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Acute and Chronic Achilles Tendon Ruptures in Athletes

  • Jonathan Thompson
    Correspondence
    Corresponding author. University Foot and Ankle Institute, Private Practice, 1101 Sepulveda Boulevard, Suite 104, Manhattan Beach, CA.
    Affiliations
    University Foot and Ankle Institute, Private Practice, 1101 Sepulveda Boulevard, Suite 104, Manhattan Beach, CA, USA

    University Foot and Ankle Institute, Private Practice, 2121 Wilshire Boulevard, Suite 101, Santa Monica, CA 90403, USA
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  • Bob Baravarian
    Affiliations
    University Foot and Ankle Institute, Private Practice, 2121 Wilshire Boulevard, Suite 101, Santa Monica, CA 90403, USA

    Santa Monica Orthopedic Hospital, 1250 Sixteenth Street, Santa Monica, CA 90404, USA
    Search for articles by this author

      Keywords

      Achilles tendon injuries are one of the most common injuries in athletes. The Achilles tendon is the largest and strongest tendon in the human body and is composed of the gastrocnemius and the soleus muscles
      • Mafulli N.
      Current concepts review: rupture of the Achilles tendon.
      to create a musculotendinous complex (triceps surae) that crosses the knee, ankle, and subtalar joint. The Achilles tendon is subjected to extensive static and dynamic loads and can be subjected to loads 2 to 3 times the body weight with walking and up to 10 times the body weight with certain other athletic activities.
      • Soma C.A.
      • Mandelbaum B.R.
      Achilles tendon disorders.
      • Hamilton W.G.
      Surgical anatomy of the foot and ankle.
      The Achilles tendon is the most injured tendon of athletes in the lower extremities and has been noted to be the most common tendon to rupture spontaneously.
      • Kongsgaard M.
      • Aagaard P.
      • Kjaer M.
      • et al.
      Structural Achilles tendon properties in athletes subjected to different exercise modes and in Achilles tendon ruptures.

      Anatomy

      The Achilles tendon is in the superficial posterior compartment of the leg and is formed from tendinous continuations of the 2 muscle bellies of the gastrocnemius and soleus muscles, inserting primarily on the central middle portion of the posterior calcaneus as well as providing fibers that extend around the heel to blend in with the plantar fascia.
      • O’Brien M.
      The anatomy of the Achilles tendon.
      The plantaris tendon (absent in 7%–20% of individuals) is located medial to the Achilles tendon apparatus and inserts medial and anterior to the Achilles complex.
      • O’Brien M.
      The anatomy of the Achilles tendon.
      • Simpson S.L.
      • Hertzog M.S.
      • Barja R.H.
      The plantaris tendon graft: an ultrasound study.
      The Achilles tendon receives its main blood supply to the midportion of the tendon from the paratenon, more proximally from the recurrent branch of the posterior tibial artery and the local small muscular branches and distally from the rete arteriosum calcaneare supplied by the posterior and fibular arteries.
      • O’Brien M.
      The anatomy of the Achilles tendon.
      • Zantop T.
      • Tilmann B.
      • Petersen W.
      Quantitative assessment of blood vessels of the human Achilles tendon: an immunohistochemical cadaver study.
      • Theobald P.
      • Benjamin M.
      • Nokes L.
      • et al.
      Review of the vascularization of the human Achilles tendon.
      The Achilles tendon is almost entirely composed of type I collagen and approximately rotates 11° to 90° in a medial direction in that the medial fibers proximally come to lie in a posterior position distally.
      • Mafulli N.
      Current concepts review: rupture of the Achilles tendon.
      This anatomic construct provides potential energy and mechanical advantage with rotational contraction; however, in doing so, it potentially “strangulates” this portion of the tendon known as the watershed area, making it the most common site of rupture.
      • Carr A.J.
      • Norris S.H.
      The blood supply of the calcaneal tendon.
      • Lagergren C.
      • Lindholm A.
      Vascular distribution in the Achilles tendon. An angiographic and micro-angiographic study.
      This area of lowest vascularity is approximately 2 to 6 cm proximal to the insertional area.
      • Carr A.J.
      • Norris S.H.
      The blood supply of the calcaneal tendon.
      • Lagergren C.
      • Lindholm A.
      Vascular distribution in the Achilles tendon. An angiographic and micro-angiographic study.
      • Astrom M.
      • Westlin N.
      Blood flow in chronic Achilles tendinopathy.
      Lagergren and Lindholm
      • Lagergren C.
      • Lindholm A.
      Vascular distribution in the Achilles tendon. An angiographic and micro-angiographic study.
      originally described this zone of reduced vascularity in the midportion of the tendon
      • Mafulli N.
      Current concepts review: rupture of the Achilles tendon.
      • Zantop T.
      • Tilmann B.
      • Petersen W.
      Quantitative assessment of blood vessels of the human Achilles tendon: an immunohistochemical cadaver study.
      • Astrom M.
      • Westlin N.
      Blood flow in chronic Achilles tendinopathy.
      and subsequent studies have supported their findings.
      • Zantop T.
      • Tilmann B.
      • Petersen W.
      Quantitative assessment of blood vessels of the human Achilles tendon: an immunohistochemical cadaver study.
      • Carr A.J.
      • Norris S.H.
      The blood supply of the calcaneal tendon.
      • Ahmed I.M.
      • Lagopoulus M.
      • McConnell P.
      • et al.
      Blood supply of the Achilles tendon.
      Although there remains some dispute regarding the zone of least vascularity,
      • Mafulli N.
      Current concepts review: rupture of the Achilles tendon.
      • Astrom M.
      • Westlin N.
      Blood flow in chronic Achilles tendinopathy.
      • Astrom M.
      • Westlin N.
      Blood flow in the human Achilles tendon assessed by laser Doppler flowmetry.
      it is generally expected that the blood flow is diminished with increasing age, with gender (decreased in men), and during certain physical loading conditions.
      • Astrom M.
      • Westlin N.
      Blood flow in chronic Achilles tendinopathy.
      • Astrom M.
      • Westlin N.
      Blood flow in the human Achilles tendon assessed by laser Doppler flowmetry.
      Astrom and Westlin
      • Astrom M.
      • Westlin N.
      Blood flow in chronic Achilles tendinopathy.
      evaluated the blood flow of Achilles tendons by comparing 35 patients, most of them competitive runner athletes, with 40 healthy volunteers using Doppler flowmetry and concluded the following: (1) blood flow was evenly distributed throughout the Achilles tendon in both groups, (2) blood flow values progressively declined when tension/contraction increased, (3) values were significantly lower at the distal insertional areas, and (4) symptomatic Achilles tendons had an increase in blood flow to the area. The Achilles tendon lacks a true synovial sheath or lining like other tendons and is surrounded by a peritendinous structure called the paratenon. The paratenon is a multilayered structure that covers the tendon and is composed of an outer layer of which the deep fascia is a portion, the mesotenon, and a very thin and delicate epitenon layer that directly surrounds the tendon.
      • O’Brien M.
      The anatomy of the Achilles tendon.
      The sural nerve and lesser saphenous vein course in the posterior midline of the leg and need to be accounted for during surgical repair.

      Incidence

      There is a paucity in the literature with few reported studies documenting the prevalence of Achilles tendon ruptures in the general population and let alone in the athletic population. The incidence of ruptured or spontaneously ruptured Achilles tendons seems to be growing; however, it cannot be determined if this incidence is from a growing population or an increasing percentage of the population. Rates of Achilles tendon rupture have been reported from 2 to 18 ruptures per 100,000.
      • Mafulli N.
      Current concepts review: rupture of the Achilles tendon.
      • Leppilahati J.
      • Puranen J.
      • Orava S.
      Incidence of Achilles tendon rupture.
      • Moller A.
      • Astros M.
      • Westland N.
      Increasing incidence of Achilles tendon rupture.
      A large study in Scotland was published in 1999 of a total of 4201 Achilles tendon ruptures between 1980 and 1995, which analyzed data on age- and gender-specific incidence rates, and demonstrated similar rupture rates of 4.7 per 100,000 in 1981 and 6 per 100,000 in 1995.
      • Waterston S.
      • Squair J.
      • Douglas A.S.
      • et al.
      Changing incidence of Achilles tendon rupture in Scotland.
      The investigators also determined that the peak incidence in men was from age 30 to 39 years but in women the risk increased after the age of 60 years, and the incidence after the age of 80 years was greater in women than in men.
      • Waterston S.
      • Squair J.
      • Douglas A.S.
      • et al.
      Changing incidence of Achilles tendon rupture in Scotland.
      Most studies demonstrated that Achilles tendon ruptures have occurred during sporting-related activities. A study by Postacchini and Puddu
      • Postacchini F.
      • Puddu G.
      Subcutaneous ruptures of the Achilles tendon.
      showed that in 44% or 12 of 27 cases the rupture occurred during athletic activities. Cetti and colleagues
      • Cetti R.
      • Christensen S.E.
      • Ejsted R.
      • et al.
      Operative versus nonoperative treatment of Achilles tendon rupture. A prospective randomized study and review of the literature.
      reported that 83% (92/111) of patients in a study injured their tendons during activities. A Scandinavian study of badminton players demonstrated that 58 of 111 patients (52%) with Achilles ruptures were playing badminton at the time of injury.
      • Mafulli N.
      Current concepts review: rupture of the Achilles tendon.
      • Fahlstrom M.
      • Bjornstig U.
      • Lorentzon R.
      Acute Achilles tendon ruptures in badminton players.
      A Hungarian study analyzed 749 patients from 1972 to 1985 who were diagnosed and surgically treated for 832 acute tendon ruptures (both upper and lower extremity ruptures).
      • Jozsa L.
      • Kvist M.
      • Balint B.J.
      • et al.
      The role of recreational sport activity in Achilles tendon rupture. A clinical, pathoanatomical, and sociological study of 292 cases.
      Of the 292 cases, 59% Achilles tendon ruptures occurred during sport-related activities in contrast to 2% of other tendon ruptures.
      • Jozsa L.
      • Kvist M.
      • Balint B.J.
      • et al.
      The role of recreational sport activity in Achilles tendon rupture. A clinical, pathoanatomical, and sociological study of 292 cases.
      There were no professional athletes included in this study; however, the ruptures occurred most often in participants of recreational soccer (33.5%), track and field (16.2%), and basketball (13.3%). Furthermore, the investigators also demonstrated that (1) there was a higher prevalence of Achilles tendon ruptures (53.7%) and reruptures (71%) in those with blood group O, (2) most patients commonly ruptured their left Achilles tendon, and (3) most ruptures demonstrated histopathologic alterations on examination.
      • Jozsa L.
      • Kvist M.
      • Balint B.J.
      • et al.
      The role of recreational sport activity in Achilles tendon rupture. A clinical, pathoanatomical, and sociological study of 292 cases.
      Parekh and colleagues
      • Parekh S.G.
      • Wray W.H.
      • Brimmo O.
      • et al.
      Epidemiology and outcomes of Achilles tendon ruptures in the National Football League.
      documented 31 cases of Achilles tendon ruptures in the National Football League (NFL) between 1997 and 2002. The average age and time in the league was 29 years (average age of NFL players is 26 years) and 6 years, respectively.
      • Parekh S.G.
      • Wray W.H.
      • Brimmo O.
      • et al.
      Epidemiology and outcomes of Achilles tendon ruptures in the National Football League.
      About 32% of players (10/31) never played in the NFL again, and those who returned showed a reduction in their performance of more than 50%.
      • Parekh S.G.
      • Wray W.H.
      • Brimmo O.
      • et al.
      Epidemiology and outcomes of Achilles tendon ruptures in the National Football League.
      There was no study that compared Achilles tendon rupture occurrence rates between professional and recreational athletes. Most studies demonstrated that recreational athletes and furthermore the “weekend warrior” athletes are more prone to ruptures and have increasing rupture rates secondary to a partial sedentary life combined with intermittent activities compared with professional athletes who are consistently exercising. It is postulated that regular exercise allows the tendon diameter to thicken and the tendon to become stronger and, in theory, decreases the chance of rupture compared with inactivity, which results in an atrophied Achilles tendon.
      • Saltzman C.L.
      • Tearse D.S.
      Achilles tendon injuries.
      Other factors that potentially differentiated the 2 groups of athletes are that the professional athletes are generally younger, are healthier with less associated comorbidities, have potentially lower body mass indexes, and have regular access to physical therapy and a controlled athletic training program.

      Etiology

      The exact cause of Achilles tendon ruptures remains unclear, but the condition has been described to be associated with multiple disorders, including, but limited to, inflammatory conditions, autoimmune disorders, collagen abnormalities,
      • Mafulli N.
      Current concepts review: rupture of the Achilles tendon.
      • Tafuri S.A.
      • Daly N.
      Achilles tendon trauma.
      • Dent C.M.
      • Graham G.P.
      Osteogenesis imperfecta and Achilles tendon rupture.
      • Rask M.A.
      Achilles tendon rupture owing to rheumatoid disease.
      • Mahoney P.G.
      • James P.B.
      • Howell C.J.
      Spontaneous rupture of the Achilles tendon in a patient with gout.
      infectious process, exposure to antibiotics (fluoroquinolones),
      • McGarvey W.C.
      • Singh D.
      • Trevino S.
      Partial Achilles tendon ruptures associated with flouroquinolone antibiotics: a case report and literature review.
      • Movin T.
      • Gad A.
      • Gunter P.
      • et al.
      Pathology of the Achilles tendon in association with ciprofloxacin treatment.
      systemic or injectable steroid use,
      • Lee H.B.
      Avulsion and rupture of the tendo calcaneous after injection of hydrocortisone.
      • Haines J.F.
      Bilateral rupture of the Achilles tendon in patients on steroid therapy.
      • Balasubramanium P.
      • Prathrap K.
      The effect of injection of hydrocortisone into rabbit calcaneal tendons.
      • Kleinman M.
      • Gross A.E.
      Achilles tendon rupture following steroid injection. A report of three cases.
      repetitive microtrauma, tendon variations, decreased blood flow with advanced age,
      • Strocchi R.
      • DePasquale V.
      • Guizzardi S.
      • et al.
      Human Achilles tendon: morphological and morphometric variations as a function of age.
      • Kannus P.
      • Natri A.
      Etiology and pathophysiology of tendon ruptures in sports.
      abnormal pronation and mechanics, ankle equinus, and Achilles calcification.
      • Clement D.B.
      • Tauntonn J.E.
      • Smart G.W.
      Achilles tendonitis and peritendinitis: etiology and treatment.
      Some investigators have proposed a possible mechanical theory, whereby injury to the tendon leads to weakening and incomplete regeneration, versus a vascular theory, whereby decreased tendon vascularity secondary to age and/or trauma leading to chronic tendon degeneration.
      • Kannus P.
      • Natri A.
      Etiology and pathophysiology of tendon ruptures in sports.
      • Deangelis J.P.
      • Wilson K.M.
      • Cox C.L.
      • et al.
      Achilles tendon rupture in athletes.
      It has been debated if a previous history or current symptomatic Achilles tendon increases the risk of Achilles rupture or if most cases are truly spontaneous. Achilles tendon disorders are more prominent in participants of running sports and has been noted to be symptomatic in 7% to 11% of runners,
      • Lysholm J.
      • Wiklander J.
      Injuries in runners.
      29% of male runners in one study,
      • Kujala U.M.
      • Sarna S.
      • Kaprio J.
      Cumulative incidence of Achilles tendon rupture and tendinopathy in male former athletes.
      and an even higher percentage of runners in other studies. One of the larger studies by Kvist

      Kvist M. Achilles tendon overuse injuries [PhD thesis]. University of Turku, Finland; 1991.

      demonstrated that approximately 53% of 455 athletes who developed Achilles tendon disorders were involved in running sports.
      • Kader D.
      • Saxeza A.
      • Movin T.
      • et al.
      Achilles tendinopathy: some aspects of basic science and clinical management.
      Because the Achilles tendon is unique compared with other tendons in the body in that it lacks a true synovial sheath it can be a potential for somewhat confusing terminology. Achilles tendon disorders are now grouped together into what is known as Achilles tendinopathy.
      • Mafulli N.
      • Khan K.M.
      • Puddu G.
      Overuse tendon conditions: time to change a confusing terminology.
      • Jarvinen T.
      • Kannus P.
      • Mafulli N.
      • et al.
      Achilles tendon disorders: etiology and epidemiology.
      • Mann R.A.
      • Holmes Jr., G.B.
      • Seale K.S.
      • et al.
      Chronic rupture of the Achilles tendon: a new technique of repair.
      Achilles tendinopathy includes tendinosis and peritendinitis. Tendinosis is differentiated from tendonitis in that there is degeneration of the tendon without inflammation or evidence of intratendinous inflammatory cells.
      • Mafulli N.
      Current concepts review: rupture of the Achilles tendon.
      • Jarvinen T.
      • Kannus P.
      • Mafulli N.
      • et al.
      Achilles tendon disorders: etiology and epidemiology.
      This distinction is important not only to understand the pathologic condition but also to dictate the proper and appropriate treatment. Puddu and colleagues
      • Puddu G.
      • Ippolito E.
      • Postacchini F.
      A classification of Achilles tendon disease.
      in 1976 defined this terminology and classified Achilles tendon disease into 3 categories: (1) pure peritendinitis or inflammation of peritendinous tissue with normal tendon, (2) peritendinitis with tendinosis or inflamed peritendinous tissue and degenerative changes of the tendon and (3) tendinosis or normal peritendinous tissue with degenerative changes of the tendon. The investigators also reported that all so-called spontaneous ruptures (patients without any history of previous pain or swelling to Achilles area) had evidence of degenerative lesions in the tendon tissue and no evidence of peritenon alteration.
      • Puddu G.
      • Ippolito E.
      • Postacchini F.
      A classification of Achilles tendon disease.
      Astrom and Rausing
      • Astrom M.
      • Rausing A.
      Chronic Achilles tendinopathy: a survey of surgical and histopathological findings.
      performed 3 biopsies (one each at the symptomatic and asymptomatic part of Achilles tendon and another at the paratenon) in 163 patients with chronic Achilles tendinopathy among which 75% were athletes. Degeneration or tendinosis was demonstrated in 90% of biopsied specimens from symptomatic parts of the tendon and in only 20% from nonsymptomatic portions, and it was found that the paratenon was mostly normal or revealed slight changes.
      • Astrom M.
      • Rausing A.
      Chronic Achilles tendinopathy: a survey of surgical and histopathological findings.
      Partial tendon ruptures were found in 19% of patients and always in the area of tendinosis,
      • Astrom M.
      • Rausing A.
      Chronic Achilles tendinopathy: a survey of surgical and histopathological findings.
      which may indicate a predisposition to rupture Achilles tendons that show signs of degeneration even though they may have been asymptomatic.
      • Fox J.M.
      • Blazina M.E.
      • Jobe F.W.
      • et al.
      Degeneration and rupture of the Achilles tendon.
      However, Mafulli and colleagues
      • Mafulli N.
      • Testa V.
      • Capasso G.
      Achilles tendon rupture in athletes: histochemistry of the triceps surae muscle.
      in a study performed bilateral percutaneous muscles biopsies in the triceps surae of 12 asymptomatic athletes within 36 hours of trauma of the affected and normal side and found no significant differences in histochemical analysis, muscle abnormalities, or fiber areas; however, the uninjured side demonstrated slight increase in capillary density.

      Diagnosis

      The diagnosis of acute Achilles tendon ruptures is usually straightforward and commonly diagnosed with appropriate patient history taking and clinical examination.
      • Mafulli N.
      Current concepts review: rupture of the Achilles tendon.
      • Mafulli N.
      • Ajis A.
      Current concepts review. Management of chronic ruptures of the Achilles tendon.
      • Tan G.
      • Sabb B.
      • Kadakia A.R.
      Non-surgical management of Achilles ruptures.
      • Mafulli N.
      The clinical diagnosis of subcutaneous tear of the Achilles tendon. A prospective study in 174 patients.
      • Movin T.
      • Ryberg A.
      • McBride D.J.
      • et al.
      Acute rupture of the Achilles tendon.
      Patients present with pain and swelling in the posterior ankle and describe a traumatic event or a feeling of being kicked at the back of the heel.
      • Mafulli N.
      Current concepts review: rupture of the Achilles tendon.
      The patients may have heard an audible popping sound
      • Pintore E.
      • Barra V.
      • Pintore R.
      • et al.
      Peroneus brevis tendon transfers in neglected tears of the Achilles tendon.
      and may have difficulty with normal ambulation or walking uphill or climbing stairs.
      • Padanilam T.
      Chronic Achilles tendon ruptures.
      • Distefano V.J.
      • Nixon J.E.
      Achilles tendon rupture: pathogenesis, diagnosis, and treatment by a modified pullout wire technique.
      • Hartog B.D.
      Insertional Achilles tendinosis: pathogenesis and treatment.
      On examination there is often calf atrophy when compared with the contralateral leg, loss of Achilles tendon congruity or palpable gap,
      • Movin T.
      • Ryberg A.
      • McBride D.J.
      • et al.
      Acute rupture of the Achilles tendon.
      weakness of ankle joint plantar flexion, and inability to do heel raises.
      • Tan G.
      • Sabb B.
      • Kadakia A.R.
      Non-surgical management of Achilles ruptures.
      Multiple investigators (Simmonds,
      • Simmonds F.A.
      The diagnosis of the ruptured Achilles tendon.
      Thompson and Doherty,
      • Thompson T.C.
      • Doherty J.
      Spontaneous rupture of the tendon of Achilles: a new clinical diagnostic test.
      Matles,
      • Matles A.L.
      Rupture of the tendo Achilles. Another diagnostic sign.
      O’Brien,
      • O’Brien T.
      The needle test for complete rupture of the Achilles tendon.
      Copeland
      • Copeland S.A.
      Rupture of the Achilles tendon: a new clinical test.
      ) have described clinical tests to diagnose Achilles tendon ruptures. The most commonly used clinical test was originally described by Simmonds
      • Simmonds F.A.
      The diagnosis of the ruptured Achilles tendon.
      and popularized by Thompson and Doherty.
      • Thompson T.C.
      • Doherty J.
      Spontaneous rupture of the tendon of Achilles: a new clinical diagnostic test.
      Patients are made to lie in a prone position with their feet hanging over the edge of the table, and the examiner squeezes the largest muscle portion of the calf complex to simulate a contraction/shortening of the Achilles tendon complex, which should normally produce a plantar flexion of the foot. An “abnormal” or positive Thompson test result is observed when there is a lack of plantar flexion response. Another reproducible test was described by Matles,
      • Matles A.L.
      Rupture of the tendo Achilles. Another diagnostic sign.
      which involves having the patient lying prone on the table with the knee flexed at 90° and the examiner evaluating the “resting tension” position of the feet. With an Achilles tendon rupture, the foot shows less plantar flexion and may even be positioned neutrally or slightly dorsiflexed compared with the uninjured leg. Maffulli
      • Mafulli N.
      The clinical diagnosis of subcutaneous tear of the Achilles tendon. A prospective study in 174 patients.
      evaluated the sensitivity, specificity, and predictive values of the calf squeeze test, palpable gap, Matles test, O’Brien needle test, and Copeland sphygmomanometer test of 174 complete Achilles tendon tears. All tests showed a high positive predictive value; however, the calf squeeze (Thompson test) and Matles tests were found to be significantly more sensitive (0.96 and 0.88, respectively) than the other tests.
      • Mafulli N.
      The clinical diagnosis of subcutaneous tear of the Achilles tendon. A prospective study in 174 patients.
      Achilles tendon ruptures have been described to be misdiagnosed approximately a quarter of the time,
      • Padanilam T.
      Chronic Achilles tendon ruptures.
      • Leslie H.
      • Edwards W.
      Neglected ruptures of the Achilles tendon.
      and other potential diagnostic modalities include radiographs, ultrasonography, and magnetic resonance imaging (MRI).
      Standard radiography is usually not indicated; however, a lateral ankle view allows the practitioner to rule out a posterior calcaneal avulsion fracture
      • Turco V.J.
      • Spinella A.J.
      Achilles tendon ruptures-peroneus brevis transfer.
      and possible distortion of Kager triangle
      • Cetti R.
      • Andersen I.
      Roentgenopraphic diagnosis of ruptured Achilles tendons.
      as well as evaluation of Toygar sign.
      • Mafulli N.
      Current concepts review: rupture of the Achilles tendon.
      Ultrasonography and MRI are useful in differentiating between a partial and complete rupture and allow a more detailed evaluation of the tendinous structure with a chronic rupture. Ultrasonography is inexpensive, easy to use, allows dynamic imaging, and is able to measure the residual gap between tendon ends.
      • Tan G.
      • Sabb B.
      • Kadakia A.R.
      Non-surgical management of Achilles ruptures.
      • Bleakney R.R.
      • White L.M.
      Imaging of the Achilles tendon.
      Ultrasonography in an uninjured Achilles tendon demonstrates hypoechogenic bands of parallel fibrillar lines contained between 2 hyperechogenic bands in the longitudinal plane and round or oval shape in the transverse plane.
      • Mafulli N.
      Current concepts review: rupture of the Achilles tendon.
      • Leslie H.
      • Edwards W.
      Neglected ruptures of the Achilles tendon.
      • Bleakney R.R.
      • White L.M.
      Imaging of the Achilles tendon.
      Ultrasonographic images of a ruptured tendon demonstrate discontinuity of normal fibrillar pattern, gap between torn ends, and an acoustic vacuum.
      • Mafulli N.
      Current concepts review: rupture of the Achilles tendon.
      • Tan G.
      • Sabb B.
      • Kadakia A.R.
      Non-surgical management of Achilles ruptures.
      • Bleakney R.R.
      • White L.M.
      Imaging of the Achilles tendon.
      • Hartgerink P.
      • Fessell D.P.
      • Jacobson J.A.
      • et al.
      Full- versus partial-thickness Achilles tendon tears: sonographic accuracy and characterization in 26 cases with surgical correlation.
      Hartgerink and colleagues
      • Hartgerink P.
      • Fessell D.P.
      • Jacobson J.A.
      • et al.
      Full- versus partial-thickness Achilles tendon tears: sonographic accuracy and characterization in 26 cases with surgical correlation.
      evaluated 26 suspected Achilles tendon ruptures with ultrasonography and compared the results of this test with surgical results and demonstrated that ultrasonography was accurate in distinguishing full-thickness tears from partial-thickness tears or tendinopathy with a sensitivity of 100%, a specificity of 83%, an accuracy of 92%, a positive predictive value of 88%, and a negative predictive value of 100%. Some investigators believe that there are some pitfalls with ultrasonography, including false diagnosis of high-grade tear if plantaris tendon remains intact
      • Bleakney R.R.
      • White L.M.
      Imaging of the Achilles tendon.
      and difficulty in differentiating between all tendinous pathologies including partial ruptures of the Achilles tendon,
      • Kayser R.
      • Mahlfeld K.
      • Heyde C.E.
      Partial rupture of the proximal Achilles tendon: a differential diagnostic problem in ultrasound imaging.
      and MRI should be used in these cases. MRI using sagittal and axial images with T1- and T2-weighted sequences are recommended for the evaluation of Achilles tendon injuries, with normal tendon demonstrating low signal intensity (black) on all images.
      • Mafulli N.
      Current concepts review: rupture of the Achilles tendon.
      • Bleakney R.R.
      • White L.M.
      Imaging of the Achilles tendon.
      A ruptured tendon shows a signal disruption on T1-weighted images and high signal intensity consistent with hemorrhage/edema with retraction of torn ends with a complete rupture on T2-weighted images.
      • Mafulli N.
      Current concepts review: rupture of the Achilles tendon.
      • Bleakney R.R.
      • White L.M.
      Imaging of the Achilles tendon.
      MRI allows adequate evaluation of the size of partial and intrasubstance tears, potential gapping of ruptured ends, and the amount of tendon degeneration/scar tissue.
      • Schweitzer M.E.
      • Karasick D.
      MR imaging of disorders of the Achilles tendon.

      Treatment

      Conservative

      There remains some controversy in the literature regarding whether nonoperative or operative treatment be pursued in the acute rupture of the general population depending on age, time or delayed presentation, activity level, and associated comorbidities.
      • Leppilahti J.
      • Orava S.
      Total Achilles tendon rupture. A review.
      Operative repair has associated risks, including inherent complications from surgery and anesthesia, which have to be accounted for. Studies advocating nonoperative approaches have demonstrated similar results as operative procedures and might be better indicated for high-risk patients.
      • Nistor L.
      Surgical and non-surgical treatment of Achilles tendon rupture.
      • Carden D.G.
      • Noble J.
      • Chalmers J.
      • et al.
      Rupture of the calcaneal tendon. The early and late management.
      Professional and collegiate athletes are generally younger and healthier and have the means for a more appropriate or timely diagnosis. Multiple studies have demonstrated that overall operative repair provides earlier return to sporting activities and less rate of rerupture.
      • Cetti R.
      • Christensen S.E.
      • Ejsted R.
      • et al.
      Operative versus nonoperative treatment of Achilles tendon rupture. A prospective randomized study and review of the literature.
      • Saleh M.
      • Marshall P.D.
      • Senior R.
      • et al.
      The Sheffield splint for controlled early mobilization after rupture of the calcaneal tendon. A prospective, randomized comparison with plaster treatment.
      • Moller M.
      • Movin T.
      • Granhed H.
      • et al.
      Acute rupture of tendon Achilles: A prospective randomized study of comparison between surgical and non-surgical treatment.
      • Weber M.
      • Niemann M.
      • Lanz R.
      • et al.
      Non-operative treatment of acute rupture of the Achilles tendon: results of a new protocol and comparison with operative treatment.
      • Wong J.
      • Barrass V.
      • Mafulli N.
      Quantative review of operative and non-operative management of Achilles tendon ruptures.
      A prospective and randomized study by Cetti and colleagues
      • Cetti R.
      • Christensen S.E.
      • Ejsted R.
      • et al.
      Operative versus nonoperative treatment of Achilles tendon rupture. A prospective randomized study and review of the literature.
      of 111 patients who were randomly assigned to either an operative or a nonoperative group found that the operative group had a significantly higher rate of resuming sport activities, lesser calf atrophy, more ankle joint range of motion (ROM), and lesser rerupture rates than the conservative group, and is the focus of this article.
      Conservative options can be divided into serial casting with gradual decrease in gravity equinus position and splinting devices/boots and early ROM. Multiple casting and rehabilitation protocols are available and are surgeon dependent. An accepted conservative regimen uses either an above-the-knee cast or a below-the-knee cast, with the ankle in plantar flexion (gravity equinus) for approximately 4 weeks.
      • Nistor L.
      Surgical and non-surgical treatment of Achilles tendon rupture.
      Serial cast changes then begin, gradually reducing equinus for the next 4 to 8 weeks and eventually transitioning to a walking boot with a heel lift while starting ROM exercises and a rehabilitation program. Gradual return to regular tennis shoes with a step-down heel lift is used as well.
      • Tafuri S.A.
      • Daly N.
      Achilles tendon trauma.
      It is important to implement physical therapy with passive and active ROM exercises. Some investigators argue for early ROM to enhance tendon healing process and to diminish side effects from immobilization. Advocates of early ROM with splint devices argue that this technique provides a speedier recovery and early ambulation.
      • Saleh M.
      • Marshall P.D.
      • Senior R.
      • et al.
      The Sheffield splint for controlled early mobilization after rupture of the calcaneal tendon. A prospective, randomized comparison with plaster treatment.
      The Achilles tendon rupture can be severely debilitating and time consuming in the athletic population. The goal of surgical repair is to allow the athlete to return to preinjury and activity levels with return of normal function, strength, and ROM. A variety of surgical repairs are described in the literature, including open repair, percutaneous repair, and mini-open repair techniques. Open repair can include end-to-end repair with or without graft augmentations and be combined with tendon lengthening, turndown flaps, or tendon transfers. A retrospective analysis by Ateschrang and colleagues
      • Ateschrang A.
      • Gratzer C.
      • Ochs U.
      • et al.
      in 104 (20 of them athletes) patients who underwent open augmentation after Silfverskiöld procedure for acute Achilles repair determined that 19 of 20 or 95% versus only 48 of 84 or 57% were able to return to original sport activity.

      Operative Repair

      End-to-end repair

      The patient can be given general, regional, or local anesthesia and is placed in prone position on the operating room table. The affected leg as well as the contralateral leg can be prepped and draped for comparison of proper length/tension of the Achilles tendon. Approximately a 6- to 10-cm incision is placed centrally or made at a more advocated posterior-medial midline of the leg to avoid the sural nerve. Dissection is carried down through subcutaneous tissue and fat with minimal dissection or undermining until the crural fascia and the overlying tendon can be visualized. The crural fascia and paratenon can then be incised and carefully reflected off the tendon and should be identified to ensure proper anatomic layered closure. The tendon is visualized, and once the cleaning or removal of the hematoma formation near rupture ends (Fig. 1) is performed, one can attempt to tie or “bundle the horse hair” ends. Unhealthy-appearing tendon ends should be cleaned and debrided before reapproximation of tendon. Sometimes the proximal portion of the rupture tendon “retracts” and should lightly be stretched for a short period to promote elongation. Then it must be determined if there is adequate tendon available to reapproximate and repair the rupture ends. Adequate length is evaluated to ensure that a tendon lengthening, turndown or rotational flap, and/or transfer procedure is not indicated. If satisfied, then the end-to-end reapproximation can be carried out.
      Figure thumbnail gr1
      Fig. 1Complete Achilles tendon rupture with retraction and hematoma formation of the proximal end.
      Simple end-to-end repair is most commonly performed via the Bunnel, Kessler, and Krackow techniques.
      • Krackow K.A.
      • Thomas S.C.
      • Jones L.C.
      A new stitch for ligamentous tendon fixation: brief note.
      All of these suturing techniques are acceptable for the repair of the Achilles tendon; however, the Krackow method has been shown to be superior in biomechanical and cadaveric studies and has the advantage of allowing 4 threads (and 2 knots) across the rupture site if desired.
      • Watson T.W.
      • Jurist K.A.
      • Yang K.H.
      • et al.
      The strength of the Achilles tendon repair: an in-vitro study of the biomechanical behavior on human cadaver tendons.
      The size and type of suture available on the market is variable and is usually the surgeon’s preference. More recently #2 or 2–0 FiberWire (Arthrex, Naples, FL, USA) has become more popular, and a recent study compared Prolene (Ethicon, a Johnson and Johnson company New Brunswick, NJ, USA), Ticron (Covidien, Mansfield, MA, USA), and FiberWire.
      • Scherman F.
      • Haddad R.
      • Scougall F.
      • et al.
      Cross-sectional area and strength differences of fiberwire, prolene, and ticron sutures.
      The investigators determined that FiberWire has a greater cross-sectional area of similar size and is 10% stronger than Prolene and 25% stronger than Ticron in knotted tensile strength.
      • Scherman F.
      • Haddad R.
      • Scougall F.
      • et al.
      Cross-sectional area and strength differences of fiberwire, prolene, and ticron sutures.
      It should be noted that common to all suturing types the location of failure seems to be located at the knot site regardless of the type of suture used. Some investigators reinforce with simple interrupted sutures across rupture site. The rupture should be repaired with the foot in a position similar to the contralateral side resting in equinus position. The paratenon and crural fascia can be reapproximated as well, and then skin closure via suture or staples is done and dressings are applied.

      Augmentation

      End-to-end repair with augmentation can be performed with additional autografts, allografts, and synthetic grafts. The most common and easiest autograft to harvest is with the plantaris tendon, which is usually intact after a rupture and easily available through the same surgical wound. The tendon is cut from its insertion on the calcaneus and stretched or “fanned out” and can be placed over the rupture site with absorbable sutures.
      • Akgun U.
      • Erol B.
      • Karahan M.
      • Beskin J.L.
      • Sanders R.A.
      • Hunter S.C.
      • et al.
      Surgical repair of Achilles tendon ruptures.
      • Rosenzweie S.
      • Azar F.M.
      Open repair of acute Achilles tendon ruptures.
      Akgun and colleagues
      • Akgun U.
      • Erol B.
      • Karahan M.
      performed 36 acute Achilles tendon end-to-end repair with Krackow technique combined with plantaris augmentation in which 31 of 36 patients participated in sporting activities and returned to preinjury sport activities after a mean of 17 weeks (range 14–20 weeks). In contrast, Aktas and colleagues
      • Aktas S.
      • Kocaoglu B.
      • Nalbantoglu U.
      • et al.
      End-to-end versus augmented repair in the treatment of acute Achilles tendon rupture.
      demonstrated no significant difference in the American Orthopeadic Foot and Ankle Society hind foot clinical outcome scores between the group that underwent single end-to-end repair and the group that underwent end-to-end repair with plantaris tendon. Furthermore, the nonaugmented group demonstrated a slight decrease in local tenderness, scar adhesions, and tendon thickness.
      • Aktas S.
      • Kocaoglu B.
      • Nalbantoglu U.
      • et al.
      End-to-end versus augmented repair in the treatment of acute Achilles tendon rupture.
      There have been a variety of biologic scaffolds described in the literature and favorable arguments include added strength of repair without sacrificing secondary structures or more dissection to allow early ROM postoperatively.
      • Barber F.A.
      • McGarry J.E.
      • Herbert M.A.
      • et al.
      A biomechanical study of the Achilles tendon repair augmentation using GraftJacket matrix.
      • Fernandez-Fairen M.
      • Gimeno C.
      Augmented repair of Achilles tendon ruptures.
      • Gilbert T.W.
      • Stewart Akers A.M.
      • Simmons-Byrd A.
      • et al.
      Degradation and remodeling of small intestinal submucosa in canine Achilles tendon repair.
      Various scaffolds and their cellular makeup, biomechanical strength, and biocompatibility have been described for augmentation in the repair of ruptured Achilles tendons.
      • Stover B.S.
      • Zelen C.M.
      • Nielson D.L.
      Use of soft tissue matrices as an adjunct to Achilles repair and reconstruction.
      These scaffolds include, but are not limited to, TissueMend (Stryker, Kalamazoo, MI, USA), Restore (Depuy Orthopaedics, Warsaw, IN, USA), GraftJacket (Wright Medical Technology, Arlington, TN, USA), Conexa (Conexa Reconstructive Tissue Matrix, Tornier, Edina, MN, USA) and Dacron (DuPont, Wilmington, DE, USA) vascular graft. There are limited prospective and randomized trials regarding the use of these grafts in Achilles tendon repairs. TissueMend has been noted to have significantly higher DNA count than most other matrices.
      • Derwin K.A.
      • Bkaer A.R.
      • Spragg R.K.
      • et al.
      Commercial extracellular matrix scaffolds for rotator cuff tendon repair. Biomechanical, biochemical, and cellular properties.
      A human cadaveric study of 8 matched pairs evaluated simulated Achilles ruptures repaired with end-to-end repair with Krackow technique and 1 limb augmented by human dermal allograft (GraftJacket) and concluded that the augmented limb had significant strength and stiffness.
      • Barber F.A.
      • McGarry J.E.
      • Herbert M.A.
      • et al.
      A biomechanical study of the Achilles tendon repair augmentation using GraftJacket matrix.
      However, there have been no follow-up studies. The graft is usually “wrapped” around the ruptured ends and sutured in place (Fig. 2). Every surgeon should be encouraged to educate themselves on the differences between these scaffolds, such as the source, tissue type, and inherent properties, to help differentiate between them.
      Figure thumbnail gr2
      Fig. 2Sutured onlay graft around ruptured ends.

      Turndown or rotational flaps

      Fascial turn down flaps of the proximal gastrocnemius fascia have also been advocated. The most common being the single strip or Silfverskiöld procedure and the double strip or Lindholm procedure, and these fascial slips are made approximately 3 cm proximal to the rupture site and rotated 180° and flapped down to cover and reinforce rupture site.
      • Lindholm A.
      A new method of operation in subcutaneous rupture of Achilles tendon.
      It should be noted that doing a turndown flap requires a longer proximal skin incision with more dissection that increases the potential for wound healing issues and sural nerve injury. A study by Pajala and colleagues
      • Pajala A.
      • Kangas J.
      • Ohtonen P.
      • et al.
      Augmented compared with non-augmented surgical repair of a fresh total Achilles tendon rupture. A prospective randomized study.
      described 66 acute Achilles tendon ruptures in 2 groups, one received end-to-end repair with Krackow locking suture and one group underwent end-to-end repair with augmentation described by Silfverskiöld, and found that it took approximately 25 minutes longer and the incision was 7 cm longer in the augmented repair with no significant advantages regarding ankle score, isolated calf muscle strength, and rerupture rates.
      Because the author is dealing with the athletic population, tendon transfers in acute ruptures have been avoided and have been reserved for possible delayed ruptures, chronic ruptures, or reruptures when indicated secondary to the increased dissection, surgical time, and potential morbidity when sacrificing another tendon. In the case that a surgeon feels more comfortable or if indicated, the author recommends using possible plantaris tendon overlay graft or turn down flaps as mentioned earlier. Peroneal tendon transfers for acute Achilles tendon ruptures were described by Perez Teuffer
      • Perez Teuffer A.
      Traumatic rupture of the Achilles tendon. Reconstruction by transplant and graft using the lateral peroneus brevis.
      in the 1970s and later popularized by Turco and Spinella
      • Turco V.J.
      • Spinella A.J.
      Achilles tendon ruptures-peroneus brevis transfer.
      • Turco V.
      • Spinella A.J.
      Team physician #2. Peroneus brevis transfers for Achilles tendon rupture in athletes.
      in 1987. It has been indicated to use these transfers in acute, chronic, and reruptured Achilles tendon injuries. After end-to-end apposition is performed for the acute rupture, then peroneal brevis tendon is detached from the base of the fifth metatarsal brought through to the posterior compartment and tunneled through the distal Achilles tendon in the medial direction and then drawn proximally along the medial Achilles tendon and secured.
      • Turco V.J.
      • Spinella A.J.
      Achilles tendon ruptures-peroneus brevis transfer.
      Turco and Spinella
      • Turco V.
      • Spinella A.J.
      Team physician #2. Peroneus brevis transfers for Achilles tendon rupture in athletes.
      performed a follow-up study in 55 athletes who sustained acute Achilles ruptures in which they found no early evidence of rerupture rate and also that the tendon transfer had minimal loss of strength. Gallant and colleagues
      • Gallant G.G.
      • Massie C.
      • Turco V.J.
      Assessment of eversion and plantar flexion strength after repair of Achilles tendon rupture using peroneus brevis tendon transfer.
      concluded that there was only mild objective weakness in eversion strength (14.9% deficit) but no functional or significant loss in eversion strength, plantar flexion strength, ankle instability, or activities of daily living when comparing the peroneal brevis tendon transfer limbs with the normal contralateral side in 8 patients.

      Minimal incision techniques

      Minimal incisional and percutaneous techniques were introduced and advocated to decrease potential wound complications, scar adhesions, and sural nerve injuries.
      • Ma G.
      • Griffith T.
      Percutaneous repair of acute closed ruptured Achilles tendon: a new technique.
      • Martinelli B.
      Percutaneous repair of the Achilles tendon in athletes.
      • Davies M.
      • Solan M.
      Minimal incision techniques for acute Achilles repair.
      Ma and Griffith
      • Ma G.
      • Griffith T.
      Percutaneous repair of acute closed ruptured Achilles tendon: a new technique.
      first described a percutaneous technique using multiple stab incision of 18 acute Achilles tendon ruptures to minimize postoperative complications and reported no complications of sural nerve injury. The anatomic path of the sural nerve has been well outlined in the literature and is not readdressed in this article, but it should be noted that percutaneous repairs are not completely benign and every surgeon should appreciate this and use caution when placing a proximal and especially proximal lateral incision even with this technique.
      • Webb J.M.
      • Moorjani J.
      • Radford M.
      Anatomy of the sural nerve and its relation to the Achilles tendon.
      There have been several modifications of the percutaneous repair described in the literature to decrease potential sural nerve injury by placing percutaneous incisions more in the midline or medial position.
      • Webb J.M.
      • Bannister G.C.
      Percutaneous repair of the ruptured tendo Achilles.
      • Young J.
      • Sayana K.
      • McClelland D.
      • et al.
      Percutaneous repair of acute Achilles tendon.
      Martinelli
      • Martinelli B.
      Percutaneous repair of the Achilles tendon in athletes.
      described percutaneous repair on 50 acutely ruptured Achilles tendon. In this study, 30 patients practiced amateur or professional sports and were able to return to preinjury sporting levels after 120 to 150 days.
      • Martinelli B.
      Percutaneous repair of the Achilles tendon in athletes.
      The mini-open technique using the Achillon System (Newdeal, Lyon, France) was introduced to decrease wound complications with smaller incisions.
      • Ceccarelli F.
      • Berti L.
      • Giuriati L.
      • et al.
      Percutaneous and minimally invasive techniques of Achilles tendon repair.
      • Rippstein P.
      • Easley M.
      “Mini-open” repair for acute Achilles tendon ruptures.
      • Elliott A.J.
      • Kennedy J.G.
      • O’Malley M.
      Minimally invasive Achilles tendon repair using the Achillon repair system.
      Favorable arguments for mini-open technique are allowing for early postoperative ROM and rehabilitation to assist proper tendon healing with the reduction of scar adhesions and allowing athletes an earlier return to sporting activities.
      • Rippstein P.
      • Easley M.
      “Mini-open” repair for acute Achilles tendon ruptures.
      Rippstein and Easley
      • Rippstein P.
      • Easley M.
      “Mini-open” repair for acute Achilles tendon ruptures.
      used the mini-open technique and Achillon device to repair acutely ruptured Achilles tendons in 89 consecutive patients. Of these patients, 75% participated in sporting activities (5 elite athletes) 1 to 3 or more times per weekend, and all patients returned to sporting activities within 1 year, with an average return to sporting activities at 6 months.
      • Rippstein P.
      • Easley M.
      “Mini-open” repair for acute Achilles tendon ruptures.
      The average American Orthopedic Foot and Ankle Society ankle–hind foot score was 98 points.
      • Rippstein P.
      • Easley M.
      “Mini-open” repair for acute Achilles tendon ruptures.
      Huffard and colleagues
      • Huffard B.
      • O’Loughlin P.F.
      • Wright T.
      • et al.
      Achilles tendon repair: Achillon system vs. Krackow suture: an anatomic in vitro biomechanical study.
      performed a cadaveric study on 10 pairs of matched Achilles tendon specimens comparing the Krackow suturing technique on 1 specimen with the Achillon suturing system on the contralateral limb. In this study the investigators found the latter technique to be biomechanically stronger.
      A study by Ceccarelli and colleagues
      • Ceccarelli F.
      • Berti L.
      • Giuriati L.
      • et al.
      Percutaneous and minimally invasive techniques of Achilles tendon repair.
      compared acutely ruptured Achilles tendons in 12 paitents who underwent repair via modified Ma and Griffith percutaneous procedure and in 12 who underwent repair using minimally invasive procedure with the Achillon system and found similar results in the time taken to return to work and sports and similar American Orthopedic Foot and Ankle Society Score values.

      Rehabilitation of acute repairs

      There are a variety of postoperative rehabilitation protocols after acute repair of the Achilles tendon regarding when to initiate ROM, rehabilitation and strengthening, and weight bearing. Mortensen and colleagues
      • Mortensen N.
      • Skov O.
      • Jensen P.
      Early motion of the ankle after operative treatment of a rupture of the Achilles tendon: a prospective, randomized clinical and radiographic study.
      prospectively randomized 71 patients who had acute repairs of the Achilles tendon into a group that underwent conventional postoperative management with a cast for 8 weeks and a group that underwent early restrictive ROM with a below-the-knee brace for 6 weeks and concluded that the early ROM group was more satisfied, developed less scar adhesions, had less initial loss of ROM, and returned to sporting activities sooner. The median percentages of strength and heel rise index of the repaired limbs compared with the normal contralateral limbs were similar in both groups.
      • Mortensen N.
      • Skov O.
      • Jensen P.
      Early motion of the ankle after operative treatment of a rupture of the Achilles tendon: a prospective, randomized clinical and radiographic study.
      Suchak and colleagues
      • Suchak A.A.
      • Bostick G.
      • Beaupré L.
      • et al.
      The influence of early weight-bearing compared with non-weight-bearing after surgical repair of the achilles tendon.
      randomized 110 patients into 2 groups of weight bearing and non–weight bearing for 4 weeks after an initial 2 weeks of non–weight-bearing casting. The early weight-bearing group demonstrated improved scores in physical and social functioning with fewer limitations in daily activities at 6 weeks; however, no significant differences were noted at 6 months.
      • Suchak A.A.
      • Bostick G.
      • Beaupré L.
      • et al.
      The influence of early weight-bearing compared with non-weight-bearing after surgical repair of the achilles tendon.
      Aoki and colleagues
      • Aoki M.
      • Ogiwara N.
      • Ohta T.
      • et al.
      Early active motion and weight bearing after cross-stitch Achilles tendon repair.
      allowed early ROM and partial weight bearing with transition to full weight bearing by 16 days in 22 athletes with end-to-end repairs of acute Achilles ruptures. The investigators reported an average period of 13 weeks for returning to the sport.
      • Aoki M.
      • Ogiwara N.
      • Ohta T.
      • et al.
      Early active motion and weight bearing after cross-stitch Achilles tendon repair.
      Mandelbaum and colleagues
      • Mandelbaum B.R.
      • Myerson M.S.
      • Forster R.
      Achilles tendon rupture: a new method of repair, early range of motion, and functional rehabilitation.
      performed the Krackow modified suture technique in 29 athletes who sustained Achilles tendon ruptures and implemented early ROM and rehabilitation programs; 90% of patients demonstrated full ROM at 6 weeks and 92% returned to sport participation by 6 months.
      It seems that early ROM most likely allows for earlier return to normal activities of daily living and recreational and sporting activities without a significant increased morbidity or increased rerupture rate regardless of operative technique and is probably the most important aspect that needs to be addressed when dealing with an athletic patient. If a surgeon can provide a solid repair and institute an early ROM and protective weight-bearing protocol, the time missed could be decreased.

      Chronic, delayed, and rerupture of Achilles tendons in athletes

      Chronic or delayed Achilles tendon ruptures in the athletic population are extremely rare. It has been described in the literature that ruptures presenting after 4 to 6 weeks of the injury can be classified as chronic or delayed ruptures.
      • Padanilam T.
      Chronic Achilles tendon ruptures.
      • Leslie H.
      • Edwards W.
      Neglected ruptures of the Achilles tendon.
      • Myerson M.S.
      Achilles tendon rupture.
      • Mafulli N.
      • Ajis A.
      • Longo U.G.
      • et al.
      Chronic rupture of tendo-Achillis.
      MRI is warranted for more precise evaluation in any patient with a concern of a suspected chronic rupture for better evaluation of the tendinous structure. It is generally accepted that operative repair is recommended for chronic ruptures, delayed ruptures, or reruptures of the Achilles tendon; however, there is no consistent surgical procedure recommendations provided in the literature.
      • Mafulli N.
      • Ajis A.
      • Longo U.G.
      • et al.
      Chronic rupture of tendo-Achillis.
      The general goal in any ruptured tendon is to attempt end-to-end anastomosis of the ruptured site; however, this attempt becomes more difficult in the ruptures that are presented with delay or in those that are neglected. Accordingly, multiple classification schemes and algorithms have been described to help guide and give surgical recommendations for surgical repair.
      • Padanilam T.
      Chronic Achilles tendon ruptures.
      • Mandelbaum B.R.
      • Myerson M.S.
      • Forster R.
      Achilles tendon rupture: a new method of repair, early range of motion, and functional rehabilitation.
      • Myerson M.S.
      Achilles tendon rupture.
      • Mafulli N.
      • Ajis A.
      • Longo U.G.
      • et al.
      Chronic rupture of tendo-Achillis.
      • Kuwada G.T.
      Classification of tendo Achillis rupture with consideration of surgical repair techniques.
      • Den Hartog B.
      Surgical strategies: delayed diagnosis or neglected Achilles tendon ruptures.
      There are limited prospective randomized trials to compare these surgical proposals in the general or athletic populations. In delayed ruptures, the tendons usually become a solid mass of scar tissue and it can be difficult to determine healthy or viable tendon and corresponding layers. The surgeon must debride and clean until potentially healthy and functional tendon remains, which obviously results in increase in gapping of the tendon and makes it difficult to oppose the ends. The surgeon must use other potential procedures that include, but are not limited to, lengthening via inverted V-to-Y or tongue-in-groove procedures, turndown rotational flaps, tendon augmentation or bridging, and tendon transfers. Often there requires a combination of the above-mentioned procedures.
      Myerson
      • Myerson M.S.
      Achilles tendon rupture.
      and Kuwada
      • Kuwada G.T.
      Classification of tendo Achillis rupture with consideration of surgical repair techniques.
      attempted to simplify the operative process and provide recommendations based on this resultant gapping. The classification by Myerson
      • Myerson M.S.
      Achilles tendon rupture.
      (Table 1) recommends the following: type 1 defect that is no more than 1 to 2 cm long can be repaired by an end-to-end anastomosis and a posterior compartment fasciotomy, type 2 defect that ranges from 2 to 5 cm can be repaired via a V-Y lengthening with possible flexor hallucis longus (FHL) tendon transfer, and type 3 defect that is longer than 5 cm and is bridged with FHL tendon transfer with possible V-Y lengthening.
      Table 1Neglected Achilles tendon ruptures
      Data from Myerson MS. Achilles tendon rupture. Instr Course Lect 1999;48:226, 227; with permission.
      Size of Defect (cm)Recommended Procedure
      1–2Simple end-to-end anastomosis, can apply tension to “stress relax” myotendinous junction before tying suture for additional length
      2–5V-Y myotendinous lengthening with end-to-end anastomosis, consider flexor hallucis longus (FHL) tendon transfer if warranted
      >5FHL tendon transfer combined with V-Y advancement if needed, turndown flaps, author advocates FHL tendon transfer over flexor digitorum longus or peroneal tendon transfer
      Kuwada
      • Kuwada G.T.
      Classification of tendo Achillis rupture with consideration of surgical repair techniques.
      classification (Table 2) recommends the following: type I lesions are partial tears and can be managed with conservative casting, type II lesions are complete ruptures smaller than 3 cm and can be repaired via end-to-end repair, type III lesions are complete ruptures of 3 to 6 cm and can be repaired with autogenesis turndown flaps and/or synthetic grafts, and type IV lesions are complete ruptures larger than 6 cm and can be repaired with gastrocnemius recession, lengthening, and/or free tendon transfer.
      Table 2Kuwada’s classification of Achilles ruptures
      Data from Kuwada GT. Classification of tendo Achillis rupture with consideration of surgical repair techniques. J Foot Surg 1990;29:362.
      TypeRecommended Treatment/Procedure
      Type I: <50% tearCast immobilization for 8 weeks
      Type II: defect<3 cmSimple end-to-end anastomosis
      Type III: defect 3–6 cmEnd-to-end anastomosis and autogenous or synthetic graft
      Type IV: defect>6 cm (includes delayed repairs)Requires gastrocnemius recession for increased length, end-to-end anastomosis with free tendon graft or synthetic graft
      Abraham and Pankovich
      • Abraham E.
      • Pankovich A.M.
      Neglected rupture of the Achilles tendon. Treatment by V-Y tendinous flap.
      first described the V-Y advancement for end-to-end repairs of Achilles tendon ruptures in an attempt to allow anastomosis between the 2 ruptured ends. The inverted “V” incision is placed at the musculotendinous junction with the arms approximately 1.5 times the length of the tendon defect and were found to close up to 6-cm gaps in the tendon ends.
      • Abraham E.
      • Pankovich A.M.
      Neglected rupture of the Achilles tendon. Treatment by V-Y tendinous flap.
      Parker and Repinecz
      • Parker R.G.
      • Repinecz E.
      Neglected rupture of the Achilles tendon. Treatment by modified Strayer gastrocnemius resection.
      introduced a tongue-in-groove procedure (Fig. 3), which they found was easier to perform, and were able to achieve 50% more length. Single and double turndown flaps can also be used as described earlier for the repair of acutely ruptured Achilles tendon and are not rediscussed.
      Figure thumbnail gr3
      Fig. 3Open repair with tongue-and-groove lengthening procedure.
      Tendon transfers have been well described in the literature for acute ruptures, chronic ruptures, and/or reruptures and most commonly use the plantaris,
      • Akgun U.
      • Erol B.
      • Karahan M.
      peroneus brevis,
      • Pintore E.
      • Barra V.
      • Pintore R.
      • et al.
      Peroneus brevis tendon transfers in neglected tears of the Achilles tendon.
      • Turco V.J.
      • Spinella A.J.
      Achilles tendon ruptures-peroneus brevis transfer.
      • Perez Teuffer A.
      Traumatic rupture of the Achilles tendon. Reconstruction by transplant and graft using the lateral peroneus brevis.
      • Turco V.
      • Spinella A.J.
      Team physician #2. Peroneus brevis transfers for Achilles tendon rupture in athletes.
      flexor digitorum longus (FDL),
      • Mann R.A.
      • Holmes Jr., G.B.
      • Seale K.S.
      • et al.
      Chronic rupture of the Achilles tendon: a new technique of repair.
      • Lin J.
      Tendon transfers for Achilles reconstruction.
      and FHL
      • Leslie H.
      • Edwards W.
      Neglected ruptures of the Achilles tendon.
      • Lin J.
      Tendon transfers for Achilles reconstruction.
      • Hansen Jr., S.T.
      Trauma to heel cord.
      tendons. The plantaris tendon is the easiest to harvest; however, most of the time, in chronic ruptures, this tendon has been incorporated into the scarred tendinous mass and is unidentifiable. The peroneus brevis tendon has been described earlier and can be used in similarly for the repair of chronic ruptures. FHL has been advocated over the FDL for Achilles tendon transfers and augmentation because of its anatomic proximity, stronger and longer tendinous structure, and lower-lying muscle belly that can be incorporated into the rupture site for added vascularity and strength.
      • Leslie H.
      • Edwards W.
      Neglected ruptures of the Achilles tendon.
      • Lin J.
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      • Wapner K.L.
      • Pavlock G.S.
      • Hecht P.J.
      • et al.
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      It is understood that any tendon transfer results in loss of strength, but it is difficult to determine how much of this loss will functionally affect the athlete during sporting activities because there is a lack of published data in the literature as well as difficulty in performing prospective randomized trials with this type of injury and athletic population. Frenette and Jackson
      • Frenette J.P.
      • Jackson D.W.
      Lacerations of the flexor hallucis longus in the young athlete.
      determined that there was no disability or activity limitation in 4 athletes who sustained complete laceration of the FHL without repair. The FHL tendon transfer seems to be gaining popularity and has been described and modified by multiple surgeons.
      • Myerson M.S.
      Achilles tendon rupture.
      • Hansen Jr., S.T.
      Trauma to heel cord.
      • Wapner K.L.
      • Pavlock G.S.
      • Hecht P.J.
      • et al.
      Repair of chronic Achilles tendon rupture with flexor hallucis longus tendon transfer.
      The FHL tendon can be harvested via a single incisional technique or double incisional technique. The single incisional technique uses the same incision with more anterior dissection through posterior fascia that is incised to identify and mobilize the FHL tendon that is cut as distally as possible (Fig. 4). The FHL tendon should be easily identified and freed with careful visualization of the neurovascular bundle as the tendon is dissected distally. The double incisional technique requires a secondary incision over the midfoot to identify the FHL near the level of the knot of Henry, which is then incised and retracted through the proximal wound. The single technique has the advantage of not using a secondary incision or dissection and possible neurovascular compromise in the foot incision but provides a potential shorter tendon available for transfer that might require screws and/or anchors for fixation into the calcaneus depending on the surgeon’s preferred technique (Fig. 5). The 2-incision technique allows for a longer tendon for transfer and augmentation and possibly allows for wrapping around both ruptured ends depending on the technique. An average of additional 3 cm with secondary midfoot incision and harvesting just proximal to the knot of Henry has been described.
      • Frenette J.P.
      • Jackson D.W.
      Lacerations of the flexor hallucis longus in the young athlete.
      Furthermore, Wapner and colleagues
      • Wapner K.L.
      • Pavlock G.S.
      • Hecht P.J.
      • et al.
      Repair of chronic Achilles tendon rupture with flexor hallucis longus tendon transfer.
      demonstrated that an additional 10 to 12 cm can be found with transecting the tendon distal to the knot of Henry when compared with a proximal posterior harvesting technique. Once the FHL tendon is harvested, the tendon can be transferred in a variety of ways. The 2-incision approach allows for a longer tendon graft, and the graft can be transferred to the calcaneus in a medial-to-lateral direction through a posterior superior calcaneal drill hole. The graft is then proximally fashioned, and if enough tendon remains, it can be weaved through the proximal and distal rupture ends of the Achilles tendon.
      • Panchbhavi V.K.
      Chronic Achilles tendon repair with flexor hallucis longus tendon harvested using minimally invasive technique.
      The single incisional approach results in a shorter tendon length and is transferred from a superior- to inferior-directed calcaneal tunnel placed anterior to the Achilles insertional area. The tendon is brought through the osseous tunnel via suture (whip stitch or other suture technique) and out the plantar aspect of the foot and held in tension as an interference screw is placed through the superior hole to secure the tendon in place. Some investigators advocate suturing the FHL muscle belly over the rupture site to provide increased strength and vascularity. Onlay allograft or synthetic grafts can be wrapped around the tendon once the earlier-mentioned procedure is performed, but this graft adds bulk to the tendon and can make layered closure and wound healing difficult.
      • Schepsis A.A.
      • Hugh J.
      • Haas A.L.
      Achilles tendon disorders in athletes.
      Figure thumbnail gr4
      Fig. 4FHL tendon exposure with single incision approach.
      Figure thumbnail gr5
      Fig. 5FHL transferred to the calcaneus. Note that the low-lying muscle belly of FHL can be used to reinforce and provide vascularity to the repaired ruptured tendon.
      Postoperative care and rehabilitation for chronic Achilles tendon ruptures generally require a more conservative approach with longer immobilization and protective casting period. The optimal immobilization and rehabilitation period is still debated.
      • Deangelis J.P.
      • Wilson K.M.
      • Cox C.L.
      • et al.
      Achilles tendon rupture in athletes.
      Functional ankle foot orthosis and patellar tendon–bearing braces that limit ankle joint dorsi flexion and allow early ROM and protective weight bearing can be used well in this patient population.

      Discussion

      Acute and chronic Achilles tendon ruptures in the athletic population are one of the most challenging and time-consuming conditions to deal with for both the athlete as well as the surgeon. These ruptures are becoming more prominent in the medical community, most likely with the increasing number of recreational, amateur, and professional athletes competing in sporting activities. Surgical repair seems to be the standard of care for treatment, especially in this subset of population.
      New surgical approaches, including percutaneous and mini-open techniques, are being introduced to potentially diminish perioperative complications, and the advent of early protective ROM and rehabilitation has shown a potential for earlier return to sporting activities for patients with acute Achilles ruptures.
      Delayed or chronic ruptures are rare in the athletic population and usually require more extensive surgical approaches with possible tendon lengthening, turndown flaps, tendon augmentation with graft substitutes, and/or tendon transfers. The FHL tendon seems to be more favorable than other tendons available for transfer secondary to its close proximity to the Achilles tendon, in-phase muscle activity, longer and stronger tendinous structure, and low-lying muscle belly for potential incorporation into the repair site for increased strength and vascularity. There remains no clear and identifiable postoperative protocol for rehabilitation and this rehasbilitation regimen remains the surgeon’s preference; however, a few studies have determined that early protective ROM has allowed an early return to physical activities. It is hoped that follow-up studies would be performed to define or redefine surgical recommendations and postoperative protocols for the athletic population.

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