JFAS 31(6):548-559, 1992

Multiple Ruptures of the Tendo Achillis

An abundance of literature has been published regarding rupture of the tendo Achillis.
Certain studies review various options for management, while others focus on the
mechanisms and pathogenesis of injury. There are, however, significant differences in the
outcomes of these studies. This article reviews the basic anatomy of the tendo Achillis, as
well as the various parameters relating to the spontaneous rupture of this tendon. A case
study of a recurrent tendo Achillis rupture is also presented, to illustrate principles of
management of recurrent ruptures.

Kieran T. Mahan, MS, DPM, FACFS1

Steven R. Carter2

Anatomy

Although spontaneous rupture of the tendo Achillis is in general an uncommon

injury, a recent increase in incidence has been reported (1). The initial diagnosis is missed
as often as 25% of the time (2-4) which may lead to significant functional disability. The
tendo Achillis, the thickest and strongest tendon in the body, is formed by the distal
tendinous fibers of gastrocnemius and soleus. The tendon of plantaris may (rarely) take
part in the combined tendon, but more commonly remains as a separate tendon coursing
down the medial border of the tendo Achillis. The entire complex inserts into the middle
1/3 of the posterior aspect of the calcaneus (5).
The vascular supply to the tendo Achillis originates primarily from three sources.
Vessels coursing through the musculotendinous junction supply the proximal portion of
the tendon, while the distal segment is supplied by branches arising from the calcaneus
and its overlying periosteum. The third source of nutrition comes from the surrounding
peritenon. It has been shown by Lagergren and Lindholm (6) that there is a significant
decrease in the number of vessels supplying the middle portion of the tendon, which is
the area that most commonly ruptures. The vessels coursing through the peritenon are
evenly distributed along the entire length of the tendon.

Demographics

Spontaneous rupture of the tendo Achillis most often occurs in a section of tendon
2 to 6 cm. proximal to the insertion into the calcaneus (6). The majority of ruptures are
sustained by healthy, primarily sedentary adult males in their 4th or 5th decade of life
who occasionally engage in athletic activity. The left more frequently ruptures than the
right (7). Ingliss et al. (8) reported that the patients in their study rarely had pain in the
calf or heel prior to injury, while Fox et al. (9) reported that a significant number of the
patients in their study had complaints of chronic Achilles tendinitis prior to injury.
Pathology and Mechanism of Injury

It was reported by McMaster (10) that spontaneous rupture of a normal healthy

tendon can not occur. Under normal circumstances the tendon is the strongest link in the
muscle, tendon, and osseous insertion complex. In fact the musculotendinous junction
and osseous insertion possess only 8% to 10% of the strength of an uninjured tendon
(11). If an excessive mechanical load is applied to a normal healthy complex, the tendon
will be last to rupture. This study implies that the muscle belly, musculotendinous
junction, and insertion into the calcaneus are much more likely to sustain injury before
rupture of a healthy tendo Achillis. Various authors (12-14) state that regressive changes
within the substance of the tendo Achillis are a prerequisite for spontaneous rupture.
The most significant factor leading to spontaneous rupture of the tendo Achillis is
an inadequate blood supply relative to the tendon's nutritional demands. Blood supply to
the tendon is especially poor in the area 2 to 6 cm. proximal to its insertion,
corresponding to the area most frequently ruptured. Lagergren and Lindholm (6) have
shown that there is a significant decrease in the number of vessels within the central
portion of the Achilles tendon, when compared with the proximal and distal ends of the
tendon which show a relatively greater number of vessels.

______________________________________________________________
From the Pennsylvania College of Podiatric Medicine and St. Joseph's Hospital,
Philadelphia, Pennsylvania.
0449/2544/92/31 06-0548$03.00/0
Copyright © 1992 by The American College of Foot Surgeons

548

In addition, the flow of blood in the central portion of the tendon decreases as one ages
(6). The most significant decrease in blood flow occurs after the age of 30. Other studies
(9, 13) have demonstrated primary degenerative changes within the substance of the
ruptured tendon. These changes were identified as primary (not secondary to traumatic
tissue damage occurring at the time of injury) because of the degenerative character of
the changes. Biopsies taken the same day as injury (most taken within 12 hr of the
rupture) demonstrated degenerative lesions at the site of rupture and also in areas not
involved in the injury. Upon histologic examination the lesions were found to be necrotic,
and degenerative in nature, confirming the role of compromised circulation as the major
causative factor (13). Inflammatory and regenerative changes were also found but were
shown to be the result of the tendon's response to injury.
Spontaneous rupture of the tendo Achillis occurs due to a combination of primary
intratendinous degeneration and excessive mechanical forces. Some of the mechanical
forces that can cause rupture include:

1. Sudden dorsiflexion of a plantarflexed foot

 2. Pushing off the weightbearing forefoot while extending the ipsilateral knee
joint (2)
3. Sudden excess tension on a taut tendon
4. A taut tendon struck by a blunt object (7)

Most ruptures are sustained during some type of athletic activity, with basketball
being the sport most commonly implicated (9). Occasionally, apparently minor events
such as stumbling, tripping, walking, or running may be responsible (8). Blazina et al.
(15) have reported that repetitive microtrauma that occurs during athletic activities
produces reactive degenerative alterations within tendon substance. These changes are
degenerative in nature and may be localized or diffuse.
Biopsies of the tendo Achillis following rupture have demonstrated areas of
fibrosis, devitalization, and altered collagen stainability. A study by Fox et al. found that
a greater number of patients (22, n = 32) sustaining spontaneous ruptures had previous
complaints, whereas only 10 of the patients (n = 32) reported no pain or disability prior to
injury (9). Only 20% of the patients with no prior complaints demonstrated chronic
reactive changes, whereas 91% of the patients with chronic symptomatology exhibited
chronic reactive changes in the area of rupture, as well as in areas not involved in the
rupture. The chronic reactive changes included thickening of the peritenon, areas of
fibrinoid and myxomatous degeneration, fibrosis and metaplastic calcification (9).
Spontaneous ruptures of the tendo Achillis are thought to be secondary to degenerative
changes in the tendon substance, produced by poor nutrition and should not be viewed as
merely simple injuries (9).

Diagnosis

Tendo Achillis ruptures may be misdiagnosed, and when suspected must be

evaluated in a careful systematic fashion. The patient's symptoms and subjective
complaints are often misleading to the examiner. The patient is normally unable to stand
on tiptoes (16) but frequently has some ability to actively plantarflex against resistance,
albeit diminished. When nonweightbearing, the patient may appear to have a normal
ability to plantarflex at the ankle (7). The injured limb frequently exhibits an excessively
dorsiflexed foot due to muscular imbalance (7).
If the examination is carried out within a short time of the injury, a palpable gap
will be found overlying the injured area (17). Inspection of the patient's gait may reveal
an abnormal push-off of the affected limb (7). The patient may report only minor
discomfort, and in some instances, none at all. Patients frequently hear an audible snap
upon rupture of the tendon (7). After injury the local soft tissues become edematous with
concomitant filling of the gap by hematoma. These two factors make palpation of the gap
difficult, and contribute significantly to the high rate of misdiagnosis (18). Upon
examination, ruptures of the tendo Achillis are frequently diagnosed as being only partial
tears, because of the patient's ability to plantarflex the foot. However, upon surgical
inspection of the area, partial rupture is rarely the case, and a complete rupture is
normally found. The tendon of plantaris may also rupture, but may remain intact as a
small palpable medial band (17).
 A useful test in the diagnosis of tendo Achillis ruptures is the Thompson-Doherty
test. It is performed by placing the patient in the prone position, with the limb in question
extended out over the table. The calf is then squeezed about its midportion which will
elicit plantarflexion at the ankle if the tendon is intact. Lack of plantarflexion indicates a
positive test. This test has been reported to have almost 100% reliability (17).
A careful examination by the physician should produce the correct diagnosis with
special studies normally being unnecessary. However, certain signs may be evident on
plain film radiographs (19): 1) the definable borders of the tendon are less clear, 2) the
tendon ends appear enlarged, 3) a lack of continuity can be visualized, and 4) a posterior
gap in the soft tissues. If x-rays and clinical examination prove to be nondiagnostic a
(MRI) study may be considered. This modality is especially useful in cases of neglected
rupture and rerupture.

549

Almost all spontaneous ruptures are complete (13, 17). The diagnosis is
frequently missed due to the minor discomfort, lack of a palpable gap, and the continuing
ability of the patient to plantarflex the foot with the aid of the secondary musculature in
the deep posterior compartment of the leg (7).

Treatment

Numerous methods have been described for repair of the ruptured tendo Achillis.
Techniques can be broadly categorized into surgical and conservative treatment. Until the
early 1900s treatment was generally nonsurgical, consisting primarily of immobilization
through the use of various straps and braces. For the most part, early conservative
measures to repair tendo Achillis ruptures met with limited success.
Early surgical treatment was popularized by Abrahamsen (20) in 1923, Quenu and
Stoianovitch (21) in 1929, and Arner et al. (13) in 1959. Simple end-to-end repair may be
employed utilizing absorbable, nonabsorbable, or stainless steel pull-out wire suture (16,
22). Apposition of the proximal and distal fragments is usually not feasible because of
shreded tendon ends and a large interposing gap. Other techniques used for repair of a
ruptured tendo Achillis include gastrocnemius or tendo Achillis turn-down techniques (2,
23-25), fascia lata strips (26), reinforcement with the plantaris tendon (27-29),
reinforcement with peroneus brevis (30), direct suture under local anesthesia (31), closed
percutaneous repair (32, 33), repair utilizing carbon fiber scaffolds (34), and
gastrocnemius recession (35, 36) to allow end-to-end repair.

Conservative Treatment

The modern technique for conservative repair of tendo Achillis ruptures was first
described by Lea and Smith (37, 38), in 1968 and 1972. The proposed treatment consists
of eight weeks of immobilization with the foot casted in gravity equinus, being careful
that the foot is not actively plantarflexed. The patient is immediately allowed to bear
weight, with the use of crutches for the first few days. Following the immobilization
period, a 2.5-cm. heel lift is placed in the shoe for a period of 4 weeks, during which time
the patient can resume using the crutches for stability. Rehabilitation is also initiated.
This primarily focuses on triceps surae strengthening exercises. In 1970, Gillies and
Chalmers (39) proposed a similar method of treatment which consists of 4 weeks
immobilization in a below-the-knee cast with the foot in equinus. This is followed by 4
weeks in a short-leg walking cast with the foot in a semi-equinus position. After removal
of the cast, a 1.3-cm. lift is placed under the heel for another few weeks.

Complications

The most significant complication following conservative management of the

ruptured tendo Achillis is rerupture, which has been reported to occur in approximately
18% of patients (1). Other complications such as deep vein thrombosis (40) and
pulmonary embolus (2) have also been reported.
In general, higher complication rates, excluding rerupture, have been reported
with open repair. A review of the literature by Wills (1) showed a 20% (n = 775)
complication rate with open repair, and a 10% (n = 20) incidence of complications with
conservative treatment. Some of the complications following surgery include wound
infections (2, 8, 22, 24, 29, 39, 41, 42) tendon adhesions (22, 43) sural nerve damage (22,
25) and skin slough (25, 42, 44). Although extremely rare, serious complications such as
deep vein thrombosis (25) and pulmonary embolus (42) have been reported.

Conservative versus Surgical Repair

Wills et al. substantiated a significantly lower rate of rerupture with open repair of
tendo Achillis ruptures versus nonsurgical treatment. This does not consider the
technique of repair or immobilization. Reruptures following open repair are less than 2%,
whereas the rerupture rate of conservatively treated patients has been reported to be as
high as 18% (1).
Much controversy surrounds the initial treatment of spontaneous rupture of the
tendo Achillis in the otherwise healthy individual. The rate of rerupture following open
repair is significantly lower than that following conservative treatment. However,
surgical repair is associated with a higher rate of infection, skin slough, and scar
adhesions (1). Most complications of surgical repair are minor in overall significance and
have not been shown to affect overall outcome (1). It also should be noted that the
complication rate associated with surgical repair is much higher in earlier studies than in
more recent studies (1). Also, the rate of surgical complications for an individual surgeon
has been shown to significantly decrease as the surgeon gains more experience with open
repair. Ingliss et al. (8) state that in their first study of 150 patients there was a 17%
incidence of wound complications. In a later study of 48 patients, the complication rate
had dropped to 4%. They attribute this significant decrease in complications to improved
surgical technique (8). Kalish et al. (45) also stress the importance of individual surgeon
technique in minimizing postoperative complications.
550

Most of the postoperative complications can be avoided by gentle manipulation of the

soft tissues and a complete understanding of the surrounding anatomy (46).
The high incidence of rerupture following conservative treatment suggests that
open repair may be the treatment of choice unless it can be demonstrated that the
conservatively treated patient who experiences rerupture will eventually do as well
following open repair as those patients initially treated surgically (47).
The consideration of patient satisfaction and the ability to return to previous
activity are extremely important when evaluating surgical versus conservative treatment.
Ingliss et al. (8) report that 93% of the patients in their study who underwent initial open
repair were satisfied with their ultimate postoperative strength and functional ability to
return to their previous activities. Another study (47) reported only a 62.5% satisfaction
rate in patients undergoing open repair for rerupture of a previous conservatively treated
rupture. Those patients that underwent a delayed initial open repair of a neglected rupture
achieved greater objective and subjective postoperative results than the patients who
underwent open repair following conservative treatment failure (47). It has been reported
that patients with ruptures of the tendo Achillis overall achieved greater strength, power
and endurance when treated surgically, and were more satisfied overall on a functional
basis (8, 47).

Neglected ruptures

Rupture of the tendo Achillis is considered neglected if treatment is delayed for

four weeks or longer (8, 43). An important point to consider in treatment of neglected
ruptures is the significant intervening gap between the ruptured tendon segments. This
gap occurs due to contraction of the gastrocnemius soleus complex, with retraction of the
proximal tendon segment. The other factor leading to the interposed defect is that the
shredded tendon ends become enmeshed in scar tissue which must be sharply dissected
prior to repair of the tendon ends. These factors almost always preclude simple end-to-
end repair of the ruptured tendon fragments.
A study by Carden et al. (40) demonstrated a significant decrease in strength of
plantarflexion in patients who received delayed conservative treatment. In this group the
average plantarflexory strength was only 74% of that measured in the uninjured limb.
This is in contrast to those patients receiving delayed surgical treatment who retained an
average plantarflexory strength of 91 % compared with the uninjured limb.

Techniques for Repair of Neglected Ruptures

Most authors advocate surgical repair if the rupture is more than a few days old
(23, 26, 40, 41). Owing to the large intervening defect between the ruptured tendon
segments, various grafting procedures have been devised to restore the tendon continuity.
These techniques include the use of fascia lata grafts (26, 48, 49), tendon strips (2, 23),
plantaris tendon (28), and peroneus brevis (50). Modifications of these procedures
include single and double pull-out wire sutures for additional stability (3, 26). Various
lengthening procedures have also been devised for bridging the large intervening gap (35,
51, 52). Gastrocnemius recession is a viable alternative (53) for reduction of the
interposing gap and re-establishment of tendon continuity.

Reruptures

Most reruptures of the tendo Achillis occur shortly after the immobilization
period regardless of whether the initial injury was treated surgically or conservatively
(46). It is very uncommon for the tendo Achillis to rerupture more than 4 months after the
original injury (8, 36, 47, 54). Scar tissue forms a bridge between the tendon ends and
over time becomes more dense due to proliferation of the collagen bundles. The tensile
strength can exceed that of the uninjured tendon, but the injured tendon is deficient in its
resiliency and elasticity (55). As a result, reruptures, therefore, more often occur during
the 4-week period following removal of the cast because the fibrous bridge is
considerably weaker than the normal tendon at that time. During this period of
reorganization, the repair site is the weakest link in the muscle tendon complex (11).
In the first 2 to 3 weeks the strength at the repair site of any ruptured tendon
depends upon the suture material and the technique with which it was applied. However,
at 6 weeks following repair and thereafter, the fibrous bridge is responsible for
maintaining the bond at the site of rupture.
Most authors suggest open repair for reruptures regardless of the form of initial
treatment. One such method of open repair was described by Schuberth et al. (36) in
1984. This repair technique involved a tongue in groove method of tendon lengthening to
bridge the gap and restore tendon continuity. This technique was a modification of the
techniques described by Baker and Hill (56) and Fulp and McGlamry in 1974 for
lengthening the tendo Achillis for an equinus deformity (53).

551

Case Report

A 32-year-old Caucasian female presented to the Foot and Ankle Institute for re-
evaluation of a right tendo-Achillis rupture sustained the previous year while playing
tennis. Her primary complaints were right heel pain, lack of balance, fatigue in the thighs,
and pain on the lateral side of the right foot. The patient was 2 months pregnant at the
time of the initial injury. She was treated conservatively with the application of a below-
the-knee cast for a period of 6 weeks. The casting period was followed by physical
therapy for a period of several weeks. Two weeks after completion of the casting the
patient felt something "pop" in her heel cord during therapy. She received no further
treatment. Past medical history included a Cesarian section, with hospitalization of 5 days
and no subsequent complications. At the time of presentation the patient was taking no
medications and denied any allergies.
Physical examination revealed an intact but elongated right tendo Achillis, with a
painful fibrous mass immediately proximal to its insertion. The patient was unable to
stand on her toes and exhibited mild flexor substitution of the right foot. An apropulsive
gait was demonstrated on the right. Thirty-five degrees of dorsiflexion at the right ankle
was demonstrated with the knee extended and with the knee flexed. Only 5° of
dorsiflexion was noted at the left ankle with the knee extended, and 10° with the knee
flexed. The patient demonstrated normal strength in all muscles (+5/5) tested, except for
the right posterior group which exhibited diminished strength (-4/5). Xeroradiographs of
the right leg were taken rather than conventional x-rays in order to yield improved soft
tissue resolution. These views revealed a hypertrophic fibrous tissue mass at the rupture
site with no gaps in the continuity of the tendon. It was determined that the right tendo
Achillis had healed in an overlengthened position, which had resulted in compensatory
pathologic gait with concomitant flexor and peroneal substitution.
It was recommended to the patient that the right tendo Achillis be shortened to
restore muscle function. The proposed surgery was performed 2 months later at a local
hospital.

Operative Technique

The patient was brought to surgery where she was placed in the prone position,
and general anesthesia was induced. Hemostasis was provided with the use of a thigh cuff
inflated to 400 mm. Hg. A longitudinal incision was placed along the posterior aspect of
the leg, medial to the midline. The incision was then carried down to the level of the
subcutaneous fat, within which the sural nerve was identified and protected. The
superficial fascia was carefully separated from the underlying deep fascia. Attention was
directed to the area of tendon rupture which had healed in an elongated position. It was
noted that the rupture occurred approximately 4 cm. proximal to the insertion of the
tendon into the calcaneus. The blood supply to this portion of the tendon is notoriously
poor, and consequently it was determined that shortening the tendon proximal to the area
of injury would be more appropriate in order to avoid the possibility of inadequate
healing in this area. The tendo Achillis was incised transversely approximately 6 cm.
proximal to the calcaneus after which a 2-cm. portion of the tendon was removed via
sharp dissection. The tendo Achillis was then reapproximated using a combination of
absorbable and nonabsorbable sutures. An 8-cm. portion of the plantaris tendon was
harvested, wrapped around the tendo Achillis, and sutured in place as a reinforcement to
the tendon. The deep fascia, superficial fascia, and skin were reapproximated using
absorbable sutures.
After surgery the patient was placed in an above-the-knee cast with slight knee
flexion, followed by crutch training and discharge on the second postoperative day. She
remained in the initial cast for 4 weeks, which was then replaced by a below-the-knee
cast with slight plantarflexion at the ankle. The patient remained in a below-the-knee cast
for a period of 6 weeks, during the last 2 of which she was allowed to bear weight and
begin isometric dorsiflexion and plantarflexion exercises. Following cast removal the
patient slowly regained muscle strength and function with the aid of physical therapy
three times weekly. Her last postoperative visit was 12 months following surgery at
which time superficial posterior muscle strength was graded as 5/5, the scar was healed
with no skin adhesions, and sagittal plane range of motion at the ankle was within normal
limits. However, the right calf was significantly smaller than the left. Furthermore, the
patient demonstrated signs of mild tendinitis after prolonged ambulation. She was then
discharged with the advice to continue the isometric exercises and to avoid jumping
activities.
The patient returned 5½ years later with complaints of intermittent burning in her
right heel, and dimpling behind the right ankle. She had no history of recent trauma and
indicated that she had noticed some diminished strength over the past few months in her
right leg. Upon physical examination, there was noted to be excessive dorsiflexion
available in the right ankle. It was determined that stretching of the right tendo Achillis
had occurred in the area of the original injury. The following day she was sent for MRI
studies of the right leg which demonstrated significant inflammation and cystic
degeneration of the distal 5 cm. of the right tendo Achillis (Fig. 1). Inflammation and
partial tear of the peroneus brevis tendon were also noted. It was recommended to the
patient that the right tendo Achillis be reshortened by removing a portion of the cystic
degenerative tissue and reinforcing it with a Lindholm flap (57).

552

The surgery was performed the following month at a local hospital under general
anesthesia with the patient in the prone position (Fig. 2). A linear incision was placed on
the posterior aspect of the right leg through the previous incision and then carried down
to the level of the subcutaneous fat. The deep fascia and paratenon were incised and freed
from the entire posterior aspect of the tendo Achillis. In the area of the original injury
substantial chronic degeneration of the tendo Achillis was noted confirming the findings
of the MRI evaluation (Fig. 3). This tissue was submitted for histopathologic
examination, and the findings were reported as being consistent with chronic
inflammation. A 3-cm. partial resection of the distal aspect of the tendon was performed
using sharp dissection, leaving only a small tag inserting into the calcaneus (Fig. 4).
Attention was directed towards the posterior aspect of the aponeurosis of the
gastrocnemius tendon where a 3-cm. wide strip of the aponeurosis was brought from
superior to inferior across the area of deficit secondary to debridement, and was then
sewn into the posterior aspect of the calcaneus. A hole was drilled through the posterior
superior aspect of the calcaneus and No. 0 polyester suture was placed through the hole.
The Bunnell technique (4, 45) was used to anchor the tendon, which was then sewn into
the posterior superior aspect of the calcaneus (Fig. 5). The plantaris tendon was harvested
and removed from its proximal aspect. The plantaris tendon had totally regenerated after
having been harvested for the first procedure. It was then utilized to reinforce the tendo
Achillis and sewn in several places.

Figure 1. MRI of right ankle demonstrating distal cystic degeneration of the tendo
Achillis.

Figure 2. Intraoperative photograph prior to beginning surgery. Note excessive

ankle dorsiflexion.
553

Because of the weakness of the triceps surae caused by prolonged overlengthening, a

peroneus brevis transfer was performed in order to provide both additional dynamic
power and additional bulk for reinforcement of the tendon (Fig. 6).
A lateral curved incision was made along the 5th metatarsal base and the peroneus
brevis was freed from its insertion and brought out through the posterior leg incision. The
tendon of peroneus brevis was then placed along the lateral aspect of the tendo Achillis
and tacked in on several areas. The peroneus brevis tendon was then inserted into the
calcaneus using a 28-mm. long 4.0 fully threaded cancellous screw and a polyacetyl
spiked washer. The defect in the gastrocnemius aponeurosis was reapproximated using a
No. 2-0 absorbable continuous running suture. The deep structures along the tendon, deep
fascia, and paratenon were reapproximated using No. 3-0 absorbable suture. Deep
structures along the posterior leg were reapproximated using No. 3-0 and, subcutaneous
structures using No. 4-0, absorbable sutures. Finally, the skin was reapproximated using
absorbable suture in a subcuticular fashion. A compression dressing was applied to the
right leg.

Figure 3. Intraoperative photograph. Central area of tendon is site of previous

tendon shortening. Distal aspect of tendon demonstrates longitudinal fissuring consistent
with the cystic degeneration.

Figure 4. Intraoperative photograph demonstrating the extent of the excision of

the degenerated portion of the tendon.

554

On the 2nd postoperative day a below-the-knee cast was applied to the right leg placing
the foot in 15° of equinus. The patient was discharged nonweightbearing on crutches. The
cast remained on for 4 weeks. At this time, the cast was replaced by a removable cast.
The amount of fixed plantarflexion was reduced from 15° to 5°. The patient was
instructed to begin very gentle isometric exercises 3 times daily starting immediately, and
to begin partial weightbearing on the cast after 3 weeks.
Two months postoperatively, the patient returned experiencing very little
discomfort. She did have some initial pain after the amount of equinus was reduced in the
cast. This pain subsided after 2 days. The tendon was strong and intact with no scar
adhesions. Her posterior group muscle strength was also improving. The amount of
plantarflexion was then reduced to 0°, and the patient was advised to gradually increase
weightbearing on the cast over the next week using both crutches. She was also instructed
to begin full weightbearing after 1 week.
 The patient returned 6 weeks later, and was experiencing only minor discomfort
behind her heel. Since her last visit she was diagnosed with a breast malignancy, for
which she has received chemotherapy monthly. She was advised to increase her physical
therapy, which included passive activity on an isokinetic unit along with active resistance
exercises.
At the 6-month follow-up, the patient indicated that she had progressed very well
and was walking much better. The plantarflexory strength of the right calf was excellent.
Her physical therapist was instructed to initiate an evaluation on an isokinetic unit
followed by strengthening of the right calf 3 times weekly. At 10-month follow-up, her
condition was unchanged.

Discussion

The most common and significant complication following conservative treatment

of a ruptured tendo Achillis is rerupture. The patient presented in the case report is
believed to have reruptured on two different occasions. The patient was pregnant at the
time of her initial treatment, and therefore casting constituted a reasonable treatment
option, in order to minimize the risk of contracting a postoperative infection, as well as
avoiding the dangers of anesthesia. However, the 6-week casting period for the initial
rupture was inadequate in duration. According to Lea and Smith (37, 38) a patient treated
conservatively should be casted for a minimum of 8 weeks. Furthermore, the physical
therapy may have been overly aggressive relative to the inadequate period of
immobilization. A ruptured tendon must be given sufficient time to regain its strength,
and resiliency before attempting rigorous rehabilitation. The surgical management may
produce a significantly stronger tendon, which is much less likely to rerupture, and is
better able to withstand weightbearing forces. Open repair is considered to be the
treatment of choice for young, physically active patients (29, 42, 44, 58) who desire to
continue their athletic activities. Patients considered to be high surgical risks, or who do
not desire surgery, may be treated conservatively (59).

Figure 5. Intraoperative photograph demonstrating completion of the Lindholm

flap. The plantaris tendon has been weaved around the tendo Achillis. Note that the
peroneus brevis has been tagged for transfer.

555

Figure 6. A, Transfer of peroneus brevis to the posterior compartment. B, The

peroneus brevis is anchored to the calcaneus with a spiked polyacetyl washer and a
cancellous screw. C, Lateral radiograph 6 weeks postoperatively showing placement of
screw and washer holding peroneus brevis in place.
556

After the patient reruptured following conservative treatment, it was decided that surgical
intervention constituted the most reasonable treatment option to restore muscle function.
In retrospect, the authors speculate that the second rerupture might have been avoided
had the section of tendon resected during the first operation been taken from the area of
original injury. Based on the xeroradiographs and intraoperative inspection, a section of
tendon was resected proximal to the area of injury, and approximately 51/2 years later,
the patient probably suffered a second rerupture. At the time of the first surgical repair, it
was felt that the initial area of injury had healed in an elongated position, but would be
strong enough to withstand weightbearing forces following repair. An MRI study of the
overlengthened tendo Achillis might also have been very useful to help evaluate the
status of the injured tendon, prior to the first operation.
The second operation involved using peroneus brevis to offer dynamic support to
the ruptured tendon. The transfer of peroneus brevis produces an extremely strong repair
even if the tendon ends are shredded. Peroneus brevis serves as a biological scaffold
while the injured tendo Achillis undergoes the healing process (60). Turco and Spinella
(60) reported that no reruptures have occurred utilizing this surgical technique. Another
important aspect to this technique is minimizing weakness of the triceps surae. Power is
added to the already weakened complex by suturing the peroneus brevis tendon under
physiologic tension to the proximal portion of the ruptured tendon segment.

Conclusion

The most important objective when faced with repair of a ruptured tendo Achillis
is restoration of muscle/ tendon function. Primary repair offers the most definitive
method for achieving this goal. The significantly lower rate of rerupture as well as the
more consistent preservation of muscle power, and especially endurance, make open
repair the treatment of choice in most instances. Gentle tissue handling, proper procedure
selection, and placement of a drain can significantly minimize the complications of
infection, sural nerve damage, skin slough, etc. It is not clear from the literature how to
best control the factors leading to conservative treatment failure. The duration of casting,
however, should not be less than 8 weeks.
Although MRI is generally not necessary in order to make the diagnosis of a
tendo Achillis rupture, there are times when only the imaging provided by MRI can
effectively discriminate the vitality and integrity of the tendon. An MRI prior to the first
surgery might have demonstrated cystic areas of the tendon requiring resection. The MRI
prior to the second surgery demonstrated the poor quality of the distal tendon and
facilitated the development of a logical surgical plan.

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559