Achilles Tendon Ruptures

Yanuarso, MD
Indonesian Army Central Hospital
 Achilles: Hero of the Iliad
 Led Greeks to conquer Troy
 Killed by arrow shot to heel
 Hippocrates – “ this tendon if bruised or
cut, causes the most acute fevers, induces
choking, deranges the mind and at length
brings death.”
 Strongest tendon in the human body
 Achilles Tendon
 Formed by tendinous portion of
gastrocnemius and soleus
 Plantaris lies medial and is distinct tendon
 Achilles progresses from round to flat as it
travels distally to insert on calcaneal
tuberosity
 Fibers of tendon rotate 90 degrees distally
with medial fibers terminating posteriorly
 Biochemistry
 Collagen comprises 70% of tendon
– 95% type I
– Small amount of elastin
 Collagen organized into fascicles
surrounded by epitenon
 Ruptured tendon contains significant type
III collagen
 Blood Supply
 Musculotendinous junction
 Surrounding connective tissue (paratenon)
 Bone-tendon junction
 Poor vascularization in midportion of
tendon

Ref: Schmidt-Rolfing, Int. Orthop., 1992

 Biomechanics
 Peak force of 2233 newtons within achilles
in vivo- Fukashiro 1995
 Force builds just before heel strike, then
released
 Force builds again and peaks at the end of
push off
 Injury can be produced by asynchronous
contraction of triceps surae
 Epidemiology
 Incidence 18 per 100,000 - Finland
 Most ruptures occur during sports
(Badminton)
 More common in males in third and fourth
decade of life
 Blood type O?
 Etiology
 Inflammatory and autoimmune conditions
 Collagen disorders
 Infectious disease
 Neurologic conditions
 Blood flow to tendon decreases with age
 Area prone to rupture relatively
hypovascular
 Etiology – continued
 Histologic evidence of collagen degeneration in all
studies of patients with rupture
 Collagen degeneration occurs prior to rupture
 Alternating exercise with inactivity
 Accumulation of trauma leads to degeneration
 Corticosteroids – injection into rabbit tendons
showed necrosis and delayed healing. Several studies
showed collagen damage with injected steroids
 Oral steroids also implicated
Fluoroquinolones and Tendon
Rupture
 Ciprofloxacin
 Direct deleterious effect on tenocytes
 Decreased transcription of Decorin which
may modify architecture of tendon and alter
mechanical properties

 Bernard-Beaubois 1998
 Mechanism of Rupture
 Pushing off foot while extending knee- 53%
– Jumping in basketball
– Volleyball
 Sudden dorsiflexion of ankle- 17%
– Fall down steps or into hole
 Violent dorsiflexion of plantar flexed foot-
10%
– Fall from height
 Clinical Presentation
 Sudden pain in affected limb
 Report being “struck in back of leg”
 Edema and bruising
 Palpable gap in tendon
 + Thompson test- 1962
 Frequently missed!!
 Imaging
 Radiographs- usually not helpful unless
avulsion of calcaneus
 Ultrasound – used to assess gap in tendon
and apposition of torn ends of tendon
– Helpful with nonoperative tx
 MRI – useful in partial tears and tendinosis
 Achilles Tendon Healing
 Rabbit model – Thermann et al Germany
 Foot and Ankle July 2002
 Nonoperative vs. operative
– No difference within first week
– Nonop tx showed aligned fibroblasts after 1 week
– At 12 weeks, nonop=op tx
 High levels of type III collagen in healing tissue of
ruptured tendons
 Achilles Tendon Healing
 Balb-C mice with ruptured achilles treated either
with mobilization or immobilization
 More rapid restoration of load to failure in
mobilized group
 112 days mobilized group regained original
tendon stiffness
 Mobilization lead to increased inflammatory cells
at rupture site.
 Palmes et al J of Orthopaedic Research 2002
 Nonoperative Treatment
 Cast immobilization 6-8 weeks
 Functional brace
 Use ultrasound to ensure tendon apposition
 Higher rerupture rate vs. operative repair
 Fewer overall complications
 Surgical Treatment
 First advocated by Pare 1575
 1-2% deep infection rate
 Rerupture rate 2-8%
 Pajala et al JBJS 2002
 409 patients, 5.6% rerupture rate
– 2.2% deep infection- Finlan
 Surgical Repair vs. Casting
 7.7% rerupture rate with cast vs. 3% with
surgery
 AOFAS scores similar at 3.5 years post
rupture.
 Greater calf atrophy with cast
 Fewer overall complications with
nonoperative tx
– Beskin et al Foot/Ankle December 2001
 Complications of Surgical
Treatment
 Wound necrosis
 Wound infection
 Sural nerve injury
 DVT and PE
 Rerupture 2-5%
Percutaneous Achilles Repair
 Developed by Ma and Griffith 1977
 6 small incisions to pass sutures
 Faster return to normal strength than cast
 Sural nerve entrapment
 Higher rerupture rate vs. open repair
 Percutaneous vs. Open
Repair
 Percutaneous
– 6.4% rerupture rate
 Open repair
– 2.7% rerupture
 Percutaneous does not reestablish length
 Injury to sural nerve
 Fewer wound complications with percutaneous tx

 JBJS Br 1999
 Chronic Ruptures
 Use V-Y advancement if gap < 4cm
 Central turn down for larger gaps > 4cm
 Augmentation with FHL tendon
 Allografts?
 Achilles Tendonitis
 Thickening and swelling of tendon
 May occur at insertion or midsubstance
 Often associated with tight gastroc
 Insidious onset
 Achilles Tendonitis -
Treatment
 Immobilization
 Physical therapy
 Heel lift
 NSAIDS
 PRP injection
 NO CORTISONE!
 Operative vs. Nonoperative
Treatment
 Willits et al, JBJS Dec 2010
 144 patients with achilles rupture
 Randomized to operative and nonoperative
 Fewer complications in nonoperative group
 Functional outcome no statistical difference
 Summary
 Functional outcome better with surgery and early
motion
 Fewer complications with nonsurgical tx
 Rerupture rate
– Surgery 2%
– Cast 8-10%
 Future
– Functional bracing
– Percutaneous repair
 Postoperative Protocol
 Non weight bearing x 4 weeks
 Cam walker brace x 6 weeks
 Active ROM exercises only
 No passive stretching for 8 weeks