Ruptur Tendon Achilles

Current Concepts Review
Rupture of the Achilles Tendon

*
BY NI COLA MAFFULLI , M.D., M.S., PH.D., F.R.C.S.(ORTH), ABERDEEN, SCOTLAND
Achilles, the warrior and hero of Homers Iliad,
lends his name to the Achilles tendon, the thickest and
strongest tendon in the human body
138
. Thetis, Achilless
mother, made him invulnerable to physical harm by im-
mersing him in the river Styx after learning of a proph-
ecy that Achilles would die in battle. However, the heel
by which he was held remained untouched by the water
and thus Achilles had a vulnerable point. Achilles led
the Greek military forces, which captured and destroyed
Troy after killing the Trojan prince Hector. However,
Hectors brother Paris killed Achilles by firing a poi-
soned arrow into his heel
164
.
Hippocrates, in the first recorded description of
an injury to the Achilles tendon, stated that this ten-
don, if bruised or cut, causes the most acute fevers, in-
duces choking, deranges the mind and at length brings
death.
26
Ambroise Par, in 1575, recommended that a
ruptured Achilles tendon be strapped with bandages
dipped in wine and spices, but advised that the result
was dubious
27
. Operative repair of a ruptured Achilles
tendon was advocated in 1888 by another Frenchman,
Gustave Polaillon
27
, although an Arabian physician per-
formed such procedures as early as the tenth century
A.D. I n the twelfth century, an I talian surgeon, Gug-
lielmo di Faliceto, believed that nature was unable to
unite divided tendons and that operative treatment was
necessary
27
.
Much research has been performed to elucidate the
etiology of a rupture of the Achilles tendon, but its true
nature still remains unclear
190
. Also, the best method of
treatment is still fiercely debated. Some physicians ad-
vocate operative repair, whereas others insist that an
operation is unnecessary and poses an unacceptable risk.
The Achilles Tendon
The tendinous portions of the gastrocnemius and
soleus muscles merge to form the Achilles tendon. The
plantaris muscle, which was present in 93 percent (752)
of 810 lower extremities in one study
38
, is medial to the
Achilles tendon and is distinct from it. The gastrocne-
mius tendon originates as a broad aponeurosis at the
distal margin of the muscle bellies
38
, whereas the soleus
tendon begins as a band proximally on the posterior
surface of the soleus muscle. The length of the gastroc-
nemius component ranges from eleven to twenty-six
centimeters
38
and that of the soleus component, from
three to eleven centimeters. Distally, the Achilles tendon
becomes progressively rounded in cross section, to a
level four centimeters proximal to the calcaneus, where
it can become relatively flatter
38
, before inserting on the
superior calcaneal tuberosity
191
. The fibers of the Achil-
les tendon spiral through 90 degrees during its descent,
such that the fibers that lie medially in the proximal
portion become posterior distally. I n this way, elonga-
tion and elastic recoil within the tendon are possible,
and stored energy can be released during the appro-
priate phase of locomotion
2
. Also, this stored energy
allows the generation of higher shortening velocities
and greater instantaneous muscle power than could be
achieved by contraction of the triceps surae alone
2
.
The calcaneal insertion of the Achilles tendon is highly
specialized
157,158
, as it is composed of the attachment of
the tendon, a layer of hyaline cartilage, and an area of
bone not covered by periosteum. A subcutaneous bursa
may lie between the tendon and the skin to reduce
friction between the tendon and the surrounding tissues.
A retrocalcaneal bursa lies between the tendon and the
calcaneus
191
.
Structure of the Tendon
Tendons act as transducers of the force produced by
muscle contraction to bone. Collagen accounts for 70
percent of the dry weight of a tendon
138
. Approximately
95 percent of tendon collagen is type-I collagen, with a
very small amount of elastin
10,35
. Elastin can undergo as
much as 200 percent strain before failure
153
. I f it were
present in the tendon in high proportions, there would
be a decrease in the magnitude of force transmitted to
bone
150
.
Collagen fibrils are bundled into fascicles containing
blood and lymphatic vessels as well as nerves
154
. The
fascicles are grouped together, surrounded by epitenon,
and form the gross structure of the tendon, which is
further enclosed by paratenon, separated from the epi-
tenon by a thin layer of fluid to allow tendon movement
with reduced friction.
Although the normal Achilles tendon consists almost
entirely of type-I collagen, a ruptured Achilles tendon
also contains a substantial proportion of type-I I I col-
lagen
35
. Fibroblasts from ruptured Achilles tendons pro-
duce both type-I and type-I I I collagen on culture
187
.
*No benefits in any form have been received or will be received
from a commercial party related directly or indirectly to the subject
of this article. Funds were received in total or partial support of
the research or clinical study presented in this article. The funding
source was Wellcome Trust, London, England.
Department of Orthopaedic Surgery, University of Aberdeen
Medi cal School, Polwarth Building, Foresterhill, Aberdeen AB25
2ZD, Scotland. E-mail address: n.maffulli@abdn.ac.uk.
Copyright 1999 by The Journal of Bone and Joint Surgery, Incorporated
VOL. 81-A, NO. 7, JULY 1999 1019
Type-I I I collagen is less resistant to tensile forces and
may therefore predispose the tendon to spontaneous
rupture.
The normal Achilles tendon shows a well organized
cellular arrangement
174
, in stark contrast to one that is
ruptured. Tenocytes, which are specialized fibroblasts,
appear in transverse sections as stellate cells and are
arranged in rows in longitudinal sections
154
. This orderly
arrangement probably is due to the uniform centrifugal
secretion of collagen around the column of tenocytes
170
,
which produce both the fibrillar and the nonfibrillar
components of the extracellular matrix
145
and may also
reabsorb collagen fibers
19,161
.
Blood Supply
Tendons can receive their blood supply from ves-
sels originating from three sources: the musculotendi-
nous junction, the surrounding connective tissue, and
the bone-tendon junction
132
. The blood flow of the Achil-
les tendon depends on age, with a higher blood flow in
younger individuals
66
. The Achilles tendon is poorly vas-
cularized, especially in its midportion
92
, with blood ves-
sels running from the paratenon into its substance
47,161
.
There is a dispute concerning the distribution of blood
vessels in the tendon
56
. Some investigations have shown
that the density of blood vessels in the middle part of
the Achilles tendon is low compared with that in the
proximal part
101
. Others have shown, with use of laser
Doppler flowmetry, that blood flow is evenly distributed
throughout the Achilles tendon and may vary accord-
ing to age, gender, and loading conditions
9
.
Biomechanics of the Tendon
Actin and myosin are present in tenocytes
76
, and the
tendon itself may have an active contraction-relaxation
mechanism, which could regulate the transmission of
force from muscle to bone
54
. Fukashiro et al.
55
measured
a peak force of 2233 newtons within the human Achilles
tendon in vivo. Komi et al.
96
used buckle-type force-
transducers attached to the ankles of volunteers to
show that, during walking, force builds up within the
tendon before the heel strikes the ground. The force is
then suddenly released for ten to twenty milliseconds
during early impact. Thereafter, force builds up rela-
tively fast until it reaches a peak at the end of the
push-off phase, in a pattern similar to that observed
during running. More recently, Arndt et al.
5
showed that
the Achilles tendon can be subjected to nonuniform
stresses through modifications of individual muscle
contributions. An injury therefore can be produced by
a discrepancy in individual muscle forces caused, for
example, by asynchronous contraction of the various
components of the triceps surae or by uncoordinated
agonist-antagonist muscle contraction due to impaired
transmission of peripheral sensory stimuli
125
.
At rest, a tendon has a wavy configuration, a re-
sult of crimping of the collagen fibrils
138
. Tensile stresses
cause the loss of this wavy configuration, accounting for
Graph showing the stress-strain curve for tendon. Wavy lines indicate the wavy configuration of the tendon at rest, straight unbroken lines
indicate the effect of tensile stresses (at strain levels of less than 4 percent, the tendon can regain its original configuration on removal of the
load), one or two broken lines indicate that the collagen fibers are starting to slide past one another as the intermolecular cross-links fail,
and the set of completely broken lines indicate macroscopic rupture due to the tensile failure of the fibers and the interfibri llar shear
failure. (Modified from: Kannus, P.: Tendon pathology: basic sciences and clinical applications. Sports Exerc. and I njury, 3: 62, 1997. Reprinted
with permission.)
FI G. 1
1020 NI COLA MA FFULLI
THE JOURNAL OF BONE AND JOI NT SURGERY
the toe-region of the stress-strain curve (Fig. 1). As col-
lagen fibers deform, they respond linearly to increasing
tendon loads
93
. I f the strain placed on the tendon re-
mains at less than 4 percent that is, within the limits
of most physiological loads
138
the fibers regain their
original configuration on removal of the load. At strain
levels between 4 and 8 percent, the collagen fibers start
to slide past one another as the intermolecular cross-
links fail. At strain levels of greater than 8 percent,
macroscopic rupture occurs because of the tensile fail-
ure of the fibers and interfibrillar shear failure
138
.
The compliance of the tendon is dependent at least
in part on intratendinous waviness
29
, which may affect
the ability of the gastrocnemius-soleus muscle complex
to generate force at the extremes of joint motion
68
. Ul-
timately, it may also influence the forces exerted by
muscle contraction on the tendon and, hence, the pro-
pensity of the tendon to rupture.
Epidemiology
Although ruptures of the Achilles tendon are rela-
tively common, the incidence in the general population is
difficult to determine but has probably increased dur-
ing the past decade
104
. Leppilahti et al.
105
estimated that
the incidence of ruptures of the Achilles tendon in the
city of Oulu, Finland, in 1994, was approximately eigh-
teen per 100,000. Most ruptures of the Achilles tendon
(range, 44 percent [twelve of twenty-seven]
144
to 83 per-
cent [ninety-two of 111]
31
) occur during sports activities.
I n the Scandinavian countries, badminton players ap-
pear to be at particular risk
49
; in a large study, fifty-eight
(52 percent) of 111 patients who had a rupture of the
Achilles tendon were playing badminton at the time of
the injury
31
. A rupture of the Achilles tendon is more
common in males, with a male-to-female ratio ranging
from 1.7:1 to 12:1
26,146,189
, possibly reflecting the greater
prevalence of males than females who are involved in
sports, although there may be other as yet unrecognized
factors. The left Achilles tendon is ruptured more fre-
quently than the right
67,172,173
, possibly because of a higher
prevalence of individuals who are right-side-dominant
and thus push off with the left lower limb. Typically,
acute ruptures of the Achilles tendon occur in men who
are in the third or fourth decade of life, work in a white-
collar profession, and play a sport occasionally
22,67,82
.
The prevalence of rupture of the Achilles tendon
has been shown to be greater in patients who have
blood group O, at least among Hungarians
80
and in some
Finns
99
. These findings have not been confirmed in other
studies
128
even when the same ethnic groups were in-
volved
105
. We were not able to prove an association with
blood group in our area of Scotland, which has a high
incidence of rupture of the Achilles tendon
152
.
Etiology
Spontaneous rupture of the Achilles tendon has
been associated with a multitude of disorders, such
as inflammatory and autoimmune conditions
46
, geneti-
cally determined collagen abnormalities
42
, infectious dis-
eases
7
, and neurological conditions
126
. However, there is
little agreement with regard to its etiology.
A disease process may predispose the tendon to
spontaneous rupture from minor trauma
114
. Blood flow
in the tendon decreases with increasing age
66
, and the
area of the Achilles tendon that is typically prone to
rupture is relatively avascular compared with the rest of
the tendon
100,101,161
.
Histological evidence of collagen degeneration was
found in all seventy-four ruptured Achilles tendons de-
scribed in a study by Arner et al.
7
. However, nearly
two-thirds of the specimens were obtained more than
two days after the rupture. Davidsson and Salo
40
re-
ported marked degenerative changes in two patients
with a rupture of the Achilles tendon who had an oper-
ation on the day of the injury. The changes, therefore,
should be regarded as having developed before the
rupture. I n a study by Waterston
187
, performed at our
center, all tendons that were operated on within twenty-
four hours after the injury showed marked degenerative
changes and collagen disruption, in accordance with the
findings in another recent study
78
.
Alternating exercise with inactivity could produce
the degenerative changes seen in tendons
97
. Sports in
addition to daily activity places additional stress on the
Achilles tendon, leading to the accumulation of trauma,
which, although below the threshold for frank rup-
ture
188
, could lead to secondary intratendinous degener-
ative changes
53
.
Corticosteroids and Rupture of the Tendon
Corticosteroids are administered for a variety of
diseases and have been widely implicated in tendon
ruptures. I njection of hydrocortisone into the calca-
neal tendons of rabbits caused necrosis at the site of
injection forty-five minutes after the injection, and the
tendons that had been given an injection of corticoste-
roids showed a delayed healing response compared with
those that had received an injection of saline solu-
tion
11
. The anti-inflammatory and analgesic properties
of corticosteroids may mask the symptoms of tendon
damage
45
, inducing individuals to maintain high levels
of activity even when the tendon is damaged. Cortico-
steroids interfere with healing, and intratendinous in-
jection of corticosteroids results in weakening of the
tendon for as many as fourteen days
91
. The disruption is
directly related to collagen necrosis, and restoration of
the strength of the tendon is attributable to the forma-
tion of an acellular amorphous mass of collagen. For
these reasons, vigorous activity should be avoided for at
least two weeks after injection of corticosteroids in the
vicinity of a tendon
91
. Unverferth and Olix
183
reported a
subcutaneous rupture in five athletes who had been
given injections of corticosteroids in the region of the
Achilles tendon for the treatment of tendinopathy. Re-
RUPTURE OF THE ACHI LLES TENDON 1021
VOL. 81-A, NO. 7, JULY 1999
sidua of the corticosteroids were found at the site of the
rupture in four of the five patients. A meta-analysis
recently has shown that corticosteroid injections do not
seem to play a beneficial role in the treatment of Achil-
les tendinopathy
165
.
Orally administered corticosteroids also have been
implicated in the etiology of tendon rupture. At our
center, twelve patients who were managed with long-
term oral therapy with corticosteroids for the treatment
of chronic obstructive small airways disease were diag-
nosed with a rupture of the Achilles tendon during a
ten-year period. Four of them sustained a bilateral in-
jury
136
(Fig. 2).
I t still is not possible to pinpoint the etiological
role of corticosteroids
127
, and some studies have not
demonstrated deleterious effects of these agents. For
example, McWhorter et al.
115
demonstrated that a sin-
gle injection of hydrocortisone acetate in a traumatized
calcaneal tendon of a rat had no important biomechani-
cal or histological adverse effect. However, given the
present evidence, prolonged oral administration and re-
peated peritendinous injection of corticosteroids prob-
ably should be avoided.
Fluoroquinolones and Rupture of the Tendon
Fluoroquinolone (4-quinolone) antibiotics such as
ciprofloxacin recently have been implicated in the eti-
ology of rupture of the tendon. I n France, between
1985 and 1992, 100 patients who were being managed
with fluoroquinolones had tendon disorders, which in-
cluded thirty-one ruptures
156
. Many of these patients
also had received corticosteroids, so it is difficult to
implicate only the fluoroquinolones. Szarfman et al.
176
noted that studies have shown that animals that re-
ceived fluoroquinolone in doses close to those admin-
istered to humans had disruption of the extracellular
matrix of cartilage, which exhibited as fissuration and
chondrocyte necrosis, as well as depletion of colla-
gen. The abnormalities seen in animals might also oc-
cur in humans. Szarfman et al. recommended that
the labeling on packaging for fluoroquinolone be up-
dated to include a warning about the possibility of
tendon rupture. I n its recommendations on the use of
this class of antibiotics, the British National Formulary
suggested that at the first sign of pain or inflamma-
tion, patients should discontinue the treatment and rest
the affected limb until the tendon symptoms have re-
solved.
24
Recently, Bernard-Beaubois et al.
16
found labora-
tory evidence of direct deleterious effects of fluoroquin-
olones on tenocytes. They suggested that pefloxacin, a
fluoroquinolone, does not affect transcription of type-I
collagen but decreases the transcription of decorin at a
concentration of only 10
-4
millimoles. The resulting de-
Photographs showing the appearance of the feet of an eighty-year-old woman who had bilateral rupture of the Achilles tendon; she had
been managed with orally administered corticosteroids for twenty-eight years because of asthma. The ruptures had been undiagnosed for 7.5
months. At the time of referral, the patient walked with plantigrade feet, with no push-off. She refused any management, as she perceived that
she had adapted well to the functional deficit originating from the ruptures of the tendons. A palpable gap in the substance of the Achilles
tendon was evident bilaterally (arrows).
FI G. 2
crease of decorin may modify the architecture of the
tendon, altering its biomechanical properties, and pro-
duce increased fragility.
Hyperthermia and Rupture of the Tendon
As much as 10 percent of the elastic energy stored
in tendons may be released as heat
92
. Wilson and Good-
ship
192
evaluated the temperatures generated in vivo
within equine superficial digital flexor tendons dur-
ing exercise. A peak temperature of 45 degrees Celsius
(a temperature at which tenocytes can be damaged
4
)
was measured within the core of the tendon after just
seven minutes of trotting. Exercise-induced hyperther-
mia therefore may contribute to tendon degeneration.
As good blood supply to tissues should help to cool
overheating, tissues such as the Achilles tendon, which
has relatively avascular areas, may be more susceptible
to the effects of hyperthermia.
The Mechanical Theory
McMaster
114
proposed that a healthy tendon would
not rupture, even when subjected to severe strain. How-
ever, Barfred
13-15
demonstrated that, if straight traction
were applied to a tendon, as in McMasters experi-
ments, the risk of rupture would be distributed equally
to all parts of the muscle-tendon-bone complex. I f
oblique traction were applied, the risk of rupture would
be concentrated on the tendon. He calculated that, if a
1.5-centimeter-wide Achilles tendon in a human were
subjected to traction with 30 degrees of supination on
the calcaneus, the fibers on the convex aspect of the
tendon would be elongated by 10 percent before the
fibers on the concave side would be strained. Therefore,
the risk of rupture would be greatest when the tendon
was obliquely loaded, when the muscle was in maxi-
mum contraction, and when the initial length of the ten-
don was short. Such factors are probably all present in
movements occurring in many sports that require rapid
push-off. Barfreds theory is largely supported by that
of Guillet et al. (reported in a study by Postacchini
and Puddu
144
), who proposed a purely traumatic theory
for rupture of the tendon in young healthy patients. A
healthy tendon may rupture after a violent muscular
strain in the presence of certain functional and anatom-
ical conditions. These include incomplete synergism of
agonist muscle contractions, a discrepancy in the thick-
ness quotient between muscle and tendon, and ineffi-
cient action of the plantaris muscle acting as a tensor of
the Achilles tendon.
Participation in sports plays a major role in the de-
velopment of problems with the Achilles tendon, and
training errors are a major factor
33,39,62,69
. The flared heel
on most sport shoes forces the hindfoot into prona-
tion when the heel strikes the ground
136
, and the heel
tabs on some shoes may play a similar role. Clement et
al.
34
, in a study on the etiology of Achilles tendinopathy,
found that sixty-one (56 percent) of 109 athletes dis-
played a so-called functional overpronation of the foot
on heel-strike, with a whipping action of the Achilles
tendon. Exaggeration of this whipping action may lead
to intratendinous microtears. Poor flexibility of the
gastrocnemius-soleus unit was also considered to con-
tribute to overpronation
33,39
. Unequal tensile forces on
different parts of the tendon may produce a so-called
torsional ischemic effect that is, transient vasocon-
striction of the intratendinous vessels and therefore
contribute to the vascular impairment already present
within the Achilles tendon
34
.
I nglis and Sculco
75
proposed that malfunction or
suppression of the proprioceptive component of skele-
tal muscle predisposes athletes to rupture of the Achil-
les tendon. They believed that athletes who resume
training after a period of rest are particularly susceptible
to rupture of the Achilles tendon as a result of this
malfunction.
Knrzer et al.
95
used x-ray diffraction spectra to
study the behavior of the structure of collagen during
tendon-loading. Tendons that rupture without previous
degenerative changes are damaged initially at the sub-
microscopic fibrillar level because of a process of in-
trafibrillar sliding, which occurs a few seconds before
macroscopic slippage of collagen fibers. Therefore, rup-
ture of tendons unaffected by degenerative changes
may result from the accumulation of fibrillar damage.
Such findings support the theory that a complete rup-
ture is the consequence of multiple microruptures and
that tendon damage must reach a critical point, after
which failure occurs.
Mechanism of Rupture
Arner and Lindholm
8
classified the trauma resulting
in the rupture in ninety-two patients into three main
categories. The first category was pushing off with the
weight-bearing forefoot while extending the knee. This
movement is seen in sprint starts and in jumping in
sports such as basketball. This mechanism accounted for
53 percent of the ruptures in their series. The second
category was sudden, unexpected dorsiflexion of the
ankle, such as that occurring when the foot slips into a
hole or the individual falls down stairs. This mechanism
accounted for 17 percent of the ruptures. The third cat-
egory was violent dorsiflexion of a plantar flexed foot,
such as may occur after a fall from a height. This mech-
anism was reported by 10 percent of their patients. The
exact mechanism of injury could not be identified for
the rest of their patients.
Pathological Characteristics
I n 1976, Puddu et al.
146
proposed a system to classify
abnormalities of the tendon. The major categories were
paratendinitis, paratendinitis with tendinosis, and pure
tendinosis. The term tendinosis describes the degener-
ative processes occurring within the tendon. Tendinosis
includes a number of pathological processes, such as
VOL. 81-A, NO. 7, JULY 1999
hyaline degeneration with a decrease in the normal cell
population, mucoid degeneration with chondroid meta-
plasia or fatty degeneration of tenocytes, lipomatous
infiltration of large areas of tendon, an increase in ma-
trix mucopolysaccharides, and fibrillation of collagen
fibers. A rupture of a tendon may be the result of this
process. I n the opinion of Puddu et al., tendinosis is
symptomless and is discovered only on rupture of a
tendon. Patients who have symptoms before the rup-
ture of a tendon commonly have a combination of peri-
tendinitis and tendinosis, and it is possible that a
patient who has tendinosis may become symptomatic
because of paratendinopathy, which may accompany
tendinosis. Kannus and Jzsa
87
noted that only one-
third of the 891 patients in their study had symptoms
before rupture of the tendon. We found that only nine
(5 percent) of the 176 patients managed because of a
rupture of the Achilles tendon at our center between
January 1990 and December 1995 had had previous
symptoms
151,187
.
Arner and Lindholm
8
reported that all ninety-two
ruptured Achilles tendons that they examined histolog-
ically had degenerative changes, including edematous
disintegration of tendon tissue, patches of mucoid de-
generation, and a marked inflammatory reaction. They
also noted that approximately one-quarter of the larger-
caliber arteries in the peritendinous tissue exhibited
pathological hypertrophy of the tunica media and nar-
rowing of the lumen.
Kannus and Jzsa
87
noted pathological alterations,
97 percent of which were degenerative changes, in all
of the 891 spontaneously ruptured tendons from all of
the sites that they studied. The most common degen-
erative lesion was hypoxic degeneration, with altera-
tions in the size and shape of mitochondria, abnormal
tenocyte nuclei, and occasional intracytoplasmic or
mitochondrial calcium deposition. I n advanced degen-
eration, hypoxic or lipid vacuoles and necrosis may be
observed. Aberrant collagen fibers also can be seen,
with abnormal variations in the diameter, angulation,
splitting, and disintegration of the fibers. Kannus and
Jzsa also noted vascular changes, mostly luminal nar-
rowing due to hypertrophy of the arterial intima and
media, in vessels of the tendon and paratenon in 62
percent of the 891 ruptures. Alterations in blood flow,
subsequent hypoxia, and impaired metabolism may
have been factors in the development of the degener-
ative changes observed in the ruptured tendons
87
. The
interval between the rupture and the repair was short
enough to suggest that the degenerative changes were
preexisting.
Failure of the cellular matrix also may lead to in-
tratendinous degeneration
103
. Jzsa et al.
82
observed fi-
bronectin on the torn surfaces of ruptured Achilles
tendons. Fibronectin normally is located in basement
membranes, is present in a soluble form in plasma, and
binds more readily to denatured collagen than to nor-
mal collagen
48
, indicating preexisting denaturation of
collagen.
Presentation and Diagnosis
Patients who have a rupture of the Achilles tendon
typically are first seen with a history of sudden pain in
the affected leg, and they often report that, at the time
of the injury, they thought that they had been struck by
an object or kicked in the posterior aspect of the distal
part of the leg. Some patients report an audible snap.
They often are unable to bear weight and notice weak-
ness or stiffness of the affected ankle
44
. Rupture of the
Achilles tendon may be associated with insufficient
warm-up exercises before sports
61
, with the injury occur-
ring late in a game. Patients who have a chronically
ruptured Achilles tendon also tend to have a fairly typ-
ical history; they often recall only very minor or perhaps
no trauma and that they first noticed the injury because
of an inability to complete everyday tasks such as climb-
ing stairs
67
.
Examination may reveal diffuse edema and bruis-
ing
44
, and, unless the swelling is severe, a palpable gap
may be felt along the course of the tendon
44
. The site of
the rupture is usually two to six centimeters proximal
to the insertion of the tendon
44
. Krueger-Franke et al.
98
measured the location of the rupture intraoperatively in
303 patients and ascertained that, on the average, it was
4.78 centimeters proximal to the insertion of the tendon
on the calcaneus.
I n general, rupture of the Achilles tendon does not
pose diagnostic problems
124
. However, even in teaching
centers, it is not uncommon to find that more than 20
percent of such injuries (sixteen of seventy-three in one
study
74
) are missed by the first doctor to examine the
patient. There are a number of diagnostic signs and tests,
both clinical and radiographic, that the examiner may
use to aid in diagnosis.
Clinical Tests
Calf-squeeze test: The description of the calf-squeeze
test is often credited to Thompson
120,122,123
, who described
the test in 1962
179,180
, five years after Simmonds
166
. With
the patient prone on the examining table and the an-
kles clear of the table, the examiner squeezes the fleshy
part of the calf. Squeezing the calf deforms the soleus
muscle, causing the overlying Achilles tendon to bow
away from the tibia, resulting in plantar flexion of the
ankle if the tendon is intact
162
. The affected leg should
always be compared with the contralateral leg
166
. A false-
positive finding may occur in the presence of an in-
tact plantaris tendon, although this has not been proved
scientifically.
Knee-flexion test: The patient is asked to actively flex
the knees to 90 degrees while lying prone on the exam-
ining table. During this movement, if the foot on the
affected side falls into neutral or dorsiflexion, a rupture
of the Achilles tendon can be diagnosed
130
.
Needle test: A hypodermic needle is inserted through
the skin of the calf, just medial to the midline and ten
centimeters proximal to the insertion of the tendon. The
needle is inserted until its tip is just within the substance
of the tendon. The ankle is then alternately placed in
plantar flexion and dorsiflexion. I f, on dorsiflexion, the
needle points distally, the portion of the tendon distal to
the needle is presumed to be intact. I f the needle points
proximally, there is presumed to be a loss of continuity
between the needle and the site of the insertion of the
tendon
139
.
Sphygmomanometer test: For this test, a sphygmo-
manometer cuff is wrapped around the midpart of the
calf while the patient is lying prone. The cuff is inflated
to 100 millimeters of mercury (13.33 kilopascals) with
the foot in plantar flexion. The foot is then dorsiflexed.
I f the pressure rises to approximately 140 millimeters
of mercury (18.66 kilopascals), the musculotendinous
unit is presumed to be intact. I f, however, the pressure
remains at around 100 millimeters of mercury (13.33
kilopascals), then a rupture of the Achilles tendon may
be diagnosed
36
.
A recent study of 174 patients managed at our in-
stitution because of a rupture of the Achilles tendon
demonstrated little or no difference in the predictive
values among the just described tests
125
. The diagnosis of
complete rupture of the Achilles tendon was certain if
the results of at least two of these clinical tests were
positive
125
.
I maging
Plain radiography: Lateral radiographs of the ankle
have been used to diagnose a rupture of the Achilles
tendon. When the Achilles tendon is ruptured, Kagers
triangle
85
, the fat-filled triangular space anterior to the
Achilles tendon and between the posterior aspect of
the tibia and the superior aspect of the calcaneus, loses
its regular configuration. Toygars sign
181
involves mea-
surement of the angle of the posterior skin-surface
curve seen on plain radiographs, as the ends of the ten-
don are displaced anteriorly after a complete tear. The
posterior aspect of Kagers triangle then approaches
the anterior aspect, and the triangle decreases or disap-
pears. An angle of 130 to 150 degrees indicates a rupture
of the Achilles tendon. Arner et al.
6
found that deforma-
tion of the contours of the distal segment of the ten-
don resulting from loss of tone was the radiographic
change most likely to be associated with rupture of the
Achilles tendon.
I n general, clinical examination is sufficient for a
diagnosis of acute rupture of the Achilles tendon. Rup-
tures that are more long-standing may be harder to
diagnose because of associated tissue swelling. Real-
time high-resolution ultrasonography and magnetic res-
onance imaging provide an adjunct to clinical diagnosis,
and they are more sensitive and less invasive than soft-
tissue radiography or xeroradiography
122,123
.
Ultrasonography: Ultrasonography of the Achilles
tendon with linear probes produces a dynamic and pan-
oramic image of the tendon
37
, the appearance of which
varies with the type of transducer that is used and
the angle of the ultrasound beam with respect to the
tendon
117
. High-frequency probes of 7.5 to 10.0 mega-
hertz provide the best resolution, but they have a short
focusing distance
51
. The Achilles tendon is composed
of longitudinally arranged collagen bundles, which re-
flect the ultrasound beam. The probe should be held
at right angles to the tendon to ensure that an optimum
amount of ultrasonic energy is returned to the trans-
ducer
37
, avoiding the production of artifacts
51
. Linear-
array transducers, therefore, are better suited than
sector-type transducers, which produce excess obliquity
of the ultrasound beam at the edges. I t also may be
necessary to use a synthetic gel spacer or stand-off pad,
which increases the definition of the surface echoes
and allows a suitable support
12
. A normal Achilles ten-
don appears as a hypoechogenic, ribbon-like image that
is contained within two hyperechogenic bands. Tendon
fascicles appear as alternate hypoechogenic and hy-
perechogenic bands that are separated when the ten-
don is relaxed and are more compact when the tendon
is strained
12
. Men have slightly thicker tendons than
women
86
. Rupture of the Achilles tendon is seen on
ultrasonography scans as an acoustic vacuum with
thick, irregular edges
10,118
. Campani et al.
25
conducted
170 ultrasonographic examinations for various types
of traumatic injury of the lower limb. The Achilles ten-
don had the highest percentage of positive findings (75
percent); in comparison, only 38 percent of the findings
in the thigh were positive for a lesion. I n a study that
I did with two colleagues, we showed that ultrasonog-
raphy is a suitable tool for assessing the structure of
the tendon after operative repair
119
. Ultrasonography
also can be used to study the elastic properties of
the tendon; this is done by measuring the distance be-
tween an intratendinous hypoechogenic or hyperecho-
genic point and the calcaneus and by assessing how
this distance changes with different forces exerted by
the gastrocnemius-soleus complex
55
.
Magnetic resonance imaging: The normal Achilles
tendon is seen as an area of low signal intensity on all
pulse sequences. The tendon is well delineated by the
high signal intensity of the fat pad of Kagers triangle
85
.
Any increase in intratendinous signal intensity should
be regarded as abnormal
43
. T1 and T2-weighted im-
ages in the axial and sagittal planes should be used to
evaluate suspected ruptures of the Achilles tendon. On
T1-weighted images, a complete rupture of the Achil-
les tendon is identified as a disruption of the signal
within the tendon. On T2-weighted images, the rup-
ture is demonstrated as a generalized increase in sig-
nal intensity and the edema and hemorrhage at the
site of the rupture is seen as an area of high signal
intensity
84
.
VOL. 81-A, NO. 7, JULY 1999
Treatment of Acute Rupture
of the Achilles Tendon
The many techniques and procedures described for
the treatment of an acutely ruptured Achilles tendon can
be grouped under three headings: open operative, per-
cutaneous operative, and nonoperative. As there is no
agreed-on protocol, the choice of treatment regimen is
still based largely on the preference of the surgeon and
the patient
108
. Nonoperative treatment has its support-
ers, but operative treatment has been the method of
choice in the last two decades for athletes and young
people and for patients who have a rupture for which
treatment has been delayed. Acute ruptures in nonath-
letes may be treated nonoperatively. For example, in a
prospective, randomized trial, forty patients who had an
acute complete rupture of the Achilles tendon were al-
located either to immobilization in a cast for eight weeks
or to immobilization in a cast for three weeks followed
by controlled early mobilization in a Sheffield splint,
which is an ankle-foot orthosis that holds the ankle in
15 degrees of plantar flexion but allows some movement
at the metatarsophalangeal joints
159
. The splint allows
controlled motion of the ankle during physiotherapy.
Patients managed with the splint regained mobility no-
tably faster and preferred the splint to the plaster cast.
The range of dorsiflexion of the ankle improved more
rapidly after treatment with the splint, and patients were
able to return to normal activities sooner. Recovery
of plantar flexion power was similar in the two groups,
and no patient had excessive lengthening of the tendon.
One repeat rupture occurred in each group
159
.
Open Operative Repair
The many operative techniques used to repair rup-
tured Achilles tendons range from simple end-to-end
suturing, with Bunnell or Kessler-type sutures, to more
complex repairs with use of fascial reinforcement or
tendon grafts
169
. Artificial tendon implants, with use of
materials such as absorbable polymer-carbon fiber com-
posites
141
, Marlex mesh (monofilament knitted polypro-
pylene)
72,140
, and collagen tendon prostheses
89
, have been
used. End-to-end suturing, which can be performed
with local anesthesia
163
, has been modified by use of ma-
terials such as Dacron vascular graft, which is passed
through the tendon in a Bunnell-type fashion
109
. Studies
of dogs have shown that Dacron supports the growth of
fibrous tissue
133
and facilitates the approximation of the
ends of the tendon, causing less tension at the repair site
than standard sutures
109
. However, maturation of colla-
gen may be favorably influenced by cyclical tensional
stimuli
131
. Therefore, lack of tension on the repair site
may not be advantageous.
Several authors have opposed operative repair, not-
ing that the high rate of complications is the main disad-
vantage
26,59,102,137,172,173
. Arner and Lindholm
8
, in a series of
eighty-six operative repairs of ruptured Achilles ten-
dons, reported a 24 percent rate of complications, in-
cluding two instances of deep-vein thrombosis, one of
which resulted in pulmonary embolism and death; three
wound infections; eleven instances of wound necrosis;
and four repeat ruptures. More recent studies have dem-
onstrated a much lower rate of complications. Soldatis
et al.
167
, in a study of twenty-three patients who had
operative repair, reported only two complications, both
delayed wound-healing. The explanation for this low
rate of complications may be greater operative experi-
ence combined with improved technique. However,
wound problems should not be unexpected when open
repair is used, as the most commonly used longitudinal
incision passes through poorly vascularized skin
63
(Fig.
3). I n a study of forty patients, Aldam
1
used a transverse
incision just distal to the gap in the tendon and reported
only one wound breakdown.
Several authors have proposed primary augmenta-
tion of the repair
177
with the plantaris tendon
112,148
, the
peroneus tendon
142
, a single central gastrocnemius fas-
cial turndown flap
21
, or two such flaps (one medial and
one lateral)
110
. However, there is no evidence that pri-
mary augmentation of a repair of an acute rupture of
the Achilles tendon is any better than nonaugmented
end-to-end repair
79
. I prefer to use augmentation in de-
layed repairs and in the treatment of repeat ruptures.
After the operation, the leg is immobilized in a cast
for four to six weeks
31,175
. Some surgeons have advocated
the use of a functional orthosis after several days of
immobilization in a cast. This orthosis allows plantar
flexion but restricts dorsiflexion and is designed to help
to prevent atrophy of the triceps surae
28,160
. Some sur-
geons allow free motion of the ankle but no weight-
bearing after operative repair
134,168
.
There is a never-ending controversy regarding the
use of open operative techniques to manage subcutane-
ous ruptures of the Achilles tendon, with some investi-
Photograph showing breakdown of the wound after operative
repair of a rupture of the Achilles tendon. The patient had removed
the cast against medical advice at four weeks after the operation and
had returned to playing volleyball. At his first jump, the skin broke
down.
FI G. 3
gators reporting a high overall rate of complications
20,58,77
and others noting few complications
30,60,71
and a low rate
of repeat rupture
17,41,75
.
Percutaneous Repair
Ma and Griffith
116
developed a method for percuta-
neous repair as a compromise between open operative
methods and nonoperative treatment. The technique in-
volves producing six small stab incisions along the medial
and lateral borders of the tendon and then passing a
suture through the tendon with use of these incisions. I n
a small series of eighteen patients managed with this
technique, Ma and Griffith reported only two minor,
noninfectious skin complications and no repeat ruptures.
Rowley and Scotland
155
described twenty-four patients
at our center who had a rupture of the Achilles ten-
don; fourteen were managed with immobilization in a
cast alone, with the ankle in the equinus position, and
ten were managed with percutaneous repair. One pa-
tient who had percutaneous repair had entrapment of
the sural nerve, but no other complications were en-
countered. The patients who were managed with su-
tures were more likely to regain nearly normal plantar
flexion strength, and they also returned to activity
sooner than the group managed with a cast alone. Other
authors have reported a much lower success rate with
this technique. Klein et al.
94
reported sural nerve entrap-
ment in 13 percent of thirty-eight patients. Hockenbury
and Johns
70
compared in vitro percutaneous repair of
the Achilles tendon and open repair of the Achilles ten-
don with use of a transverse tenotomy of the Achilles
tendon in ten fresh-frozen below-the-knee specimens
from cadavera. The specimens were divided into two
groups of five specimens each; one group had open repair
of the Achilles tendon with use of the Bunnell suture
technique, and the other had percutaneous repair with
use of the technique of Ma and Griffith
116
. The tendons
that were repaired with an open technique were able to
resist almost twice the amount of ankle dorsiflexion
before a ten-millimeter gap appeared in the repaired
tendon compared with those that were repaired with a
percutaneous technique (a mean of 27.6 degrees com-
pared with a mean of 14.4 degrees; p < 0.05). Entrap-
ment of the sural nerve occurred in three of the five
specimens that had percutaneous repair. The tendon
stumps sutured with use of the percutaneous technique
were malaligned in four of the five specimens. On the
basis of the findings in that study, it appears that percuta-
neous repair of a ruptured Achilles tendon provides ap-
proximately 50 percent of the initial strength afforded by
open repair and places the sural nerve at risk for injury.
Percutaneously repaired Achilles tendons are less
thick than are those repaired with open procedures, and
some patients may prefer the better appearance that
this may afford
23
. Overall, most studies have demon-
strated that the rate of repeat rupture after percuta-
neous repair is higher than that after open operative
repair
3,23
. Also, disturbingly high rates of transfixion of
the sural nerve have been reported
70,155,171
, with persis-
tent paresthesias and the necessity of a formal operative
exploration to remove the suture and free the nerve
50,94
.
Nonoperative Treatment
The most commonly used form of nonoperative treat-
ment is immobilization in a plaster cast, usually for a
period of six to eight weeks
31
. I mmobilization has been
advocated by those who think that it produces re-
sults similar to those achieved with operative treat-
ment
26,59,102,137,172,173
. When the Achilles tendon ruptures, the
paratenon generally remains intact
172
. Stripping of the
paratenon during an operation reduces the amount of
reactive tissue that is produced later at the site of the
injury
172
. Those authors have therefore suggested that
operative repair of a ruptured Achilles tendon should
be avoided, as the paratenon provides a valuable blood
supply to the damaged tendon. Lea and Smith
102
, in a
study of fifty-five spontaneously ruptured Achilles ten-
dons treated with eight weeks of immobilization in a
plaster cast, reported that seven (13 percent) of the
patients had a repeat rupture and only three patients
were dissatisfied with the result. These results contrast
sharply with those of Persson and Wredmark
143
, who
reported on twenty patients who were managed non-
operatively. Seven patients had a repeat rupture, and
seven patients not necessarily those who had a re-
peat rupture were not satisfied with the result. Al-
though function after nonoperative repair is generally
good, the high prevalence of repeat rupture is consid-
ered unacceptable. A primary goal of the treatment of
a rupture of the Achilles tendon is to avoid lengthen-
ing of the tendon, and this cannot be achieved with
nonoperative treatment
169
.
Recently, on the basis of results reported with use
of functional postoperative bracing
28
, McComis et al.
113
managed fifteen patients nonoperatively with a func-
tional bracing protocol to repair a rupture of the Achilles
tendon. They achieved good functional results, proving
that, for selected patients, nonoperative functional brac-
ing may be a viable alternative to operative intervention
or to use of a plaster cast for the treatment of an acute
rupture of the Achilles tendon.
Some patients, especially those who are elderly, may
be seen with a long-standing rupture that has been dis-
covered by chance. These patients often adapt well to
the disability, but they are warned that an operation may
be necessary if the symptoms caused by the rupture of
the Achilles tendon worsen. Such patients are followed
at regular intervals, but they usually do not need addi-
tional treatment
125
.
Physiological Effects of Immobilization
After a Rupture of the Achilles Tendon
The cross-sectional area of a muscle is directly re-
lated to the muscle force that the muscle can develop
64,73
,
VOL. 81-A, NO. 7, JULY 1999
and immobilization results in a profound alteration of
the morphological and physiological characteristics of a
muscle
147
. The soleus muscle appears to be particularly
susceptible to the effects of immobilization, whereas
the gastrocnemius, a biarticular muscle, is able to move
when a below-the-knee cast is used and thus is less
affected. The human soleus contains a high proportion
of type-I muscle fibers
64
, which are particularly suscep-
tible to atrophy if immobilized, as they are responsible
for postural tone and are continually activated while
the person is standing
184
. When the leg is immobilized,
the muscle spindle relaxes and afferent impulses to
type-I fibers cease, causing them to atrophy. The Achil-
les tendon is susceptible to the effects of prolonged
immobilization
88
. Problems due to immobilization occur
after open operative repair as well as after percutaneous
repair, but not to the same extent. Hggmark et al.
65
reported on fifteen subcutaneous ruptures of the Achil-
les tendon that were treated operatively and eight that
were treated nonoperatively. They found a significant
decrease in the circumference of the calf in the group
that was treated nonoperatively (p < 0.01), whereas the
group that was treated operatively showed no signifi-
cant difference between the injured and the uninjured
calf. Patients who have an open operative or percutane-
ous repair wear a plaster cast for less time
31
than do
those managed nonoperatively and on the whole are
often more serious athletes who comply well with post-
operative management regimens. The lack of tension on
the immobilized musculotendinous unit is a major fac-
tor in the development of atrophy in the calf
31
. I f opti-
mum results from a repair of a ruptured Achilles tendon
are necessary, the site of the repair should be put under
as much tension as possible as early as possible
64
and the
cast should be changed regularly, decreasing the angle
of plantar flexion as much as possible each time.
A viable alternative is immobilization of the foot
and ankle in a plantigrade position
149
. This minimizes the
number of changes of the plaster cast as well as the
discomfort at the time of the changes when the ankle
must be progressively dorsiflexed. I t requires a suffi-
ciently strong repair that can be subjected to early ten-
sile stresses.
Operative Compared with Nonoperative Treatment
The results after operative treatment of ruptured
Achilles tendons often have been compared with those
after nonoperative treatment, but only a few well con-
trolled, prospective, randomized trials have been con-
ducted
31,137,193
. A major problem is the lack of a valid,
reliable, reproducible protocol for subjective and objec-
tive evaluation of the results of repair of a ruptured
Achilles tendon
107
.
Gillies and Chalmers
59
measured plantar flexion
strength after operative and nonoperative treatment of
a rupture of the Achilles tendon. Little difference was
found between the two groups, and the results of the
operation were not sufficiently superior to warrant
the risk associated with use of anesthesia and an oper-
ation. I nglis et al.
74
followed forty-four patients who had
been managed operatively and twenty-three who had
been managed nonoperatively. No repeat ruptures oc-
curred in the patients who had been managed opera-
tively, but nine (39 percent) of the patients managed
nonoperatively had a repeat rupture. Strength-testing
revealed superior strength, power, and endurance after
operative treatment, and the authors advocated the
use of this type of management. Nistor
137
conducted a
prospective, randomized trial that included 105 pa-
tients; forty-five had operative management, and sixty
had nonoperative management. The rate of repeat rup-
ture in the group managed operatively was 4 percent
compared with 8 percent in the group managed non-
operatively. However, there were a large number of
secondary complications in the group that had an oper-
ation. The patients who were managed nonoperatively
were found to have less absence from work, less ankle
stiffness, and similar strength compared with the opera-
tively managed group. Nistor recommended nonopera-
tive management, as there were only minor functional
differences between the two groups and the operation
caused more complications. I n a study by Carden et al.
26
,
seventy-six patients were managed nonoperatively and
fifty-six were managed operatively. The patients who
were seen less than forty-eight hours after the injury
were compared with those who were seen more than
forty-eight hours after the injury. The overall rate of
complications was 4 percent in the group managed non-
operatively compared with 17 percent in the group
managed operatively. The subjective results were also
better in the group managed nonoperatively. The au-
thors concluded that patients who are seen less than
forty-eight hours after the injury should be managed
nonoperatively, with eight weeks of immobilization in a
cast, whereas patients who are seen one week or more
after the injury should be managed operatively.
I n a randomized trial, twenty-two patients who had
operative management were compared with twenty-
eight who had nonoperative management; both groups
had functional treatment with a newly developed boot
178
.
No significant differences were found between the
groups with respect to either the functional results or
the course of healing. The functional treatment in both
groups allowed shorter periods of rehabilitation.
Kellam et al.
90
performed a review of the literature
and identified 609 patients who had been managed
operatively and 208 who had been managed non-
operatively. The rate of repeat rupture was 1 percent for
the patients who had had an operation compared with
18 percent for the patients who had had nonoperative
management. Also, 83 percent of the patients managed
operatively and 69 percent of those managed with im-
mobilization in a cast returned to the preinjury level
of activity. I n addition, 93 percent of the patients man-
aged operatively and 66 percent of those managed non-
operatively were satisfied with the result of treatment.
Cetti et al.
31
, in a prospective, randomized study, re-
ported on fifty-six patients who were managed opera-
tively and fifty-five who were managed nonoperatively.
The rates of complications and repeat ruptures were
9 and 5 percent, respectively, for the patients man-
aged operatively compared with 16 and 15 percent,
respectively, for the patients who were managed non-
operatively. The differences between the groups, how-
ever, were not found to be significant. The authors also
conducted a review of the literature and identified 4597
ruptures of the Achilles tendon. Operative treatment
of the ruptures was associated with lower rates of com-
plications and repeat ruptures than was nonoperative
treatment. Cetti et al. concluded that operative treat-
ment was the method of choice, but nonoperative treat-
ment was an acceptable alternative.
Recently, Lo et al.
111
performed a quantitative re-
view of all of the studies on the treatment of rupture of
the Achilles tendon in the English-language literature
published between 1959 and 1997 to determine the op-
timum treatment of acute ruptures. All of the identi-
fied articles were reviewed independently by at least
three of the four authors to decide the eligibility of each
study on the basis of predetermined criteria. Eligible
studies were reviewed independently, and the data were
extracted with use of standardized coding forms. I n-
consistencies in data extraction were settled by discus-
sion and majority vote. The main outcomes extracted
were strength, time until the patient returned to work,
frequency of return to sports, rate of repeat rupture,
and complications. Complications were classified as ma-
jor, moderate, or minor. Lo et al. identified a total of
742 patients who were managed operatively and 248
patients who were managed nonoperatively. The over-
all rate of repeat rupture was 3 percent for those man-
aged operatively and 12 percent for those managed
nonoperatively (p < 0.001). Although the rate of repeat
rupture after operative treatment was lower than that
after nonoperative treatment, the rate of minor and
moderate complications associated with operative treat-
ment was twenty times greater in some reports (Fig. 4).
I n summary, treatment should be individualized ac-
cording to the concerns and health of the patient. I f
optimum performance is necessary, operative manage-
ment is probably the treatment of choice. Operative
management should be used in athletes and in patients
who have a high level of physical activity. Percutaneous
repair should be considered for patients who do not
wish to have open repair, possibly for cosmetic reasons
or perhaps because they view an open operative repair
as a more serious procedure
160
. Nonoperative treatment
should be reserved for older patients who are unlikely
to derive any major benefit from an operative proce-
dure and for patients who view an operation as an un-
necessary risk.
Treatment of an Older Rupture
of the Achilles Tendon
When patients are operated on within seventy-two
hours after the injury, it is usually possible to suture the
Photograph showing a repeat rupture in a fifty-four-year-old man who was originally managed nonoperatively. The repeat rupture occurred
when the patient stumbled on a step as he was going to work seven months after the original injury. Note the presence of the plantaris longus
tendon.
FI G. 4
VOL. 81-A, NO. 7, JULY 1999
stumps of the tendon in an end-to-end fashion
121
. How-
ever, more than 20 percent of patients who have a rup-
ture of the Achilles tendon may be diagnosed late
122
.
I n these instances, young and middle-aged patients gen-
erally are first seen with a limp and severe impairment
in the performance of day-to-day activities. When, af-
ter trimming, the tendon stumps cannot be approxi-
mated without undue tension (Fig. 5), the gap can be
bridged with a single central gastrocnemius fascial turn-
down flap
21
or with two such flaps (one medial and one
lateral)
110
. I f it is available, the tendon of the plantaris
longus can be used as a reinforcing membrane
112
.
When a patient has an extreme rupture, in which the
gap resulting from the rupture of degenerated tissue
does not allow direct suture, the tendons of the tibialis
posterior and peroneus brevis can be split longitudinally
and used as pedicled transplants. The plantaris tendon
is used as reinforcement, and the construct is augmented
by a turndown flap of the superficial aponeurosis of the
gastrocnemius
52
.
More recently, Wapner et al.
185,186
used a transfer of
the flexor hallucis longus muscle and tendon to pro-
vide a dynamic repair. The procedure was performed on
seven patients with a mean age of fifty-two years. Af-
ter a mean of seventeen months (range, three to thirty
months), there were no postoperative infections, loss of
skin, or repeat ruptures. Each patient had a small loss in
the range of motion of the involved ankle and hallux,
but it was of no functional importance. All patients were
satisfied with the functional result, although one needed
a molded foot-ankle orthosis for prolonged walking
185
.
When the gap between the ends of the tendon is
such that the ends cannot be juxtaposed, the gap can be
bridged by Marlex (monofilament knitted polypropyl-
ene) or Dexon (polyglycolic acid) mesh
72,140
, and tendon
graft can be used to cover the mesh. Postoperatively, the
patients should be managed more conservatively, with
restricted weight-bearing and immobilization in a plas-
ter cast for eight weeks instead of six weeks.
Postoperative Care
Normally, patients are discharged on the day of the
operation or the next day, after an orthopaedic phys-
iotherapist has instructed them regarding the use of
crutches
111.125
. Patients are allowed to bear weight on the
involved leg as tolerated, but they should be told to keep
the affected leg elevated for as long as possible to pre-
vent postoperative swelling
121
. Patients are followed on
an outpatient basis at two-week intervals, and the cast
is removed six weeks after the operation
119,121,125
. I f the
cast has been applied with the ankle in the equinus
position, the cast is changed at two and four weeks, with
the ankle placed in gradually increasing dorsiflexion
until a plantigrade position is reached. The cast is re-
moved altogether six weeks after the operation
119
.
Patients are allowed partial weight-bearing and
gradual stretching and strengthening exercises, increas-
ing the frequency as tolerated, only after removal of
the cast
119
. Gradually, patients proceed to full weight-
bearing at eight to ten weeks after the operation.
During the period of immobilization in the cast,
patients are instructed to perform gentle isometric con-
tractions of the gastrocnemius-soleus complex after
weight-bearing has become comfortable
119
. After re-
moval of the cast, patients mobilize the ankle under the
guidance of the physiotherapist. Two weeks after re-
Photograph showing a rupture that had been unrecognized for four months in a forty-seven-year-old male farmworker. Note the hyper-
trophic paratenon and the rounded-off tendon stump.
FI G. 5
moval of the cast, cycling and swimming are started and
the mobilization exercises of the ankle are continued.
Patients are prompted to increase the frequency of the
self-administered exercise program. Patients are nor-
mally able to return to sports activities in the third or
fourth postoperative month.
Postoperative Management of Athletes
Treatment that avoids immobilization of the ankle
should be considered for athletes and well motivated,
reliable patients. These patients are managed with an
anterior below-the-knee plaster-of-Paris slab applied
with the ankle in gravity equinus
28
. Patients are dis-
charged on the day of the operation or the day after, and
they are allowed toe-touch weight-bearing on the in-
volved limb as tolerated. They are instructed to keep the
involved leg elevated for as long as possible. At forty-
eight to seventy-two hours after the operation, by which
time the postoperative swelling (if any) has substan-
tially decreased, the anterior below-the-knee plaster-of-
Paris slab is changed to an anterior below-the-knee
synthetic slab with the ankle in gravity equinus. The slab
is kept in place by an elastic bandage, which allows
plantar flexion of the ankle, while dorsiflexion is lim-
ited by the foot-piece of the slab
28
. Patients are allowed
weight-bearing as tolerated, with use of crutches. The
slab is changed at the second and fourth postoperative
weeks, so that the ankle can dorsiflex to neutral by the
fourth postoperative week. The limitation of dorsiflex-
ion is continued for a total of six weeks, at which time
the slab is removed. High-level, well motivated athletes
who comply with the postoperative protocol normally
are able to return to sports activities six to eight weeks
after the removal of the anterior slab. A hinged orthosis
could be used as an alternative to the anterior slab
129
.
However, it is more expensive than a simple synthetic
cast, although it is reusable.
Solveborn and Moberg
168
prospectively studied sev-
enteen consecutively managed patients (fifteen men
and two women) who had operative repair of a subcu-
taneous, complete acute rupture of the Achilles tendon.
The patients were managed with a new postoperative
regimen that allowed free motion of the ankle in a pa-
tellar ligament-bearing cast that had a protective frame
under the foot to permit weight-bearing immediately
after the operation. Early free motion of the ankle after
repair of a ruptured Achilles tendon proved to be safe,
with satisfactory clinical results.
Overview
The etiology of what would appear to be a simple
condition still has not been completely clarified. Despite
extensive investigation, few definitive answers have
been found. The lack of study of human tissue is an
important problem, but it is difficult to see how this
could be overcome. I t is notable that animal models
of rupture of the Achilles tendon have relied mostly
on tenotomy
18,83,135
. The model developed by Barfred
13-15
hardly reflects clinical practice and has not found wide
application.
The treatment of acute rupture of the Achilles ten-
don depends on the preference of the individual sur-
geon. Open operative repair probably produces better
functional results than nonoperative management does,
but it may lead to a higher rate of postoperative com-
plications. Nonoperative management may result in a
poorer functional result, but the problems of postoper-
ative complications are avoided.
A major problem has been the lack of a universally
accepted system for scoring results of treatment of a
ruptured Achilles tendon. Leppilahti et al.
106,107
proposed
a scoring scale that included subjective assessment of
clinical factors and isokinetic evaluation of strength.
However, it has been used only by those authors
107
, and
isokinetic dynamometry is time-consuming, expensive,
and not widely available.
I f the reports that have described a rising incidence
of rupture of the Achilles tendon are accurate, the field
of operative repair of the Achilles tendon will become
an increasingly important one for orthopaedic surgeons.
Future developments may include the use of adhesives
in operations on the tendon
182
. An understanding of the
role that cytokines play in tendon-healing
32
also may
lead to new treatments, possibly based on gene ther-
apy
57
. However, such novel interventions are unlikely to
be in routine clinical use for some time.
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