NB This page is from the 2005 Hyperbook.
Last evidence check November 2004.
Rupture usually occurs about 4-6cm above the insertion, in the watershed region and at the usual site of non-insertional tendonopathy. Rupture does not usually occur in a normal tendon. The tendon has areas of degeneration and macroscopically is ragged and unhealthy.
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| Site of Achilles tendon rupture 2-6cm above insertion |
Steroid injection into or around the tendon has been associated with rupture. Although the association has been disputed we do not recommend injection into or around the Achilles tendon.
Other causative factors in rupture of the Achilles tendon include:
Patients typically complain of the acute onset of calf pain during sport or other activity. The pain may be felt as though the patient had been struck on the calf. Most patients find it difficult to walk after an Achilles rupture and rising on the affected heel is usully difficult or impossible. However, the long flexors can be sufficient to allow rising on the heel and the ability to do this does not exclude an Achilles rupture. Misdiagnosis as an ankle sprain or other benign injury is quite common.
Examination reveals tenderness over the tendon with swelling and a gap can usually be palpated. The Simmonds or Thompson calf squeeze test (both described the test almost simultaneously) is probably the best diagnostic method, although no publication has examined the accuracy of the test. The patient kneels facing away from the examiner or lies prone. Squeezing the calf normally produces plantarflexion of the ankle. If the Achilles tendon is ruptured this does not occur. In the Matles test the patient lies prone and the knee is flexed to 90deg. Any dorsiflexion of the foot indicates a ruptured tendon.
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| Inspection with the patient prone - the right tendon is ruptured and the foot lies in dorsiflexion | The Matles test - with the knee and hip flexed to 90deg the ruptured right tendon allows the foot to fall into dorsiflexion |
Normally the diagnosis is on clinical grounds. Ultrasonography is useful to confirm the diagnosis if in doubt. It also allows assessment of apposition of the tendon ends if non-surgical treatment is intended. MR scanning also shows the anatomy well but probably does not add anything to the results of ultrasonography unless skill in the latter is not available.
The debate between surgical and non-surgical treatment of Achilles tendon rupture has pointed first one way, then the other. The introduction, over the last decade, of functional treatment both after surgery and without surgery, has led to a reappraisal of best practice.
The advantages of surgery include a lower re-rupture rate, averaging 1.4% versus 13% for non-surgical treatment and the ability to start functional rehabilitation almost immediately post-operatively. Non-surgical treatment avoids the complications of surgery which occur in about 10% of patients. These figures are derived from older studies which employed prolonged casting after both surgical and non-surgical treatment.
Surgical repair may be open or percutaneous. Percutaneous repair minimises the risk of wound complications, but has an increased risk of sural nerve injury. No RCT has shown a difference in the outcome of open or percutaneous surgery. Jigs are now appearing on the market to aid suture placement and reduce the risk of nerve injury. Early results are promising but no comparative studies have been reported.
Carter et al described free active motion of the ankle after tendon repair in 1992, with excellent functional results and no re-ruptures. Cetti (1994) reported the results of an RCT comparing functional and cast treatment following repair. The functional results were better in the the functional group, with no increase in re-rupture. Other authors have reported good results with functional after treatment without an increase in rerupture, although a few series have found no difference between functinal and static splinting. Functional aftertreatment should now probably be considered best practice and casting for the traditional 6-8 weeks can no longer be justified for the average patient provided the necessary facilities and expertise are available.
Thermann et al introduced a degree of functional non-surgical treatment for Achilles tendon rupture, showing no difference between the results of functional treatment post tendon repair and functional non-surgical treatment in a small RCT. Webb et al reported a larger RCT comparing functional treatment in a brace which blocked dorsiflexion at 1 week post surgery (percutaneous) or after 3 weeks in non-surgical treatment. The functional results were the same although there were 4(11%) re-ruptures in the non-surgically treated group versus 1(3%) in the repaired group - the difference was not significant at the 5% level. Functional non-surgical treatment appears to be a reasonable option although there may still be a higher risk of re-rupture, set off against the surgical risks.
We currently use surgical and non-surgical treatment regimes based on those of Webb et al, using a walker boot in which the patient can do protected exercises with the front flap of the boot to block excessive dorsiflexion. We advise patients that non-surgical treatment probably has a higher risk of re-rupture and may produce a slightly weaker calf, but avoids the complications of surgery and that overall the functional results are similar for most patients. We find that about 1/3 opt for surgery and 2/3 for non-surgical treatment, with the main determinant being level of sporting activity.
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| Walker boot for functional treatment of Achilles tendon rupture. Can be used after surgery or with non-surgical treatment |
A few patients present for treatment weeks or even months after rupture, or sustain a re-rupture. Occasionally, they have little functional deficit and surgery seems to have little to offer. However, surgical repair is generally advisable. Small gaps can generally be closed either by primary suture or a turn-down flap. Gaps from 3-6cm usually require a V-Y advancement of the tendon. Larger gaps usually require a tendon transfer. The main donor options are the peroneus longus or flexor hallucis; we prefer the latter.
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