Achilles tendon rupture
Anatomy
- Achilles tendon formed from combined tendons of soleus and gastrocnemius
- Approximately 15 cm in length
- Often transmits forces ten time body weight
- Tendon is enclosed with a paratenon rather than synovial sheath
- Blood supply is tenuous 3-6 cm proximal to calcaneal insertion
Pathology
- Rupture usually occurs in fit, active men
- Commonest age is 20 to 40 years
- Rupture occurs within tendon
- Usually occurs 3-4 cm proximal to insertion
- Rupture is usually caused by sudden force to dorsiflexed foot
Picture provided by J M Gauer, Kantonsspital Schaffhausen, Switzerland
Clinical features
- Usually no preceding pain or history of trauma
- Presents with snapping sensation
- Followed by acute pain over the tendon
- Plantar flexion of the foot is reduced
- Often a gap is palpable at the site of the rupture
- With the patient prone, plantar flexion on calf compression is abolished (Thompson's test)
Management
- Aim is to restore continuity of the tendon
- Can be achieved with surgical or non-operative approaches
- Surgery is probably more appropriate in fit, active individuals
- Non-operative management is probably more appropriate in elderly or unfit
Surgery
- Can be performed by either an open or percutaneous technique
- During open surgery
- Incision is made over the tendon
- Paratenon is opened
- Ends of tendon are apposed using a non-absorbable suture
- Repair performed using either a Kessler or Bunnell Technique
- Paratenon is closed over repair
- Same can be achieved using a percutaneous technique
- Patient requires an equinus splint for 2 weeks
- The ankle is then gradually dorsiflexed
- Re-rupture rate is less than 5%
Picture provided by J M Gauer, Kantonsspital Schaffhausen, Switzerland
Non-operative approach
- Patient is maintained in short-leg equinus cast for at least 6 weeks
- Re-rupture rate as high as 40% have been recorded
Bibliography
Coull R, Williams R L. Common injuries of the foot and ankle. Hosp Med 2002;
63: 624-625.
McClelland D, Maffulli N. Percutaneous repair of ruptured Achilles tendon. J R Coll Surg
Ed 2002; 47: 613-618.
Maffulli N. Rupture of the Achilles tendon. J Bone Joint Surg Am 1999; 81:
1019-1036. |