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Updated: Dec 19 2023

Achilles Tendon Rupture

Images key image.jpg 1 resting tension.jpg gap.jpg tear ultrasound.jpg
  • summary
    • Achilles Tendon Ruptures are common tendon injuries that occur due to sudden dorsiflexion of a plantarflexed foot, most commonly associated with sporting events. 
    • Diagnosis can be made clinically with weakness of plantarflexion with a positive Thompson's test. MRI studies may be indicated for surgical management of chronic injuries. 
    • Treatment may be nonoperative or operative depending on patient age, patient activity demands and chronicity of injury.
  • Epidemiology
    • Incidence
      • 18:100,000 per year
        • may be missed in up to 25%
    • Demographics
      • more common in men
      • most common in ages 30-40
    • Risk factors
      • episodic athletes, "weekend warrior"
      • flouroquinolone antibiotics
      • steroid injections
  • Etiology
    • 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
    • Achilles tendon
      • 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
      • patient 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
        • increased passive dorsiflexion
      • provocative test
        • Thompson test
          • lack of plantar flexion when calf is squeezed
  • Imaging
    • Radiographs
      • indications
        • used to rule out other pathology
    • Ultrasound
      • indications
        • may be useful to determine complete vs. partial ruptures
    • MRI
      • indications
        • equivocal physical exam findings
        • chronic ruptures
      • findings
        • will show acute rupture with retracted tendon edges
  • Treatment
    • Nonoperative
      • functional bracing/casting in resting equinus
        • indications
          • acute injuries with surgeon or patient preference for non-operative management
          • sedentary patient
          • medically frail patients
        • outcomes
          • equivalent plantar flexion strength compared to operative management
          • new studies show equivalent rates of re-rupture if functional rehabilitation used versus operative repair
          • fewer complications compared to operative treatment
    • Operative
      • open end-to-end achilles tendon repair
        • indications
          • acute ruptures (approximately <6 weeks)
        • outcomes
          • decreased rate of re-rupture compared to non-operative management
            • new Level 1 evidence has suggested no difference in re-rupture rates with functional rehab protocol
          • no significant difference in plantar flexion strength with functional rehab protocol
            • decreased risk of re-rupture after surgical repair when early ROM protocol used
      • percutaneous Achilles tendon repair
        • indications
          • concerns over cosmesis of traditional scar
        • outcomes
          • higher risk of sural nerve damage
          • lesser risk of wound complications/infection compared with open repair
      • reconstruction with VY advancement
        • indications
          • chronic ruptures with defect < 3cm
      • flexor hallucis longus transfer +/- VY advancement of gastrocnemius
        • indications
          • chronic ruptures with defect > 3cm
          • requires a functioning tibial nerve
  • Techniques
    • Functional bracing/casting in resting equinus
      • technique
        • cast/brace in 20 degrees of plantar flexion
        • early functional rehab for those treated without a cast
    • 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
      • technique
    • Reconstruction with VY advancement
      • technique
        • make V cut with apex at musculotendinous junction with limbs divergent to exit the tendon
        • V is incised through only the superficial tendinous portion leaving the muscle fibers intact
    • Flexor hallucis longus transfer ± VY advancement of gastrocnemius
      • technique
        • excise degenerative tendon edges
        • release FHL tendon at the Knot of Henry and transfer through the calcaneus
        • residual hallux plantarflexion weakness
  • Complications
    • Re-rupture
      • incidence
        • higher with non-operative management (~10-40% vs 2%)
          • new Level 1 evidence has shown no difference in re-rupture rates
      • treatment
        • surgical repair
    • Wound healing complications
      • incidence
        • 5-10%
      • risk factors
        • smoking (most common)
        • female gender
        • steroid use
        • open technique (versus percutaneous)
      • treatment
        • deep infection
          • debridement of necrotic/infected Achilles tendon
          • culture-specific antibiotics for 6 weeks
    • Sural nerve injury
      • incidence
        • higher when percutaneous approach is used
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