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Achilles Tendon Rupture

M.Mazloumi MD

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)
2)
3)

Musculotendinous junction
Osseous insertion on calcaneus
Multiple mesotenal vessels on anterior
surface of paratenon (in adipose)

Anterior mesentery

Hypovascular area at 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
Spans

complex

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

Achilles Tendon Rupture

May be on the
background of a
degenerative
tendon

Achilles Tendon Rupture


Antecedent

tendinitis/tendinosis in 11%

75%

of sports-related ruptures happen in


patients between 30-40 years of age.

Most

ruptures occur in 4cm proximal to


the calcaneal insertion.

Achilles tendon disorders

Achilles Tendon Rupture


History

Case reports of fluoroquinolone use, steroid


injections
Mechanism

Eccentric loading (running backwards in tennis)


Sudden unexpected dorsiflexion of ankle
Direct blow or laceration
Fall from a hight

Achilles Tendon Rupture


Physical
Partial
Localized

tenderness +/- nodularity

Complete
Defect
Can

not heel raise


Positive Thompson test

Imaging
Ultrasound
Inexpensive

, dynamic
examination possible

Good

screening test for


complete rupture

Imaging
MRI
Expensive
Better

at detecting
1-partial ruptures
2- staging degenerative
changes
3- monitor healing

Management Goals
Restore

musculotendinous length and

tension.
Optimize

gastro-soleous strength and

function
Avoid

ankle stiffness

Conservative Management
Cast in Plantarflexion

Start physio for ROM


exercises

2 wks

CAM Walker or cast with


plantarflexion q 2
wks
4 weeks

Allow progressive weightbearing in removable cast


When WBAT and
foot is plantigrade

Start a strengthening
program

2- 4 weeks

Remove cast and walk with


shoe lift. Start with 2cm x 1
month, then 1cm x1 month
then D/C

Functional Bracing

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
Kerachow suture technique

Dynamic loop suture of Peroneus


brevis

Surgical Management
Lynn technique

Percutaneous repaire

Old rupture
Bosworth technique for repairing old
ruptures of Achilles tendon

Wapner technique with FHL tendon

Percutaneous versus open repair


Percutaneous repair

Open repair

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.

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
No difference in
functional outcome

5%

infection

2% Sural nerve inj.

Conservative vs Surgical
Acute Achilles tendon rupture: minimally invasive surgery versus nonoperative
treatment with immediate full weightbearing--a randomized controlled trial.
Am J Sports Med. 2008 Sep;36(9):1688-94. Epub 2008 Jul 21.

83 patients

Casted x 8 wks

Surgery +
Early functional rehab in
brace

5 \ 41 re-rupture

3 \ 42 re-rupture
No difference in
functional outcome

0.5%

infection

0.1% Sural nerve in

Limited open technique


1.

Outcome of achilles tendon ruptures treated by a limited open


technique. Jung HG, Lee KB, Cho SG, Yoon
Foot Ankle Int. 2008 Aug;29(8):803-7.

2.

Repair of achilles tendon rupture under endoscopic control. Fortis AP,


Dimas A, Lam
Arthroscopy. 2008 Jun;24(6):683-8.

3.

Minimally invasive repair of ruptured Achilles tendon. Chan SK, Chu


Hong Kong Med J. 2008 Aug;14(4):255-8.

Summary of Pooled Outcome Measures