworth DM. Repair of defects in the tendo Achilles. J Bone Joint Surg Am. 1956;38:111-114.
36. Abraham E, Pankovich AM. Neglected rupture of the Achilles tendon: treatment by V-Y tendinous flap. J
Bone Joint Surg Am. 1975;57:253-255.
37. Lynn TA. Repair of the torn Achilles tendon, using the plantaris tendon as a reinforcing membrane. J Bone
Joint Surg Am. 1966;48:268-272.
38. Coughlin, MJ. Disorders of tendons. In: Coughlin MJ, Mann RA, eds. Surgery of the Foot and Ankle, Vol 2.
7th ed. St. Louis, Missouri: Mosby, Inc; 1999:826-861.
39. Teuffer A. Traumatic rupture of the Achilles tendon: reconstruction by transplant and graft using the lateral
peroneus brevis. Orthop Clin Nor Am. 1962;32:461-465.
40. Turco VJ, Spinella AJ. Achilles tendon ruptures--peroneus brevis transfer. Foot Ankle Int. 1987;7:253-259.
41. Mann R, Holmes G, Seale K, Collins D. Chronic rupture of the Achilles tendon: a new technique of repair. J
Bone Joint Surg. 1991;73(suppl A):214-219.
42. Wapner KL, Hecht PJ. Repair of chronic Achilles tendon rupture with flexor hallucis longus tendon transfer.
Operative Techniques in Orthopedics. 1994;4:132-137.
43. Cetti R. Operative versus nonoperative options. In: Myerson MS, Mandelbaum BR, eds: Foot and Ankle
Clinics. Philadelphia, Pennsylvania: WB Saunders Company; 1997;2:511.
Medscape Orthopedics. 2001;5(3) © 2001 Medscape
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Complete Ruptures of the Achilles Tendon

Medscape Orthopedics. 2001;5(3)

Drug- and Disease-Related Risk Factors

Ruptured Achilles tendon, as indicated by absence of plantarflexion motion on Thompson testing.

Ultrasonography and MRI

Treatment of Acute Achilles Tendon Ruptures

Treatment of Chronic Achilles Tendon Ruptures

3. Leppilahti J, Orava S. Total Achilles tendon rupture. Sports Med. 1998;2:79-100.

6. Myerson M. Achilles tendon ruptures. Instr Course Lect. 1999;48:219-230.

13. Achilles tendon rupture. Lancet. 1973;1(7796):189-190.

Medscape Orthopedics. 2001;5(3) © 2001 Medscape

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