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