ACHILLES TENDON

RUPTURE
NUR HIKMAH KUSUMA C111 10 319 LIEM MEYSIE HARLIMTON C111 10 006
NADHIRAH MOHD NOH C111 10 847 NOOR SYAHANIM ISMAIL C111 10 840
MIFTHAH ROSYADI C111 09 251 NABILA S AHMAD C111 09 792
DIAN ROSYIDAWATI C111 08 203 RINI NURDIANA C111 09 343

ADVISORS:
DR. ANGGA ANGGRIAWAN
DR. ARIES HUBARAT
DR. SYARIF HIDAYATULLAH

SUPERVISOR:
DR. NOTINAS HORAS MKES SP.OT
ORTHOPAEDIC AND TRAUMATOLOGY DEPARTMENT
HASANUDDIN UNIVERSITY
2015
 ANATOMY

Netters Concise Atlas of Orthopedics Anotomy 2nd Ed, 2002

Netters Concise Atlas of Orthopedics Anotomy 2 nd Ed, 2002
TENDON ACHILLES INJURY
Disruption of the Achilles tendon (heel cord)
usually occurs 5 to 7 cm proximal to the
insertion of the tendon on the calcaneus.
Thiscondition commonly affects middle-aged
men who play quick, stop-and-go sports such
as tennis and basketball. Partial tears of the
tendon can also occur at the calcaneal
insertion.

S Sivananthan, Sherry E, Mow C. Mercer's Textbook of Orthopaedics and Trauma. London: Hodder Edu; 2012.
Sarwark S. Essentials of Musculoskeletal Care. America: . USA: American Academy of Orthopedic Surgeons; 2010
EPIDEMIOLOGY
The peak incidence of Achilles tendon ruptures is in the third to fifth
decade of life.
Highest in the age group 3039 years with a smaller peak incidence
between 50 and 59 years.
Of all spontaneous tendon ruptures, complete Achilles tendon tears
are most closely associated with sports activities.
Achilles tendon rupture is predominantly a male disease and the
dominance of males with a male : female ratio of 2 : 1 to 12 : 1,
probably reflecting the higher prevalence of males involved in sports

Maffuli N. Tendon Injuries Basic Science and Clinical Medicine. London 2005.
S Sivananthan, Sherry E, Mow C. Mercer's Textbook of Orthopaedics and Trauma. London: Hodder Edu; 2012
 RISK FACTORS
Multiple predisposing risk factors
for Achilles tendon ruptures have been described.

Maffuli N. Tendon Injuries Basic Science and Clinical Medicine. London 2005.
Brontzman S. Chapter 5: Foot and Ankle Injury. Clinical Orthopaedic Rehabilitation: An Evidence-Based Approach. 3rd edition. Philadelphia: Elsevier Mosby;
ETIOPATOGENESIS
Repetitive micro-trauma

repetitive loading well below the normal ultimate

tensile strength
Microtrauma with poor healing

Macro-trauma

forces above the ultimate tensile strength results in

partial or complete rupture

Ramachandran M. Basic Ortopedic Science. London: Hodder Arnold; 2007

MECHANISMS OF INJURY

Direct force Indirect force

sudden forceful overload

involves a blow to the
of the Achilles tendon forcefully pushing off with
posterior ankle, a
during unexpected or the affected leg while the
crushing injury or a
violent dorsiflexion of the knee is fully extended
laceration of the tendon.
ankle

S Sivananthan, Sherry E, Mow C. Mercer's Textbook of Orthopaedics and Trauma. London: Hodder Edu; 2012
 CLINICAL MANIFESTATIONS
Sudden, severe calf pain typically is
described as a gunshot wound
Partial tears can be described as
strains or a calf pull.
The severe acute pain may heal
quickly, and the injury may be
misdiagnosed as an ankle sprain.
Impaired ambulation
Missed rupture: significant weakness

Sarwark S. Essentials of Musculoskeletal Care. America: . USA: American Academy of Orthopedic Surgeons; 2010
Physical examination
TEST PROCEDURE RESULT PHOTOS
Inspection Look for any deformities in posture Positive when the
of the foot foot plantarflexion

Palpation Patient in pronation. Palpate the Positive when there

(Gap test tendon while the patient continues is gap
Maffulli) resisted
plantarflexion. Compare the sides.
Any gap in
the tendon should
be obvious.
Thompson test Squeeze the patient calf Positive when
plantarflexion is
absent
Copeland test Patient is prone. Examiner places Positive if little or
sphygmomanometer around no pressure rise is
middle of calf and inflates it to noted on
100mmHg and examiner passively sphygmomanomete
plantarflexes and dorsiflexes ankle r cuff

McRae R. The Ankle. In: McRae R, editor. Clinical Orthopaedic Examination. Edinburgh: Churchill Livingstone Elsevier; 2010.
Physical examination
TEST PROCEDURE
Matles test Patient is in prone position while
actively flexing their knee to 90
The needle test Insert the hypodermic needle
through the skin and calf, medial to
the midline approximately 10cm
proximal to tendon insertion. The
ankle is then alternately plantar
flexed and dorsiflexed
Leg, ankle and foot injuries.. Mercers Textbook of Orthopaedics and Trauma 10 th edition.
RESULT PHOTOS
Positive if the feet
on the affected side
fell into neutral or
dorsiflexed position
Positive if it points
to the proximal (loss
of contuinity
between the tendon
insertion nd the
needle)
 Radiology Examination
Conventional X-ray
On lateral projection conventional
radiographs, the normal margination
of the Achilles tendon and adjacent
pre-Achilles fat pad (Kagers triangle)
is seen as a sharp soft tissue interface
along the anterior (volar) margin of
the tendon.

Maffuli N. Tendon Injuries Basic Science and Clinical Medicine.

London2005.
Rupture of the Achilles
tendon, Achilles
tendinopathy, or infl
ammation/hemorrhage
within the pre-Achilles fat
pad may obscure this sharp
interface between the
tendon and adjacent fat
 ULTRASONOGRAPHY

Transverse ultrasound images of a normal Achilles tendon. (A)

Probe orientated at 90 to the tendon demonstrating a normal
oval echobright tendon (arrowheads). (B) Probe angled off
perpendicular to the tendon demonstrating a hypoechoic (dark)
tendon (arrowheads).
(A) Longitudinal ultrasonographic image of a normal Achilles
tendon. Note the echogenic, parallel fibrillar pattern (between
arrowheads). (B) Transverse ultrasonographic image of a
normal Achilles tendon showing echogenic ovoid shape
(arrowheads)
(A) Longitudinal extended field of
view USc image of a complete tendon
tear showing the gap in the
tendon (*) and the torn tendon ends
(solid arrows). The muscle belly of
flexor hallucis longus is well seen
deep to the tear. (B) Longitudinal
extended field of view
ultrasonographic image of a complete
tendon tear. Note more retraction,
compared to case A, with a larger gap
in the tendon, torn tendon ends (solid
arrows), & echogenic(bright) fat
herniating into the tendon gap (*).
MRI
excellent soft tissue contrast characteristics
Sagittal and axial planes are most useful in the evaluation of the Achilles tendon
commonly using a combination of T1 and T2 weighted imaging sequences.
In general, T1 or intermediate weighted sequences provide
optimal delineation of anatomic detail, and T2 weighted sequences are most
sensitive to the abnormal increase in fluid signal that accompanies most
pathological conditions of the tendon.
Axial T2 weighted sequence
of a normal ankle,
demonstrating a normal
Achilles tendon (arrowheads),
adjacent plantaris tendon
(solid arrow), and Kagers fat
pad (*).
Sagittal T1 (A) and T2 with fat saturation (B) images, of a normal
Achilles tendon. Note the parallel anterior and posterior tendon
surfaces (arrowheads) and its low signal (black) appearance on
both sequences
Sagittal T1 (A) and sagittal T2 with fat saturation (B) weighted
images in a patient with an Achilles tendon rupture. Note
discontinuity of fibers, high signal within the tendon gap
(arrowheads), and the torn tendon ends (solid arrows).
DIFFERENTIAL DIAGNOSES

Netter F. Netters Concise Atlas of Orthopedics Anatomy 2nd edition. Philadelphia: Elsevier; 2002
Non-Operative Management

Cast in CAM Walker or cast

2 with
Plantarflexion plantarflexion
wks
4 weeks

Start physio for Allow progressive weight-

ROM exercises bearing in removable
cast
When WBAT 2- 4
and foot is weeks
plantigrade
Start a
strengthening Remove cast and walk
program with shoe lift. Start with
2cm x 1 month, then 1cm
x1 month
Treatment
Operative

Acute Rupture
Krackow Suture Technique
Lindholm technique

Chronic Rupture

Canale Terry. Champbells. Operative Othopedics . 12th Edition. 2012

 Krackow Suture Technique

With the patient prone, make a posteromedial incision

approximately 10 cm long about 1 cm medial to the
tendon and ending proximal to where the shoe counter
strikes the heel.
Sharply dissect through the skin, subcutaneous tissues,
and tendon sheath. Reflect the tendon sheath with
the subcutaneous tissue to minimize subcutaneous
dissection.
Approximate the ruptured ends of the tendon with a 2-
0
nonabsorbable suture (Fig. 48-15).
Check the repair for stability after the sutures are tied.
Close the peritenon and subcutaneous tissues with 4-0
absorbable sutures.
Close the skin, and apply a sterile dressing and a
posterior
splint or short-leg cast with the foot in gravity equinus.
Canale Terry. Champbells. Operative Othopedics . 12th Edition.
 Lindholm technique for repairing ruptures of
Achilles tendon
With the patient prone, make a posterior curvilinear incision
extending from the midcalf to the calcaneus.
Incise the deep fascia in the midline, and expose the tendon rupture.
Dbride the ragged ends of the tendon, and appose them with a box
type of mattress suture of heavy nonabsorbable suture material or
wire; also use fine interrupted sutures
Fashion two flaps from the proximal tendon and gastrocnemius
aponeurosis, each approximately 1 cm wide and 7 to 8 cm long.
Leave these flaps attached at a point 3 cm proximal to the site of
rupture.
Twist each flap 180 degrees on itself so that its smooth external
surface lies next to the subcutaneous tissue as it is turned distally
over the rupture.
Suture each flap to the distal stump of the tendon and to one
another so that they cover the site of rupture completely.
Close the wound, being careful to approximate the tendon sheath
over the site of repair.
Chronic Rupture
 REHABILITATION
Strom and Casillas (2009) outlined five goals of the
rehabilitation program after repair of Achilles tendon rupture:
1. Reduce residual pain and swelling.
2. Recover motion while preserving integrity of the repair.
3. Strengthen the gastrocnemiussoleusAchilles motor unit.
4. Improve the strength and coordination of the entire lower
extremity.
5. Provide a safe and competitive return to athletic activity that
avoids rerupture.

Brontzman S. Chapter 5: Foot and Ankle Injury. Clinical Orthopaedic Rehabilitation: An Evidence-Based Approach. 3rd edition. Philadelphia: Elsevier Mosby;
Thank You