Introduction 

Achilles tendon ruptures are at the end of the spectrum which includes tendonitis, partial rupture, and complete rupture. Achilles tendon ruptures are the third most common tendon ruptures (Lipscomb et. al., 1956). They are commonly occur in males in poor athletic condition who participate in intermittent recreational sports. Males are more commonly afflicted with a male:female ratio of ranging from 2 to 10:1. Mechanisms associated with ruptures include sudden forced dorsiflexion of the ankle (eccentric contraction of the gastrocnemius and soleus), pushing off with the weight-bearing forefoot while extending the knee, and from a laceration or direct blow to the contracted tendon.

Anatomy 

The Achilles tendon connects the gastrocnemius and soleus muscles to the calcaneus. A relatively hypovascular area, 2-6 cm above the insertion into the calcaneus (Lagergren et. al., 1959), has been implicated in disorders of the tendon. Age-dependent changes in collage cross-linking result in increased stiffness and loss of viscoelasticity predispose the tendon to rupture.

Classification 

Achilles tendon ruptures are partial or complete.  Ruptures can also be divided into acute traumatic ruptures or chronic attritional ruptures.  However, ruptures are often due to a combination of age related attrition and an acute traumatic incident.   

Presentation 

The patient with Achilles tendon rupture presents with pain in the area of the Achilles tendon.  Pain is often described as an intense burning sensation or sharp stabbing pain.  Patients may hear an audible pop after landing or pushing off.  Patients may describe a feeling of being kicked or shot in the heel.  In the presence of complete tear, will experience significant ankle plantarflexion weakness.

Diagnosis 

The diagnosis of Achilles tendon rupture can be made by palpating the defect in the tendon.  The Thompson squeeze test is executed by squeezing the calf muscle with the patient prone and observing the presence or absence of resultant ankle plantarflexion.  MRI can accurately demonstrate ruptures, but are not usually required.

Treatment 

Operative:

The longitudinal incision should be approximately 1 cm medial to and off the center of the tendon to avoid irritation by footwear.  The incision should be carried straight through the skin, subcutaneous tissue, and tendon sheath to minimize postoperative wound complications.  The ends of the tendon can be reapproximated with a large nonabsorbable suture, paying special attention to the position of the ankle and knee.  The plantaris, flexor digitorum longus, flexor hallucis longus, peroneus brevis, and semitendinosis can be used to supplement repair strength, as well as local soft-tissue advancements. 

Repair of neglected Achilles ruptures typically involves removing intervening scar tissue, lengthening of the proximal portion of the tendon, and supplementation with soft-tissue advancement and/or tendon.

Non-operative:

Conservative treatment varies, but usually involves casting in a long leg cast with knee flexed and ankle in equinus (2-3 weeks), then short leg casting (8 weeks).  Non-weight bearing is typically recommended initially (the first 6 weeks).  

Complications 

• Operative treatment      
  • Rerupture                   (~2%) 
  • Skin complications       (~5%) 
  • Deep infection             (~1%) 
  • Stiffness 
• Non-operative treatment 
  • Rerupture                   (10-30%) 
  • Decreased strength 

Red Flags and Controversies 

• Controversy exists regarding operative versus non-operative treatment.  Many advocate non-operative treatment due to similar strength, power, range of motion, and functional level results obtained with conservative and operative treatments.  Others have recommended surgical repair in athletic patients due to a lower rerupture rate (2-3 versus 10-30%).  
• Carden et. al. reported non-operative results comparable to operative results when ruptures were casted in the first 48 hours.

Outcomes 

As mentioned, controversy exists, but it is generally thought that surgical treatment results in good return of strength, endurance, and power with a low rerupture rate. 

Further web resources

Orthopaedic Web Links (OWL) Category - Tendo Achilles Rupture [OCOSH Code: C21.866.761\_WI\_R\_H] http://www.orthopaedicweblinks.com/OCOSH_Classification/Trauma/Rupture/Heelcord_Ruptures/index.html