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 more rapid return to work, with equivalent 1-year function 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