Achilles tendon ruptures are the most common tendon ruptures of the lower extremity. They can occur at any age, but are most common in the third to fifth decade. There is a significant male preponderance. The classic description is the "weekend warrior" athlete.
The Achilles tendon is the common tendon of the gastrocnemius and soleus muscles and provides their attachment to the calcaneus. The soleus muscle arises from the posterior tibia while the gastrocnemius arises from the posterior distal femur. This allows the the gastrocnemius to be effective with an extended knee and the soleus to be more effective with a flexed knee.
The tendons from both muscles coalesce just distal to the musculotendinous junction to form the Achilles tendon. The tendon has a relative avascular portion 2-6 centimeter above the insertion. The tendon also rotates approximately 90 degrees during during its course, with the gastrocnemius fibers being more lateral. The tendon inserts upon the posterior calcaneus primarily along the posterior tuberosity with slightly more medial than lateral extension (Chao F&A 1997, Lohrer CORR 2008).
A relatively hypovascular area exists approximately 2-6 cm above the insertion into the calcaneus. This hypovascularity has been implicated in disorders of the tendon. Age-dependent changes in collagen cross-linking result in increased stiffness and loss of viscoelasticity, which may predispose the tendon to rupture. Mechanisms associated with ruptures include sudden forced dorsiflexion of the ankle (eccentric contraction of the gastrocnemius and soleus), pushing off with the weight-bearing forefoot while extending the knee, and laceration or direct blow to the contracted tendon.
Achilles tendon ruptures are partial or complete. Ruptures can also be divided into acute traumatic ruptures, chronic ruptures, or chronic attritional ruptures. However, ruptures are often due to a combination of age-related attrition and an acute traumatic incident.
Patient History and Physical Findings
The patient with Achilles tendon rupture presents with pain in the area of the Achilles tendon. The pain of an acute rupture is often described as an intense burning sensation or sharp stabbing pain. Patients may hear an audible pop after an eccentric muscle contraction or pushing off; they usually describe a feeling of being kicked, hit, or shot in the heel. A small percentage of patients will have prodromal symptoms. In the presence of a complete tear, patients will experience significant ankle plantar flexion weakness. However, many patients continue to be able to actively plantarflex the ankle using accessory muscles. This may confound some examiners and result in a missed diagnosis.
Physical findings include a visible soft-tissue depression in the posterior ankle on observation. The tendon defect can often be palpated along the posterior leg and ankle. Patients may be unable to walk or walk only with a limp secondary to weak or absent pushoff. Absence of active plantarflexion is often expected, but many patients effectively recruit other muscles to plantarflex against manual testing. However, they are rarely able to perform a single leg heel raise. With the patient in the prone position and the knees flexed, the Thompson squeeze test is executed by squeezing the calf muscle and observing the presence or absence of resultant ankle plantarflexion and comparing with the contralateral side. Another helpful test is to observe the resting position of the ankle compared to the unaffected side with the patient prone and the knees flexed to 90 degrees.
Imaging and Diagnostic Studies
Radiographs are rarely diagnostic. They may be warranted in cases of extremely distal ruptures when avulsion of part of the calcaneus needs to be ruled out. Ultrasound and MRI can accurately demonstrate ruptures, but are rarely necessary with classic clinical findings. These studies may be helpful when the diagnosis is unclear.
Treatment for acute Achilles tendon ruptures can be operative or non-operative and much controversy exists. Historically, the pendulum swung towards operative treatment (especially of younger, healthier patients) because of the much lower reported re-rupture rate (2% for surgical and 11-30% for non-surgical), accepting the trade-off of potential wound complications. Recent investigations have reported much better results with non-operative treatment, often using aggressive functional rehabilitation protocols.
The AAOS and AOFAS have issued a clinical practice guideline and evidence report regarding Achilles tendon ruptures. It can be viewed at http://www.aaos.org/Research/guidelines/atrguideline.asp
Conservative treatment varies and classically involved casting in a long leg cast with knee flexed and ankle in equinus (2-3 weeks), then short leg casting (8 weeks). Non-weight-bearing was typically recommended initially (the first 6 weeks).
More recent approaches include functional bracing with immediate weight-bearing. These more aggressive protocols describe immediate full weight-bearing in a functional brace or pre-fabricated boot. Patients are started with with the ankle in up to 45 degrees of plantarflexion, which is gradually decreased to neutral over 6 to 12 weeks. They often perform active plantarflexion exercises with restricted dorsiflexion during that time then graduate to more aggressive strengthening protocols.
Operative treatment has evolved to include open, limited open, and percutaneous techniques.
The classic open approach involves a longitudinal incision approximately 1 cm medial to the tendon to avoid irritation by footwear. The incision should be carried straight through the skin and subcutaneous tissue to the tendon sheath (paratenon) to minimize postoperative wound complications. Careful preservation of the paratenon is important for later closure and gliding of the tendon. The ends of the tendon are gently debrided and then re-approximated with a large nonabsorbable suture. This may vary from 2-, 4-, or 6-strand repairs (4 being the most common), and Bunnell and Krackow techniques have been reported.
There is some controversy about the benefit of an epi-tenon stitch. Special attention should be directed to the tension of the repair and it should be matched as close as possible to the contralateral side. The plantaris is often available for local supplementation if the Achilles tissue is poor. More significant disruption, and especially chronic tears, could require tendon transfer utilizing the flexor digitorum longus, flexor hallucis longus, or peroneals.
Percutaneous techniques have become more popular. Several devices (Integra Achillon, Teno-lig) have been promoted to minimize the risk of entrapment of the sural nerve that is the major complication associated with percutaneous repairs. Typically, a small (1 cm) incision is made at the rupture site (either transverse or longitudinal), allowing visualization of the rupture. The proximal tendon is grasped with a clamp and then sutures are passed percutaneously through the tendon more proximally and pulled into the tendon sheath and out the small incision. The process is repeated for the distal portion and then these suture are tied together.
The theoretical benefits include less disruption of the tendon sheath (and therefore less disruption of the blood supply and better tendon gliding) and less risk of wound complications. The drawbacks can include poor purchase of tendon ends and a small risk of sural nerve injury (more likely in percutaneous technique). The incidence of sural nerve injury ranges from 0 to 10.5% in the literature(Rouvillian 2010, Jung FAI 2008, Haji 2004, Lansdaal 2007 and others).
Limited open techniques use hybrid elements of open and percutaneous techniques to minimize tissue disruption. The principles of stable fixation, appropriate tendon length, careful soft tissue handling, and protection of nervous structures must be kept in mind with any approach.
Repair of neglected Achilles ruptures typically involves removing intervening scar tissue, lengthening the proximal portion of the tendon, and supplementation with soft-tissue advancement and/or tendon transfer. This is further described elsewhere.
Pearls and Pitfalls
- Restore the tension in the gastrosoleus musculotendinous unit following surgical repair. Both legs may be included in the surgical field so that the tension in the uninjured side can be compared with the one that is being repaired to avoid problems with a tendon that is too long or too short.
- In an open repair, minimize retraction of the skin edges to avoid wound edge necrosis.
- For an acute repair, tourniquet control is rarely necessary.
- Always be aware of the location of the sural nerve, just lateral to the Achilles tendon.
After surgery, patients are commonly splinted for 2 weeks in equinus and remain non-weight-bearing. At 2 weeks, treatment can differ substantially among surgeons. Some may cast for an additional 4-6 weeks and then transition to shoe-wear with a heel lift. Others may progress from the splint to an Achilles-type cam boot that can hold the ankle in varying degrees of equinus. Patients are allowed to weight-bear and gradually adjust the cam boot to a neutral position by 6-8 weeks postop. Patient are then transitioned to shoes with a heel lift and physically therapy is intensified. Athletes may require 6 months to return to adequate playing strength, and studies suggest full strength may take 1-2 years to achieve and may never equal the pre-rupture strength.
Outcomes are typically quite good, although some patients may never regain full strength. As mentioned earlier, surgical re-ruptures rates are around 2%, while non-operative treatment has historical re-ruptures rates up to 35%. Current functional non-operative protocols appear to have a much lower re-rupture rate.
- Rerupture (~2%)
- Skin complications (~5%)
- Deep infection(~1%)
- Thickened tendon in repair area
h5 Non-operative Treatment
- Rerupture (10-30%)
- Decreased strength
Red Flags and Controversies
- Controversy exists regarding operative versus non-operative treatment. Many advocate non-operative treatment due to similar strength, power, range of motion, and functional level results obtained with conservative and operative treatments. Others have recommended surgical repair in athletic patients due to a lower re-rupture rate (2-3% for surgical treatment versus 10-30% for non-surgical treatment).
- Carden et al (1987) reported non-operative results comparable to operative results when ruptures were casted in the first 48 hours.
- Studies suggest wound complications and re-rupture are higher with open techniques but sural nerve entrapment is a problem with percutaneous techniques. See Percutaneous Achilles Repair.
As mentioned, controversy exists, but it is generally thought that surgical treatment results in good return of strength, endurance, and power with a low re-rupture rate.
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