1. Presenter: Dr. Ankur Mittal

2. Diagnostic Tests
•Xrays
•Ultrasound
•MRI
Imaging is rarely necessary in acute cases, but MRI or US may be helpful in the
chronic cases for diagnosis and surgical planning.
Ultrasound most often used for determining the thickness of the tendon and the
size of the gap on a complete rupture; requires skilled / experienced hands.
MRI is more expensive and has its best place in diagnosing incomplete tears and for
diagnosis of and planning surgical treatment for chronic tears.

3. Imaging
 X-rays
 Indicated if fracture or
avulsion fracture
suspected

5. KAGER’S TRIANGLE

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

7. Longitudinal sonogram shows a partial-thickness tear or tendinosis that was confirmed with
surgical findings in a 49-year-old woman with chronic pain in the Achilles tendon.
Hartgerink P et al. Radiology 2001;220:406-412
©2001 by Radiological Society of North America

8. Longitudinal sonogram shows a full-thickness tear, confirmed with surgical findings, in a 40-
year-old man.
Hartgerink P et al. Radiology 2001;220:406-412
©2001 by Radiological Society of North America

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

10. ACUTE
ACHILLES
TENDON
RUPTURE
HEALTHY
ACHILLES
TENDON
CHRONIC
ACHILLES
TENDON
RUPTURE

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

12. TREATMENT
Acute and Chronic Achilles Tendon Ruptures
Chronic Ruptures
>4-6 weeks since time of initial
injury
Acute Ruptures
Operative repair versus
nonoperative protocol
Options
Techniques
Results
Complications
Rehabilitation

13. ACUTE RUPTURES
Treatment
 Controversial topic
 Lack of defined universally accepted outcome measures
 Multitude of different reparative techniques
 Diverse range of postoperative protocols
 Closed treatment was widely accepted as the standard of care in the early 20th
century
 Operative repair has gained popularity in recent decades

14. Nonoperative Treatment
 Initial period of immobilization in equinus short leg non-weight bearing cast or
splint for 2 weeks
 Then convert to short leg walking cast or walking boot
 Boot or cast is typically worn for 6-8 weeks
 Gradual return to neutral ankle position over this time period
Gentle ROM exercises begin after 6-8 weeks immobilization
2-cm heel lift used during this transition period
Progressive-resistance exercises begun for calf muscles at 8-10 weeks
Goal is return to running at 4-6 months and near normal power at 12
months

15. Essential principles of conservative management —
immobilisation in equinus had to be maintained for a full 8
weeks and for a further month the patient should walk with the
shoe heel raised.
The likelihood of rerupture was increased if the period of
immobilisation was shortened.

16. Operative Treatment
 Direct primary repair
 End-to-end repair
 Bunnell suture with modified Kessler technique
 Interlocking suture technique
 Augmented repair
 Fascial turn-down
 Plantaris tendon augmentation
 Peroneus brevis augmentation
 Percutaneous repair (sural nerve entrapment)

17. CHRONIC RUPTURES
Treatment
Basic tenets of reconstruction
1. Restore optimal length,
strength, and function
2. Reconstruct the gap with
appropriately strong tissue
Non-Operative Treatment
Limited indications
Medically ill, household ambulators
Treat with spring-loaded hinged AFO

18. Chronic Rupture
 Reconstruction
 Turn-down flaps
 V-Y plasty
 Turn-down flap
 Tendon transfer
 FHL
 FDL
 Peroneus Brevis
 Artificial materials

19. Operative Treatment
Defects of 1 cm or less
Direct repair without augmentation (rarely feasible)
Defects 1 - 2 cm
Muscle mobilization augmentation (plantaris)
Can gain up to 2 cm with mobilization
Defects 2 - 5 cm
No consensus on best reconstruction technique
Flexor hallucis longus (FHL) tendon transfer
FHL second strongest ankle plantar flexor
FHL contractile axis most closely approximates Achilles tendon
Other transfers, to include flexor digitorum longus (FDL) or peroneal brevis
tendons
V-Y myotendinous lengthening FHL transfer

20. Defects > 5 cm
V-Y myotendinous lengthening FHL transfer or other augmentation
Turndown procedure augmentation
Requires at least 1-cm wide strip of Achilles tendon
Length of strip must be long enough to span 2 cm above and 2 cm
below the defect
Massive incision required
Bulk of residual tissue at turndown junction may become
symptomatic
Synthetic materials (Marlex / Dacron)
Mixed results; longterm durability questionable
Potential for wound healing complications

21. Surgery or Not ?
 Taylor your treatment to the patient

22. Surgery or Not ?
 Repair is stronger
 Less risk of re-rupture
 Earlier return to activity
 Open or percutaneous

23. 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

24. Many different techniques of surgical repair have been described however which by
itself suggests that there may be difficulties.
One of these is that when spontaneous rupture occurs the tendon is frequently
degenerate and the torn ends can be ragged and not ideal for a neat suture.
The loads transmitted through the Achilles tendon are so great that even the
most perfect suture cannot be relied upon until healing is advanced and therefore
the repair must be supplemented by some method of splintage for several
weeks as in conservative management.

25. It has been known for many years that tendons which are ruptured or divided
outside synovial sheaths have a strong tendency to undergo spontaneous repair.
The collagen fibres in the scar which grows between the ends becomes
organised and orientated to resemble closely the structure of tendon.
Provided the tendon ends are held in close apposition
this natural repair will occur without lengthening and virtually normal function
can be restored
successful method of treatment which involved bandaging the calf and raising the
heel of his shoe for a few weeks with excellent recovery.
If the divided ends of the tendon are allowed to retract, healing will still take place but
with lenthening and consequent loss of power in the affected muscles.

26. Suture Material
A variety of satisfactory suture materials are available for tendon repair
BUT
In clinical situations, most surgeons find that the braided polyester sutures
(Ethibond,Dacron,Ticron, Mersilene) provide sufficient resistance to disrupting
forces and gap formation, handle easily, and have satisfactory knot
characteristics; consequently these sutures are widely used

27. Surgical Management
 Bunnell Suture
 Modified Kessler
 Many techniques
available

28. A, Conventional Bunnell stitch. B,
Crisscross stitch
. E, Modified Kessler stitch with single
knot at repair. F, Tajima modification of . C, Mason-Allen (Chicago) stitch. D,
Kessler stitch with double knots at Kessler grasping stitch
repair site.

29. Techniques for acute Achilles tendon rupture
Krackow suture

30. Lindholm devised a method of repairing ruptures of the Achilles tendon
that reinforces the sutures with living fascia and prevents adhesion of the
repaired tendon to the overlying skin
Lindholm technique for repairing
ruptures of Achilles tendon

31. Lynn described a method of repairing ruptures of the Achilles tendon in which
the plantaris tendon is fanned out to make a membrane 2.5 cm or greater wide
for reinforcing the repair. The method is useful for injuries less than about 10
days old; later the plantaris tendon becomes incorporated in the scar tissue and
cannot be identified easily.
Lynn technique for repairing fresh
rupture of Achilles tendon. A, Ruptured
Achilles tendon has been sutured, and
plantaris tendon has been divided
distally and is being fanned out to form
membrane. B, Fanned-out plantaris
tendon has been placed over repair of
Achilles tendon and sutured in place

32. Teuffer described a method to be used when the possibility of end-to-end
suture of a ragged tendon is remote. His method uses the peroneus brevis
tendon as a dynamic transfer and a reinforcing tendon graft.
Dynamic loop suture of peroneus brevis
to itself when end-to-end suture is
impossible

33. Turco and Spinella described a modification in which the peroneus brevis is
passed through a midcoronal slit in the distal stump of the Achilles tendon. The
graft is sutured medially and laterally to the stump and proximally to the tendon
with multiple interrupted sutures to prevent splitting of the distal tendon stump
(Fig. 46-15). This modification can be beneficial if a long distal stump is present.
Turco and Spinella modification.
Peroneus brevis is passed through
midcoronal slit in distal stump of
Achilles tendon and sutured to stump
and to tendon.

34. Surgical: Percutaneous
 Ma and Griffith
 6 stab incisions
 Less wound
complications
 Injury to sural nerve
 Not anatomic
 Tension hard to
establish
 Guided instruments

35. Techniques for neglected rupture of Achilles tendon
. A, Exposure of Achilles tendon and
tuberosity through posterolateral
incision. Peroneus brevis is passed
through hole drilled in tuberosity
and sutured to Achilles tendon. B,
Plantaris tendon is passed through
ruptured ends of tendon.

36. Bosworth technique for repairing old
ruptures of Achilles tendon

37. V-Y repair of neglected rupture of Achilles tendon. A, Incision.
B, Design of V flap. C, Y repair and end-to-end anastomosis

38. Repair of chronic Achilles tendon
rupture with flexor hallucis longus. A,
Two incisions are made. Medial midline
incision on midfoot is used to harvest
flexor tendon. Posteromedial incision
anterior to Achilles tendon is used to
expose tendon. B, Hole is drilled just
deep to Achilles tendon insertion and is
directed plantarward. Second drill hole
is made from medial to lateral to
intersect first drill hole midway through
posterior body of calcaneus. C, Flexor
hallucis longus is woven through
remaining portion of Achilles tendon to
secure fixation and supplementation of
tendon.

39. TURN DOWN FLAP

40. Turn down flap Artificial material

41. Percutaneous vs. Open
 Less wound complications
 Lim et al.
 33 patients General Consensus: Perc
 7 infections
 Higher re-rupture rate Less wound complications
 Wong et al. Better cosmesis
 367 repairs
 12% re-rupture
 Bradley General Consensus: Open
 12% perc vs. 0% open
 Greater Strength Return to preinjury level
 Cetti Decreased calf atrophy
 111 patients Better motion
Less re-rupture

42. POST OP COMPLICATIONS
•deep infection (1%)
• fistula (3%)
• skin necrosis (2%),
• rerupture (2%).

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

44. Rehabilitation
 Physical Therapy
 Stretching and flexibility exercise are key to helping tendon heal
without shortening and becoming chronically painful.
 Ultrasound heat therapy improves blood circulation, which may aid
the healing process.
 Transcutaneous electrical nerve stimulation (TENS) is sometimes
used and may provide pain relief for some people.
 Massage helps you increase flexibility and blood circulation in the
lower leg and can help prevent further injury.
 Wearing a night brace keeps your leg flexed and prevents your
Achilles tendon from tightening while you sleep. An Achilles
tendon that chronically tightens at night is not able to heal properly.

45. Post Surgery Rehabilitation
 Phase I- PWB(partial weight bearing) beginning 4 weeks post-op
 Gait training (wean from heel lift after 2 weeks if applicable)
Soft tissue massage and/or modalities as needed
Exercises:
 Towel calf stretch
(without pain)

46. Theraband exercises – dorsi and
plantar flexion, inversion, eversion

47. Sitting calf raises BAPS(Biomechanical ankle platform system
Straight leg raises
BAPS (Biomechanical ankle platform system) in sitting
Bike light if ROM (range of motion) allows
May perform pool ex’s also
 The patient may do this mainly as an independent program if
appropriate
 Progress to Phase II when:
 -tolerates all Phase I without pain or significant increase in swelling
-ambulates FWB (full weight bearing) without device
-ROM for plantar flexion, inversion and eversion are normal
-dorsi flexion is at approximately neutral

48. Post Surgery Rehab
 Phase II (6-8 weeks post op)
 Gait training
Soft tissue work and/or modalities as needed
Exercises:
 Standing gastroc and soleus stretches
Bike light to moderate resistance as tolerated
Leg press:
 quads bilateral to unilateral
 calf raises (sub-maximal bilateral to unilateral)
 Sitting calf raises to standing at (generally 8-10 weeks)
BAPS(Biomechanical ankle platform system) board standing (with
support as needed)

49. Step ups
Step downs
Unilateral stance; balance activities with challenges if appropriate (such
as ground clock)
Mini-squats – bilateral to unilateral
Stairmaster – short steps 4", no greater than level 4 if no pain or
inflammation
May continue pool if appropriate

50. Post Surgery Rehab
 Phase III (generally not before 10-12 weeks)
 Frequency at discretion of therapist
Gait normal without device
Standing calf raises to unilateral (generally 16 weeks)
Outdoor biking
Full/maximal one leg PRE's [progressive resistance exercises] (generally
at 16 weeks)
Agility drills (generally not before 16-20 weeks. Should be discussed
with physician first.)
- jogging to running when pain-free
-sport-specific; cutting, side shuffles, jumping, hopping

51. Progress to Phase III when:
-cleared by physician
-can do each of Phase II activities without pain or swelling
-ROM equal bilaterally
-able to do bilateral calf raise without difficulty and weight equal
bilaterally
-unilateral stance balance equal bilaterally

52. Return To Play
 After surgery an athlete should not return to play until
they meet the criteria for progression to Phase III.
 Even after completing Phase III the athlete should
return at the discretion of their doctor and/or physical
therapist.

53. •
Prevention
 Avoid activities that place excessive stress on your heel
cords, such as hill-running and jumping activities
(especially if done consistently).
 If you notice pain during exercise, rest.
 If one exercise or activity causes you persistent pain, try
another.
 Alternate high-impact sports, such as running, with low-
impact sports, such as walking, biking or swimming.
 Maintain a healthy weight.
 Wear well-fitting athletic shoes with proper cushioning in
the heels.

54. Prevention
 To avoid reoccurrence of an Achilles tendon injury:
 Use warm-up and cool down exercises and calf-
strengthening exercises.
 Apply ice to your Achilles tendon after exercise.
 Alternate high-impact sports with low impact sports, so
as not to overwork your Achilles tendons.

55. SUMMARY
 Chronic Achilles tendon rupture
Operative treatment when possible
 Acute Achilles tendon rupture
 Operative treatment for the young athletic higher
demand patient
 Closed treatment for those patients with limited
functional goals or medical comorbidities
 Results for both options similar
 Functional rehabilitation when possible