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 sheath

 Paratenon has visceral and parietal layers
 Allows for 1.5cm of tendon glide
Anatomy

 Paratenon
 Anterior – richly vascularized
 The remainder – multiple thin membranes
Anatomy

 Blood supply
1) 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 stress

 Exercise induces tendon diameter increase
 Inactivity or immobilization causes rapid
atrophy
 Age-related decreases in cell density,
collagen fibril diameter and density
 Older athletes have higher injury
susceptibility
Biomechanics

 Gastrocnemius-soleus-Achilles complex
 Spans 3 joints
 Flex knee
 Plantar flex tibiotalar joint

 Supinate 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

 Physical
 Partial
 Localized tenderness +/- nodularity
 Complete
 Defect
 Can not heel raise

 Positive Thompson test

Imaging

 Ultrasound
 Inexpensive , dynamic
examination possible

 Good screening test for

complete rupture
Imaging

 MRI
 Expensive
 Better 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
2 wks plantarflexion q 2 wks

4 weeks

Start physio for ROM Allow progressive weight-

exercises bearing in removable cast

When WBAT and 2- 4 weeks

foot is plantigrade

Start a strengthening Remove cast and walk with

program shoe lift. Start with 2cm x 1
month, then 1cm x1 month
then D/C
Functional Bracing
Surgical Management

 Preserve anterior paratenon blood

supply
 Beware of sural nerve
 Debride and approximate tendon ends
 Use 2-4 stranded locked suture
technique
 May augment with absorbable suture
 Close 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 Wapner technique with FHL tendon
ruptures of Achilles 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

Casted x 8 wks Surgery +

Early functional rehab in
brace

21 % re-rupture 1.7% re-rupture

5% infection
No difference in
functional outcome 2% Sural nerve inj.
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

Casted x 8 wks Surgery +

Early functional rehab in
brace

5 \ 41 re-rupture 3 \ 42 re-rupture
0.5% infection
No difference in
functional outcome 0.1% Sural nerve in
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
‫متشكرم‬