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Achilles Tendon Rupture

Occurring in a sports-related injury in the middle-aged athlete, this tendon
rupture may well be overlooked, but it should always been suspected, even
though the patient may think that an ankle sprain has occurred. The
Thompson test, which consists of squeezing the calf and noting the foot
to plantar flex, is most useful. These injuries may be treated by conservative
means using a cast in plantar flexion or surgically by direct tendon
repair. Occasionally, a sudden pain in the calf may be interpreted as a
torn Achilles tendon, but more often only a few fibers of the gastrocnemius
tear, similar to the so-called ruptured plantaris. Rest, elevation, and/or
walking at first with an elevated heel amazingly relieve discomfort. Nonsteroidal
antiinflammatory drugs for prevention of deep venous thrombosis
may be added to the treatment regimen. (See Chapter 13 for further
details.)

History and Physical Examination

A complete medical and surgical history, the mechanism of injury, and the
duration of the symptoms should be elicited. The location and quality of
pain should be documented. Existing systemic disorders should be ruled
out, with an emphasis on diabetes and gout. Musculoskeletal history involving
the spine and lower extremities is helpful. A physical examination
should be done with both stockings and shoes removed. Gait patterns
should be determined with the patient walking both toward and away from
the examiner. The stance phase or station should be examined with emphasis
placed on the relationship of the hindfoot with the forefoot and longitudinal
arch. Once inspection has been completed, examination of the
bony and soft tissue structures follows. The area should be examined for
the presence of edema, effusion, skin temperature changes, and previous
sites of surgery or trauma. Systemic examination can be divided into the
ankle, hindfoot, midfoot, and forefoot subgroups. When examining the
ankle, note any effusion. Range of motion of the ankle is normally 20
degrees of dorsiflexion and 40 to 50 degrees of plantarflexion. Loss of ankle
dorsiflexion may be associated with a tight Achilles tendon, posterior
capsular contracture, or bony impingement. Limitation of dorsiflexion with
the knee in full extension that improves passively with the knee flexed to
90 degrees indicates a contracture of the gastrocnemius muscle. Ligamentous
laxity should be evaluated in comparison with the contralateral ankle
joint, and palpation of the tendons should be performed to note evidence
of subluxation or dislocation. Midfoot examination involves selective palpation
of the bony anatomy to isolate specific joint or joint involvement.
Forefoot examination should include MTP joint motion with any documentation
of subluxation and pain.
Radiology of the Foot and Ankle
Radiographic studies of the foot and ankle require weight-bearing X-rays
when possible. Important views involve the anteroposterior (AP), lateral,
and oblique views of the foot, and AP, lateral, and mortise views of the
ankle. The AP view of the foot can be used to assess forefoot and midfoot
pathology. The lateral view of the foot shows the relationship of the talus
and calcaneus to that of the midfoot, forefoot, and ankle joint. The medial
oblique view is used to evaluate the lateral tarsometatarsal joints. Other
studies are available to assess the sesamoids, the calcaneus, or the subtalar
joint. The sesamoid view involves the X-ray beam directed tangential to
the plantar surface of the sesamoid region while the patient’s toes are in
hyperextension. The Harris axial heel view is used to assess the calcaneal
tuberosity and is important in calcaneus fractures or tarsal coalitions.
13. The Foot and Ankle 483
Ancillary radiographic studies include computed tomography (CT)
(Fig. 13-9), magnetic resonance imaging (MRI), and radionuclide studies.
MRI can be used to assess soft tissue structures such as soft tissue tumors,
osteomyelitis, avascular necrosis, bone tumors, chondral lesions, and
tendon abnormalities.

Ruptures of the Achilles tendon can be acute or chronic. These ruptures

commonly occur in middle-aged men at the hypovascular zone of the
Achilles tendon approximately 3 to 5 cm above its insertion site. Ruptures
occur because of forceful eccentric contraction of the elongating tendon;
they rarely result from direct trauma. Symptoms include severe pain at the
back of the calf. Patients often describe being hit in the back of the leg and
an audible “pop.” Diagnosis is made by a palpable defect above the Achilles
insertion with the patient in a prone position. Two findings are consistent
with rupture of the tendon. The first is loss of passive resting tension
in comparison to the opposite extremity, which causes the foot to be at a
right angle to the remainder of the lower extremity. The second finding is
performing the Thompson test, which is done with the patient’s foot
hanging over the edge of the examination table in a prone position. The
midcalf is squeezed. If the tendon is intact, the ankle passively plantarflexes.
If the tendon is ruptured, no plantarflexion occurs. In difficult cases, MRI
or ultrasound can confirm the diagnosis. Treatment of an acute rupture of
theAchilles tendon can be conservative or surgical. Nonoperative management
includes immobilization in a plantarflexed position, nonweightbearing,
for approximately 3 months; this should be reserved for elderly,
less active patients with a medical history that makes surgery dangerous.
Disadvantages of conservative management include a higher rerupture rate
than surgical repair. Surgical repair includes direct repair of the ends
of the Achilles tendon. Advantages include a lower rerupture rate than
conservative treatment. Disadvantages include wound complications,
infection, and sural nerve injury. Treatment of chronic neglected ruptures
includes bracing with an ankle-foot orthosis and other complex surgical
reconstructions including flexor hallucis longus tendon transfer.

Achilles Tendon Disorders

Disorders of the Achilles tendon include peritendonitis, tendinosis, partial
and complete rupture, and insertional tendonitis with retrocalcaneal bursitis.
Achilles tendonitis is painful inflammation and degeneration of either
the surrounding peritenon (peritendonitis) or tendon (tendinosis) or both
that occurs proximal to the insertion site of the Achilles in the calcaneus.
This condition is often seen in runners with tight Achilles tendons and
poor flexibility. Treatment is often conservative, with a period of immobilization
to allow inflammation to subside, followed by physical therapy and
stretching of the Achilles tendon daily. When conservative measures fail,
debridement of the Achilles tendon can be done surgically. When tendonitis
occurs at the Achilles tendon insertion onto the posterior aspect of the
calcaneus, it is called insertional Achilles tendonitis. Often, there is an
enlarged posterior superior calcaneal process called a Haglund’s deformity. This tendonitis is also
associated with a retrocalcaneal bursitis, which
is inflammation of the bursa directly anterior to the Achilles tendon at its
insertion. Conservative treatment includes a period of immobilization, heel
lifts to shorten the Achilles tendon and take the pressure off the insertion,
stretching exercises through physical therapy, and modification of shoe
wear. When conservative measures fail, surgery, with debridement of the
insertion and removal of the Haglund’s deformity as well as a reattachment
of the Achilles tendon, is done.