Achilles Tendon Ruptures

Reviewed by Dr Martin Blum Unaccredited Orthopaedic Registrar

Western Health Orthopaedic Registrar presentation – Acute Achilles Tendon Ruptures

Definition

  • Tendon disruption in its watershed region

Anatomy

  • The Achilles tendon is the strongest tendon in the body and is subject to loads of 5-7 times body weight.
  • ~15 cm long and inserts on the posterior calcaneal tuberosity Is surrounded by a paratenon, which allows it to glide freely
  • Is composed mainly of type 1 collagen
  • The blood supply to the tendon is poorest in a watershed region from 2-6 cm proximal to the tendon’s insertion on the calcaneus.
  • The tendon rotates 90° as it courses distally, concentrating mechanical stress in the watershed area.

Classification

  • Acute versus chronic
  • Open versus closed
  • Complete versus incomplete

Epidemiology

  • Bimodal distribution
    • Young to middle-aged athletes (30-40 years old)
      • 60-75% occur during sports activity.
    • Older nonathletes (~13% of ruptures)
  • Incidence
    • Unclear, varying from 2-37.3 per 100,000
    • Increasing incidence seen in recent decades
    • predominantly males.
    • Left side injury> right (possibly because right-hand dominant athletes push-off with the left leg).

Risk Factors

  • Previous rupture – 6% of patients
  • Medications
    • Corticosteroids, either oral or injected locally into the Achilles tendon area
    • Anabolic steroids
    • Fluoroquinolone antibiotics
  • Systemic diseases
    • Diabetes
    • Rheumatoid arthritis and other inflammatory arthritides
    • Gout

Pathophysiology

  • degenerative changes and chronic tendinosis.

Aetiology

  • Indirect mechanism
    • Pushing off with weightbearing foot while extending the knee
    • Most common
    • Eccentric contraction of gastrocnemius soleus complex
  • direct trauma
    • such as a laceration or gunshot wound
    • rare
  • Associated Conditions
    • Achilles tendinopathy
      • Insertional: Retrocalcaneal bursitis, insertional tendinopathy
      • Noninsertional: Tendinosis, peritendinitis

History

  • Usually, a sudden snap is felt in the back of the ankle.
  • describe a sensation of being kicked in the back of the leg.
  • Pain may be severe.
  • Ask about previous pain or symptoms of tendinopathy.

Physical Exam

  • Look
    • General foot and ankle examination
    • swelling
  • Feel
    • tenderness
    • palpable gap in the tendon
  • Move
    • Check muscle strength.
    • Patient still may be able to plantarflex the ankle by compensating with other muscles, but strength will be weak
  • Special Test
    • Single-limb heel rise
      • will not be possible
    • Knee flexion test
      • Check resting position of ankle with patient prone and knees flexed 90°.
      • Loss of normal resting gastrocnemius soleus tension will allow ankle to assume a more dorsiflexed position than that on the uninjured side.
    • Thompson test:
      • Position the patient prone with ankles clear of the table.
      • Squeezing the calf normally produces passive plantarflexion of the ankle.
      • If the Achilles tendon is not in continuity, the ankle will not passively flex with compression of calf muscles.

Investigations

Xray

  • calcaneal tuberosity fracture and Achilles tendon avulsion,

US / MRI

  • if clinically unsure

Differential Diagnosis

  • Achilles tendinopathy
  • Partial Achilles tendon rupture
  • Calcaneus fracture

Treatment

Prevention

  • Training and stretching result in tendon adaptation, including increased cross-sectional area.

Initial

  • the ankle should be splinted in equinus with a well-padded, below-the-knee, nonweightbearing splint.
  • Ice and elevation help to control swelling.

Nonoperative

Operative

  • Open
    • Technique
      • Prone position:
      • Both legs should be draped into the operative field so that resting ankle position can be approximated to the normal side when sutures are tied.
      • A medial longitudinal incision along Achilles tendon often is used to decrease the risk of sural nerve injury.
      • A running locking technique with 2 suture strands in each segment of tendon produces the strongest repair
      • The paratenon should be preserved and repaired to help prevent adhesions.
      • If present, the plantaris tendon can be unfolded and wrapped around the repair to minimize adhesion formation.
  • Percutaneus
  • Chronic ruptures:
    • Options
      • end-to-end repair
      • V-Y lengthening,
      • turndown advancement flap,
      • tendon transfer or augmentation (flexor hallucis longus, flexor digitorum longus)
      • allograft tendon

Prognosis

The prognosis is good for both operatively and nonoperatively managed Achilles tendon tears.

Evidence Based Medicine

Cochrane

Khan RJK, Carey Smith RL. Surgical interventions for treating acute Achilles tendon ruptures. Cochrane Database of Systematic Reviews 2010, Issue 9. Art. No.: CD003674. DOI: 10.1002/14651858.CD003674.pub4

Open surgical treatment compared with non-surgical treatment (6 trials, 536 participants) was associated with a statistically significant lower risk of rerupture (risk ratio (RR) 0.41, 95% confidence interval (CI) 0.21 to 0.77), but a higher risk of other complications including infection (RR 4.89, 95% CI1.09 to 21.91), adhesions and disturbed skin sensibility (numbness). Functional status including sporting activity was variably and often incompletely reported, including frequent use of non standardised outcomemeasures, and the results were inconclusive.

Open surgical repair compared with percutaneous repair (4 trials, 174 participants) was associated with a higher risk of infection (RR 9.32, 95% CI1.77 to 49.16). These figures should be interpreted with caution because of the small numbers involved. Similarly, no definitive conclusions could be made regarding different tendon repair techniques (3 trials, 147 participants).