Achilles Tendon Trauma

Achilles Tendon Trauma

Alan Ng

Keith L. Jacobson

In 1541, Paré was given credit for recognizing Achilles tendon ruptures as a clinical entity. It was not reported in the literature until 1633 (1). It was not until the 1920s that Abrahamsen (2) and Quénu (3) advocated surgical repair. Since the 1920s, surgical management has been the preferred choice of treatment. Surgical repair has been advocated because it consistently affords for greater strength, endurance, and power, with less incidence of rerupture, as compared with nonsurgical management (4,5,6,7,8 and 9).

Ruptures of the Achilles tendon often occur between the third and fifth decades of life. There has always been a male predilection. This injury is often associated with an athletic activity in individuals who generally lead sedentary lifestyles. We often refer to these individuals as “weekend warriors.”

Most Achilles ruptures occur within an area roughly 2 to 6 cm from the insertion. We know that the fibers of the Achilles tendon do not course straight down but actually rotate from medial to lateral in a spiral fashion. The maximal twist is reached about 2 to 6 cm from the insertion. Within this 2 to 6 cm area is also a zone of hypovascularity, as described, in 1958, by Lagergren and Lindholm (10). This defined area is also commonly referred to as the “watershed area.”

There are several physiologic factors that are thought to contribute to the two common theories of Achilles tendon ruptures. The mechanical stress theory leading to Achilles rupture, as popularized by Inglis and Sculco (11), described the malfunction of the inhibitory mechanism within the muscle, which normally prevents excessive tension and monitors forces during sudden muscle overload. Nonetheless, this explanation has been generally dismissed as not credible. However, there are three types of indirect trauma, described by Arner and Lindholm (12), which are thought to cause ruptures. They include a direct push-off from a weight-bearing forefoot and an extended knee; sudden dorsiflexion of the ankle, such as slipping on a stair or ladder; and violent dorsiflexion of a plantarflexed foot that occurs when jumping or falling from a height and landing with the foot plantarflexed.

The degenerative theory (13,14) describes a hypovascular tendon exposed to repetitive trauma, resulting in local degenerative changes within the midsubstance of the tendon. This weakened state, of the tendon, predisposes it to rupture after an excessive load is applied.

There are other external factors, which have also been shown to contribute to Achilles tendon ruptures. They include systemic (15) and local steroids (16), blood type O (17), genetics (18), renal insufficiency (19), arteriosclerosis (20), hyperlipidemia (21), gout (21), hypothyroidism (21), rheumatoid arthritis (21), and fluoroquinolones (21).

When surgically addressing Achilles tendon ruptures, it is important to understand not only the theoretical causes of rupture but also the systemic and external factors that may influence your approach to treatment.



Patients will present complaining of weakness at the ankle and will often state that they felt that an object struck them. The injury is usually only painful at the time the rupture occurs and is not significantly painful upon presentation to the office. The observed gait pattern is often abducted and antalgic.


Advanced imaging can also be used to assess a complete rupture or to assess the amount of deficit noted between the ruptured ends. The use of diagnostic imaging is primarily a physician’s choice; oftentimes advanced imaging is not needed if clinical examination is definitive for the rupture. If delay in treatment occurs, advanced imaging can be useful for assessing the amount of tendon retraction and the resultant deficit that needs to be repaired.

Radiographs are not necessary unless there is a suspicion of an avulsion fracture off the posterior calcaneus.

Figure 101.1 “Hatchet strike defect.” Subtle deficit compared with normal Achilles tendon presentation.


Magnetic resonance imaging (MRI) can be utilized to assess the amount of deficit created from the rupture (Fig. 101.4).

If the clinical exam is in nondefinitive, MRI can help determine if there is a complete or partial rupture. False negative exams can also occur with MRIs. After rupturing, the tendon may lay back down into its anatomic position. This can give the appearance of a partial tear, when in fact it is completely ruptured (Fig. 101.5).

When addressing chronic ruptures, MRIs are very helpful in determining the amount of deficit present, essentially assisting in presurgical planning (Fig. 101.6).


Ultrasound can be used to image the Achilles trauma. It has been used to assess acute and chronic injuries. Ultrasound may give false negative results in acute injuries due to the hematoma filling the deficit. Astrom et al (25) compared ultrasonography and MRI in assessing chronic Achilles tendinopathy with regard to the nature and severity of the lesion. In 27 histologically verified cases, ultrasonography was positive in 21 and MRI was positive in 26 of 27 cases.

Figure 101.2 Positive Thompson-Doherty exam. Note the leg flexed with patient in prone position and lack of plantarflexion upon compression of the calf.

The majority of Achilles tendon ruptures can be diagnosed clinically. If there is any question of deficit, complete rupture, or level of rupture, advanced imaging may be appropriate to verify the diagnosis or to assist in surgical planning.

Figure 101.3 A: Nonaffected extremity with plantarflexion exam. Note the foot in slight plantarflexion with the patient prone. B: Positive plantarflexion test, note the affected extremity is at 90 degrees with the leg flexed.

Figure 101.4 A: Sagittal MRI of Achilles rupture with deficit visualized with increased signal intensity. B: Axial MRI through deficit; note the significant increase in intensity at level of deficit (1). In this case, the plantaris tendon is intact (2).


In the past, there has been controversy regarding treatment of acute Achilles tendon ruptures with surgical intervention or cast immobilization. Current literature and studies show a much better result and decreased rerupture rate in surgically repaired Achilles tendons (26,27,28 and 29). Also, the postoperative recovery time for surgically repaired tendons is typically less than nonsurgically treated ruptures. The problem often associated with casted repairs relates to the tendon functionally lengthens due to the scar tissue forming the bridge between the two ruptured ends. This creates a significant loss of strength and loss of the length/tension relationship. Surgical repair has become more favorable with new stronger repair products and better repair techniques allowing earlier mobilization and faster return to activity. Nonoperative care is usually reserved for those patients who are not surgical candidates because of local or systemic contraindications. Patients with severe immunocompromised status, elderly, low-demand patients, vascular compromised patients, and patients that are at risk for compliance are also candidates for nonsurgical care. Patients should be surgically repaired in the acute setting if they do not fall into the above stated categories.

Figure 101.5 Complete Achilles rupture but MRI shows no appreciable deficit. In this case, the tendon has laid back down to its anatomic position but is in fact ruptured.


There are multiple described tendon repair techniques in treatment of Achilles tendon ruptures. The basis of these repair techniques involves allowing end-to-end apposition of the two ruptured ends of the Achilles tendon. Three main suture techniques have been utilized with excellent results: the Bunnell, Kessler, and Krackow suture techniques. Watson et al (35) tested these techniques in cadavers and found that all techniques ultimately demonstrated failure at the repair site.

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Jul 26, 2016 | Posted by in MUSCULOSKELETAL MEDICINE | Comments Off on Achilles Tendon Trauma

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