The Achilles tendon connects the calf muscles to the heel bone and is active during walking, running, and jumping. It is susceptible to injury from overuse or sudden strain. Common injuries include Achilles tendinitis, which is inflammation from overuse, and Achilles tendon rupture, which is a complete tear of the tendon. Ruptures are typically treated with surgery followed by immobilization in a cast or brace followed by physical therapy to regain strength and range of motion. While surgery lowers the risk of re-rupture compared to non-surgical treatment, both approaches can successfully treat ruptures if rehabilitation is done correctly.

2. Achilles Tendon Disorders
Dr. Siddharth Gupta
SMO Rajawadi Hospital

3. Anatomy
 Largest tendon in
the body
 Origin from
gastrocnemius and
soleus muscles
 Insertion on
calcaneal
tuberosity

4. Anatomy
Lacks a true synovial sheath
Paratenon has visceral and parietal layers
Allows for 1.5cm of tendon glide

5. Anatomy
Paratenon
Anterior – richly vascularized
The remainder – multiple thin membranes

6. Anatomy
 Blood supply
1) Musculotendinous junction
2) Osseous insertion on calcaneus
3) Multiple mesotenal vessels on anterior
surface of paratenon (in adipose)
– Transverse vincula
 Fewest @ 2 to 6 cm proximal to osseous insertion

7. Physiology
Remarkable response to stress
Exercise induces tendon diameter increase
Inactivity or immobilization causes rapid
atrophy
Age-related decreases in cell density,
collagen fibril diameter and density
Older athletes have higher injury
susceptibility

8. Biomechanics
Gastrocnemius-soleus-Achilles complex
Spans 3 joints
 Flex knee
 Plantar flex tibiotalar joint
 Supinate subtalar joint
Up to 10 times body weight through
tendon when running

9. Achilles Tendon Rupture
Pathophysiology
 Repetitive
microtrauma in a
relatively
hypovascular area.
Reparative process
unable to keep up
May be on the
background of a
degenerative tendon

10. Common causes of injury:
•Repetitive or sudden increase of stress
on the tendon.
•Increase in exercise intensity.
•Not allowing recovery time between
exercises.
•Decreased range of motion-tight calf
muscles.
•Bone spur-rubbing against the tendon.

11. Types of injury
1-Achilles tendonitis Chronic inflammation
Due to
Stresses
Micro-tears
Inflammation and
scar formation
2-Achilles tendon rupture

12. Achilles tendonitis - presentation
•Pain in the back of the heel
•Occasional swelling due to thickening of
tendon
•Often occurs in runners.

14. Treatment includes
Anti-inflammatory
Physical therapy.
Massage therapy
Ice therapy
Immobilization
Injections: prolotherapy, platelets or
needling.

15. Achilles tendon rupture
Patient will feel or hear a “pop” when the
tendon ruptures.
Pain is felt in the back of the ankle.
Foot becomes floppy and weak.
Patient feels as if being kicked in the
back of the ankle where the tendon
snapped.

16. Achilles Tendon Rupture:
Textbook Facts
Antecedent tendinitis/tendinosis in 15%
75% of sports-related ruptures happen in
patients between 30-40 years of age.
Most ruptures occur in watershed area
4cm proximal to the calcaneal insertion.

18. Achilles Tendon Rupture
 History
 Feels like being kicked in the leg
 Case reports of fluoroquinolone use, steroid
injections
 Mechanism
 Eccentric loading (running backwards in tennis)
 Sudden unexpected dorsiflexion of ankle
 (Direct blow or laceration)

19. Physical Exam
 Prone patient with feet over edge of bed
 Palpation of entire length of muscle-tendon
unit during active and passive ROM
 Compare tendon width to other side
 Note tenderness, crepitation, warmth, swelling,
nodularity, palpable defects

20. Achilles Tendon Rupture
Physical
Partial
 Localized tenderness +/- nodularity
Complete
 Defect
 Cannot heel raise
 Positive Thompson test

21. Achilles Tendon Rupture
Diagnostic Pitfalls
23% missed by Primary Physician
(Inglis & Sculco)
Tendon defect can be masked by
hematoma
Plantar-flexion power of extrinsic foot
flexors retained
Thompson test can produce a false-
negative if accessory ankle flexors also
squeezed

23. Imaging
X RAYS
Avulsion fracture at the
insertion , with marked
seperation of fragments.

24. Imaging

25. Imaging
Ultrasound
Inexpensive, fast,
reproducable, dynamic
examination possible
Operator dependent
Best to measure
thickness and gap
Good screening test for
complete rupture

26. Imaging
MRI
Expensive, not
dynamic
Better at detecting
partial ruptures
and staging
degenerative
changes, (monitor
healing)

27. Management Goals
Restore musculotendinous length and
tension.
Optimize gastro-soleous strength and
function
Avoid ankle stiffness

28. Conservative Management
Cast in Plantarflexion CAM Walker or cast with
plantarflexion q 2
wks
2 wks
Allow progressive weight-
bearing in removable cast
Remove cast and walk with
shoe lift. Start with 2cm x 1
month, then 1cm x1 month
then D/C
4 weeks
Start physio for ROM
exercises
When WBAT and
foot is plantigrade
Start a strengthening
program
2- 4 weeks

30. Surgical Management
Preserve anterior paratenon blood
supply
Beware of sural nerve
Debride and approximate tendon ends
Use 2-4 stranded locked suture
technique
May augment with absorbable suture
Close paratenon separately

31. Surgical Management
 Bunnell Suture
 Modified Kessler
 Many techniques
available

41. Complications After Open Repair of Achilles Tendon
Rupture
Minor
 􀀀 Wound
 & Superficial infection
 & Wound hematoma
 & Delayed wound healing
 & Adhesion of scar
 & Suture granuloma
 & Skin necrosis
 & General
 & Pain
 & Disturbances in sensibility
 & Suture rupture
Major
 􀀀 Wound
 & Deep infection
 & Chronic fistula
 & General
 & Deep vein thrombosis
 & Tendon lengthening
 & Death
Classification given by - Wong et al.

42. Surgical Management :
Post– op Care
Assess strength of repair, tension and
ROM intra-op.
Apply cast with ankle in the least amount
of plantarflexion that can be safely
attained.
Patient returns to fracture clinic 2 weeks
post-op.

43. Variations in Post-op Protocols

44. Functional Bracing

45. Post- Op Care
Cast applied in OR Remove sutures, apply a
walking cast with heel lift2 wks
Allow progressive weight-
bearing in removable cast
Remove cast and walk with a
1cm shoe lift x 1 month then
D/C.
2 weeks
Start physio for ROM
exercises. No active
plantarflexion
When WBAT and
foot is plantigrade
Start a strengthening
program
2- 4 weeks
Touch WB

46. Surgical Management:
Post-op Care
J Trauma. 2003 Jun;54(6):1171-80; discussion 1180-1.Kangas J et al.
Early functional treatment versus early immobilization in tension of the
musculotendinous unit after Achilles rupture repair: a prospective,
randomized, clinical study.
50 pts had repair
of Achilles rupture
Casted in neutral x 6
weeks. WBAT at 3 weeks
Immediate active ROM from
PF to neutral. WBAT at 3 wk
Better calf strength only
for first 3 months.
One re-rupture
Two re-ruptures
One deep infection
Same satisfaction
25 25

47. Conservative vs Surgical
Acute rupture of tendon Achillis. A prospective randomised study of
comparison between surgical and non-surgical treatment.
Moller M, et al. J Bone Joint Surg Br. 2001 Aug;83(5):863-8
112 patients
Surgery +
Early functional rehab in
brace
Casted x 8 wks
21 % re-rupture 1.7% re-rupture
5% infection
2% Sural nerve inj.
No difference in
functional outcome

49. Summary of Pooled Outcome Measures

50. Risk of Re-Rupture
 Surgery =
68% risk
reduction for
re-rupture