Achilles Tendon Rupture
synonyms: Achilles tendon tear, Achilles rupture, Achilles tear
Achilles Tendon Rupture ICD-9
- 727.67 (Rupture of tendon, nontraumatic; Achilles tendon)
- 845.09 (Sprain and strain of ankle and foot; Achilles tendon)
Achilles Tendon Etiology / Epidemiology / Natural History
- Generally occurs in males in the 3rd to 5th decade participating in recreational sports (basketball, racket sports)
- May be due to intrinsic degeneration or overloading (active forceful plantar flexion)
- Has been associated with ciprofloxacin/fluoroquinolones use. (Movin T, Foot Ankle Int 1997;18:297)
- Risk of sustaining a rupture of the contralateral side may be as high as 26% (Jessing P, Acta Chir Scand 1975;141:370)
- Risk Factors: steriod injection into the tendon shealth or retrocalcaneal bursa, ciprofloxacin/fluoroquinolones use, type O blood, male gender, gout, hyperthyroidism, renal insufficiency, arteriosclerosis (Paavola M, Foot Ankle Clin 2002;7:501).
Achilles Tendon Anatomy
- Achilles tendon is formed by the confluence of the Gastrocnemius and Soleus @15cm above the calcaneous.
- Hypovascular zone of the Achilles is 3-6cm proximal to its calcaneal insertion. (Stein V, Acta Orthop Scan 2000;71:60)
- Sural nerve is most at risk during surgical approach. It crosses near the midline at the level of the musculotendinous junction of the achilles (@9.8 cm from the calcaneus) before descending to its more lateral location distally. At the level of insertion of the Achilles into the calcaneus, the sural nerve is 18.8 mm from the lateral border of the Achilles tendon. (Webb J, Foot ankle Int 2000;21:475)
Achilles Tendon Clinical Evaluation
- Pop or snap in posterior ankle with acute pain usually associated with sudden push-off movement during sporting activity, generally in middle aged patient.
- swollen painful ankle with posterior ecchymosis, tender posteriorly
- Affected foot rests in slight dorsiflexion
- Palpable defect in Achilles usually 2-4 cm above calcaneous.
- Thompson sign = squeeze calf muscle with pt prone, feet extended off end of table. The foot plantar flexes if tendon is intact. No foot movement = ruptured Achilles. (Thompson TC, J Trauma 1962:2:126).
- O'Brien test = 25-gauge needle inserted must medial to the midline 10cm proximal to the superior border of the calcaneous. Foot is passively dorsi/plantar flexed. Needle movement in the opposite direction of the foot indicates the tendon is intact. No movement = postive test = tendon completely ruptured. Positive Thompson test with negative O'Brien test indicates parital rupture of the musculotendinous junction of the Gastrocnemius. (O'Brien T, JBJS 1984;66A:1099)
- Hyperdorsiflexion sign: with patient prone and both knee flexed 90º, maximal passive dorsiflexion demonstrates increased dorsiflexion on injured side.
- Repetitive heel rises: patient with a torn Achilles will not be able to perform repetitive heel rises.
- Resting equines: ankle is normally in 7-12º of equinus when laying prone at rest. Loss of normal resting equinus position indicates Achilles rupture.
Achilles Tendon Xray / Diagnositc Tests
- A/P, mortise and lateral ankle xray indicated to r/o fracture or avulsion. Avulsion fx best seen on lateral xray
- MRI has been shown to be sensitive and specific, but is no better then physical exam
- Ultrasound: is useful in the diagnosis, provided skilled operator is available. Useful for determining tendon end location if considering non-op treatment. Ruptured area is hypoechogenic on ultrasound. (Hufner TM, Foot Ankle Int 2006;27:167).
Achilles Tendon Classification / Treatment
- Initial treatment: short leg splinting in plantar flexion. Surgical and nonsurgical rx give simlar long-term outcomes.
- Nonsurgical treatment requires immobilization for 8-12 wks Disadvantages: higher recurrence rate(15.2%), higher percentage of dissatisfied patients, significant loss of power, strength and endurance compared to surgical treatment. Monitoring with Ultrasound or MRI recommended to confirm apposition of the tendon ends. Benefits: lack scar, no wound complications, less expensive. Indicated for lower demand older pt, pts on systemic steroids/methotrexate, IDDM, vascular compromise.
- Surgical treatment. Advantages: lower re-rupture rate (1.1%), higher percentage of return to sport, greater strength, power, and endurance recovery. Disadvantages: higher cost, wound breakdown, DVT, Sural nerve injury. Indicated for: quicker return to work/sport, less atrophy, better range of motion, restore normal tension, decreased re-rupture. (Nistor L, JBJS63A:394;1981)
- OR= Mandelbaum BR, Am J Sports Med 1995;23:392-395
- Percutaneous repair-risks sural nerve entrapment, decreased strength compared to open repair,: prone, zero monofilament polydioxanone suture, 2 Keith needles. Should be done within 7 days of rupture with the ankle splinted in platar flexion on the day of injury. (Bradley JP, AJSM 1990;18:188)
- Chronic ruptures / defect >7cm-- treatment of choice is a transfer of the flexor hallucis longus (release at the knot of Henry) through the calcaneus.(Wilcox, DK Foot Ankle Int 2000;21:1004) Consider concomitant V-Y advancement of the gastrocnemius. Primary repair will most likely fail because the proximal musculotendinous stump is too contracted. A turn-down flap is not vascularized; therefore, it is a less than ideal choice. The peroneus brevis transfer is useful, particularly with old lateral incisions, but is less preferable in primary situations. Flexor digitorum longus transfer, fascia lata transfer, gracilis transfer are also a viable alternative.
- Achilles Avulsion from the Calcaneous: direct repair to bone with transosseous sutures or suture anchors.
- Patient Information: Mayo Clinic,
Achilles Tendon Rupture Non-operative Treatment
- Lea RB, JBJS 1972;54A:1398
- Weight-bearing short leg cast with the foot in a gravity equinus position for 8 weeks.
- Cast removed at 8 weeks. Start 2.5cm heel lift and gastric stretching / strengthening.
Achilles Tendon Rupture Surgery
- CPT: 27650 (primary repair), 27652 (primary repair with graft)
- Achilles repair case card.
- Surgery can be done immediately or delayed 7 to 10 days. Delaying can reduce swelling and allow some organization of the "mop-ends" of tendon allowing restoration of the anatomic length. There is no difference in outcomes if repaired within 30 days.
- Turn-down gastroc fascial flap augmentation of acute repairs does not improve outcomes (Pajala A, JBJS 2009;91A:1092).
- Pre-op antibiotics.
- Prone, all bony prominences well padded.
- Thigh tourniquet.
- Prep and drape in standard sterile fashion.
- Posteromedial incision (medial to the medial border of the Achilles). Dissect down to paratenon (deep crural fascia), without making large skin flaps.
- Paratenon incised longitudinally.
- Hematoma evacuated, tendon ends debrided.
- Plantaris tendon passes deep to crural fascia along medial aspect of Achilles, may be used to augment repair.
- No 2 nonabsorbale suture (Orthocord) placed using Kessler technique. Repairs may be done with Bunnell suture technique, modified-Kessler technique, Krakow locking loop technique, tiple bundle technique (Beskin JL, AJSM 1987;15:1)
- Knee flexed, foot plantar flexed for suture tying.
- Vertical locking circumferential 2-0 absorbable suture placed to augment repair.
- Augmentation: gastroc fascial turndown(Jessing P, Acta Chir Scand 1975;141:370), plantaris tendon (Lynn TA, JBJS 1966;48:268), or biologic tissue scaffold.
- Consider Platelet-rich plasma injection. (Sánchez M, AJSM 2007; 35:245)
- Irrigate.
- Paratenon repaired with 2-0 absorbable suture.
- Close in layers.
- Below-knee bulky compressive dressing with plaster splints holding foot in gravity equines.
Achilles Tendon Associated Injuries / Differential Diagnosis
Achilles Tendon Complications
- Skin necrosis
- Infection / Dehiscence
- Painful scar tissue
- DVT
- Sural nerve injury / neuroma
Achilles Tendon Follow-up Care
- Post-Op: place in a gravity equinus splint, non-weight bearing
- 10 day f/u, casted at 20º flexion, NWB; Consider functional boot with heel wedge. Consider early weight bearing if repair and tissues are adequate.
- 4wks; functional boot with 20º heel wedge. WBAT. Begin gentle passive ROM, no passive dorsi flexion.
- 6-8wks; 1” heal lift, begin active physical therapy:passive stretching, active theraband. Heal lift continued until able to reach 10 degrees of dorsiflexion.
- Perform stretching exercises prior to commencing any sports permanently. May return to sports at 3-4 months.
- Achilles Tendon Rehab Protocol.
Achilles Tendon Review References
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