Achilles Tendon Disorders

Daniel Penello
Foot & Ankle Rounds
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)
– Transverse vincula
 Fewest @ 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
 May be on the
background of a
degenerative tendon
Achilles Tendon Rupture:
Textbook Facts
 Antecedent tendinitis/tendinosis in 15%

 75% of sports-related ruptures happen in

patients between 30-40 years of age.

 Most ruptures occur in watershed area

4cm proximal to the calcaneal insertion.
Achilles Tendon Rupture

 History
 Feels like being kicked in the leg
 Case reports of fluoroquinolone use, steroid
injections
 Mechanism
 Eccentric loading (running backwards in tennis)
 Sudden unexpected dorsiflexion of ankle
 (Direct blow or laceration)
Physical Exam
 Prone patient with feet over edge of bed

 Palpation of entire length of muscle-tendon

unit during active and passive ROM

 Compare tendon width to other side

 Note tenderness, crepitation, warmth, swelling,

nodularity, palpable defects
Achilles Tendon Rupture

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

 Positive Thompson test

Achilles Tendon Rupture

 Diagnostic Pitfalls
 23% missed by Primary Physician
(Inglis & Sculco)
 Tendon defect can be masked by
hematoma
 Plantar-flexion power of extrinsic foot
flexors retained
 Thompson test can produce a false-
negative if accessory ankle flexors also
squeezed
Imaging

 Ultrasound
 Inexpensive, fast,
reproducable, dynamic
examination possible
 Operator dependent

 Best to measure thickness

and gap
 Good screening test for
complete rupture
Imaging

 MRI
 Expensive, not
dynamic
 Better at detecting
partial ruptures
and staging
degenerative
changes, (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
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

 Bunnell Suture

 Modified Kessler

 Many techniques
available
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.
Variations in Post-op Protocols
Functional Bracing
Post- Op Care
Cast applied in OR Remove sutures, apply a
2 wks walking cast with heel lift

Touch WB 2 weeks

Start physio for ROM Allow progressive weight-

exercises. No active bearing in removable cast
plantarflexion
When WBAT and 2- 4 weeks
foot is plantigrade

Start a strengthening Remove cast and walk with a

program 1cm shoe lift x 1 month then
D/C.
Surgical Management:
Post-op Care
Early functional treatment versus early immobilization in tension of the
musculotendinous unit after Achilles rupture repair: a prospective,
randomized, clinical study.
Kangas J et al. J Trauma. 2003 Jun;54(6):1171-80; discussion 1180-1.
50 pts had repair
25 of Achilles rupture 25

Casted in neutral x 6 Immediate active ROM from

weeks. WBAT at 3 weeks PF to neutral. WBAT at 3 wk

Two re-ruptures Better calf strength only

for first 3 months.
One deep infection
One re-rupture
Same satisfaction
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.
Summary of Pooled Outcome Measures
Risk of Re-Rupture
 Surgery =
68% risk
reduction for
re-rupture