Achilles Tendon Rupture

BY:

AHMED NABEEL EMARA

• often misdiagnosed as an ankle sprain

• may be missed in up to 25%

• Epidemiology

incidence

18:100,000 per year

demographics

more common in men

most common in ages 30-40

Risk factors

episodic athletes, "weekend warrior"

flouroquinolone antibiotics

steroid injections

Mechanism

usually traumatic injury during a sporting event

may occur with

sudden forced plantar flexion

violent dorsiflexion in a plantar flexed foot

Pathoanatomy

rupture usually occurs 4-6 cm above the calcaneal insertion in hypovascular

region

• Anatomy

largest tendon in body

formed by the confluence of

soleus muscle tendon

medial and lateral gastrocnemius

tendons

• blood supply from posterior tibial artery

Presentation

• History

patients usually reports a "pop"

• Symptoms

weakness and difficulty walking

pain in heel

• Physical exam

• inspection

increased resting ankle dorsiflexion in

prone position with knees bent

calf atrophy may be apparent in chronic

cases

• palpation

palpable gap

• motion

weakness to ankle plantar flexion

• provocative test

Thompson test

lack of plantar flexion when calf is

squeezed

Imaging

• Radiographs

used to rule-out other

pathology

• Ultrasound

may be useful to determine complete vs.

partial ruptures

• MRI

will show acute rupture with retracted tendon

edges

Treatment

• Nonoperative

functional bracing/casting in resting equinus

sedentary patient

elderly patients

medically frail patients

technique

cast/brace in 20 degrees of plantar flexion

early functional rehab for those treated

without a cast

• Operative

• end-to-end achilles tendon repair

• percutaneous achilles tendon repair

• reconstruction with VY advancement

• flexor hallucis longus transfer +/- VY

advancement of gastrocnemius

• End-to-end achilles tendon repair

approach

make incision just medial to achilles

tendon to avoid sural nerve

technique

incise paratenon

expose tendon edges

repair with heavy non-absorbable

suture

postoperative care

immobilize in 20° of plantar flexion to

decrease tension on skin and protect

tendon repair for 4-6 weeks

percutaneous achilles tendon repair

concerns over cosmesis of traditional scar

higher risk of sural nerve damage

• reconstruction with VY advancement

chronic ruptures with defect < 4cm

– technique

make V cut with apex at

musculotendinous junction with limbs

divergent to exit the tendon undefined

V is incised through only the superficial

tendinous portion leaving the muscle fibers

intact

• flexor hallucis longus transfer +/- VY

advancement of gastrocnemius

chronic ruptures with defect > 4cm

technique

excise degenerative tendon edges

release FHL tendon at the Knot of

Henry and transfer through the calcaneus

Complications

• Re-ruptur

generally considered to be higher with

non-operative management (~10-40%

vs 2%

Wound healing complications 5-10%

• Sural nerve injury

higher incidence when percutaneous

approach is used

postoperative care

• Traditionally, postoperative rehabilitation

involved wearing a splint with the ankle in

equinus during the immediate

postoperative period. A cast is then placed

within a few days and continued for 6

weeks. The patient is seen in the clinic at

2-week intervals during which the cast is

changed and placed in an increasingly

more dorsiflexed position. After 4 to 6

weeks in the cast, it is advanced to a

plantigrade position. With the cast in

place, the patient is instructed to begin

isometric gastrocnemius-soleus complex

exercises once weight bearing is tolerated.

• A recent trend toward a more functional

rehabilitation program is gaining

popularity. These protocols use an anterior

plaster slab or an orthosis/walking boot

for 6 weeks allowing full range of motion

with the exception of dorsiflexion beyond

neutral.

• The long period of immobilization

increases the likelihood of muscle atrophy,

joint stiffness, cartilage atrophy,

degenerative arthritis, adhesions, and

deep venous thrombosis. In contrast, early

mobilization limits atrophy, promotes fiber

polymerization to collagen, and increases

the organization of collagen at the repair

site, which ultimately increases muscle

and tendon strength

Rehabilitation Program

Following cast removal, gentle passive

range of motion of the ankle and subtalar

joints is initiated.

After 2 weeks, progressive resistance

exercises (PREs) are added to the

regimen.

This is followed by aggressive gait training

exercises at about 10 weeks following the

injury (nonoperative patients) or surgery

(operative patients), leading toward

activity-specific maneuvers and a return to

activities at 4-6 months