3 - Achilles Tendon Rupture

Question 1

Achilles tendon blood supply

Answer 1

• Musculotendinous junction
• Osseous insertion
• Peritenon
• Zone of avascularity (ischemia) = 2 - 6 cm proximal to insertion, MOST common site of pathology

Question 2

Tendon healing

Answer 2

• When the Achilles tendon ruptures, the tendon stumps become frayed like a mop. The proximal portion of the tendon retracts. The void within the paratenon is filled with a gelatinous then fibrous scar. Then remodeling of the scar occurs resulting in a healed tendon.

Question 3

Tendon healing timeline - Week 1

Answer 3

o Ruptured tendon joined by a fibroblastic splint through a jelly-like bridge of serous and granulation tissue

Question 4

Tendon healing timeline - Week 2

Answer 4

o Paratenon vascularity increases and collagen proliferates. Gap is bridged by tendon elements in 10 - 14 days

Question 5

Tendon healing timeline - Week 3

Answer 5

o Collagen fibers begin to coalesce and align longitudinally. A moderate degree of bond strength present. Cleavage between tendon and surrounding tissue begins.

Question 6

Tendon healing timeline - Week 4

TEST QUESTION

Answer 6

o Reduction in vascularity and edema. Some gliding available.
o This is when Dr. Smith will start passive ROM, but on national exams, end of week 3 or beginning of week 4 is typically the answer

Question 7

Clinical findings

Answer 7

• Most common in males between the third and fifth decades
• Weekend warrior
• Usually precipitated by pre-existing disease (repeated trauma, decreased vascularity)
• Diagnosis missed 25% of the time (emergency, family practice, urgent care)

Question 8

Patient HPI

Answer 8

o May hear a snap or tear
o May state “it felt like someone kicked me in the back of the leg or hit me with a board”
o May have a sudden feeling of weakness
o Leg will just give out

Question 9

Diagnosis

Answer 9

o	Pain and edema
o	Palpable or visible gap
o	Thompson-Doherty squeeze test
o	Absence of active plantarflexion
o	Knee flexion examination
o	Needle test

Question 10

Thompson-Doherty squeeze test

Answer 10

• Patient lying prone with feet hanging off table
• Midportion of the calf muscle is squeezed
• If the foot plantarflexes, then the Achilles tendon is intact and the test is NEGATIVE***
  o If the foot does NOT plantarflex, it is positive for a possible rupture
  o Because you are looking for a rupture, a lack of plantarflexion is positive
• Can get a false-negative due to deep flexors

Question 11

Radiographic findings

Answer 11

Evaluation of the posterior triangle:
o Kager’s triangle borders
o Increased opacity within the triangle
o Irregularities in the contour of the Achilles tendon

Question 12

Kager’s triangle borders

Answer 12

• Superior calcaneus
• Anterior edge of Achilles tendon
• Deep flexors

Question 13

Ultrasound evaluation

Answer 13

• Inexpensive
• Non-invasive
• Dependent on technician and transducer
• Limited anatomic detail

Question 14

MRI

Answer 14

• Excellent affinity for soft tissue
• Actual tendon defect visualized
• Expensive
• Often not needed for an acute rupture
• Most useful for a delayed rupture

Question 15

Treatment options

Answer 15

o Conservative
o Surgical

THE GREAT DEBATE
o	One side or the other
o	30 to 40 age group
o	Activity level
o	Geriatric patient

Question 16

Or is it a debate?

Answer 16

o If the patient is active, they will benefit from surgery

o Patients who have surgical treatment do better than conservative treatment

Question 17

Conservative treatment - advantages

Answer 17

o Simple
o No anesthesia
o Cost

Question 18

Conservative treatment - disadvantages

Answer 18

o Re-rupture (10-15%)
o Decrease in strength
o Decrease in power
o Decrease in endurance

Question 19

Surgical treatment - advantages

Answer 19

o More strength
o More power
o More endurance
o Less re-rupture (0-5%)

Question 20

Surgical treatment - disadvantages

Answer 20

o Complicated
o Anesthesia
o Cost

Question 21

CASE STUDY

Answer 21

HPI: Pt. is a 45 year old female that presents to clinic for evaluation of a sprained left ankle. Pt. was playing basketball in her driveway with her son and sprained her ankle. She went to family practice and was given Motrin 800mg QID, instructed to apply ice and wear and ACE bandage. Injury occurred 2 weeks ago and was referred to podiatry after ankle did not improve. Pt. denies pain, she is able to walk but ankle is weak.

Question 22

Physical exam

Answer 22

o Musculoskeletal: No pain on palpation of the left Achilles tendon, palpable defect in Achilles tendon just proximal to the insertion. Pt. unable to actively plantarflex left foot. Muscle strength in posterior left lower extremity group 1/5. Thompson-Doherty positive.

Question 23

MRI

Answer 23

o Since the patient was injured 2 weeks ago, you would want an MRI to see the gap
o Based on Kuwada classification, you would want an MRI
o On a T2 MRI, there will be a lot of brightness
o After you “clean up” the frayed ends, the gap will be bigger than it actually was