Achilles Tendon Ruptures

Dr. Jeffrey A. Oster, Medical Director Of Myfootshop.com.

The Achilles tendon is the single strongest tendon in the human
body. The primary function of the Achilles tendon is to transmit
the power of the calf to the foot resulting in the ability to
move us forward, allow us to jump, dance; you name it. If it has
to do with motion, the Achilles tendon is a part of that
activity. Occasionally the Achilles tendon looses the ability to
keep up with us and the tendon becomes inflammed resulting in
Achilles tendonitis. This article discusses the onset, symptoms
and treatment of Achilles tendonitis. Achilles tendon ruptures
are also discussed.



Acute Achilles tendonitis

Acute Achilles tendonitis (also known as Albert's Disease)
typically has a abrupt onset with moderate pain 2-3 cm proximal
to the tendons' insertion on the back of the heel. Most
individuals with acute Achilles tendonitis can describe an
injury or single event that initiated the pain. Symptoms of
acute Achilles tendonitis occur at the beginning of an activity
and are typically described as a sharp pain. As the activity
progresses, the pain decreases for a period of time. With
excessive use, the tendon again becomes painful at the end of
activity. For example, runners with Achilles tendonitis
experience pain as they begin their run. The pain subsides
during their run only to recur near the end of their normal
running distance.



Chronic Achilles tendonitis

Chronic Achilles tendonitis exhibits the same type of pain as
acute Achilles tendonitis but the location of the pain is
usually at the insertion of the Achilles tendon into the heel.
Chronic Achilles tendonitis can also cause hypertrophy
(enlargement) of the posterior heel and in limited cases,
enlargement of the tendon. This bony enlargement of the back of
the heel goes by many names including retrocalcaneal bursitis,
pump bump or Haglund's Deformity.

In cases of chronic Achilles tendonitis it's important to
differentiate between pain strictly due to the Achilles tendon
or from the enlargement of the heel rubbing against the shoe.
The difference between Achilles tendonitis and a pump bump can
easily be understood by evaluating the pain while barefoot
(suggestive of Achilles tendonitis) compared to pain while
wearing shoes with an enclosed heel (pump bump). It's not
unusual to find both conditions simultaneously.

This picture shows the back of a right heel, the outside of the
ankle and a few of the small toes. The red dotted line outlines
the Achilles tendon. This is the area within the tendon where we
are most likely to find an acute tear of the Achilles tendon or
tendonitis. The red circle shows the area where the Achilles
tendon inserts into the calcaneus and is the location of chronic
Achilles tendonitis. This are will often become hypertrophied
(enlarged) as the result of spurring that forms on the posterior
heel at the insertion of the tendon. The red circle is also the
area where we would find pain associated with retrocalcaneal
bursitis. The blue area is on the outside, or lateral aspect of
the heel. The blue area is where we would find the symptoms of
Haglund's Deformity or a pump bump.



Treatment of acute and chronic Achilles tendonitis

Knowing that the single greatest contributor to acute and
chronic Achilles tendonitis is equinus (see the biomechanics
section below for more information on equinus), we know that we
need to weaken the calf muscle to allow the Achilles tendon an
opportunity to heal. This can be done by elevating the heel with
heel lifts or by high heel shoes. Inflammation of the tendon can
be calmed by ice, both before and after activities.
Anti-inflammatory medications, casting or ultrasound treatment
can also be used. Steroid injections are typically not used to
treat Achilles tendonitis since injecting the tendon has a
tendency to weaken the tendon resulting in a possible rupture.

Manipulation techniques are also helpful to increase the range
of motion of the ankle. One new technique involves manipulation
of the fibula (smaller outer bone of the ankle and leg) to allow
greater excursion of the talus (foot bone of the ankle). This
technique must be performed by someone other than the patient
and is performed as follows;

1. The patient is placed in a sitting position with the hip and
knee flexed. Standing on the side of the chair opposite to the
leg that will be manipulated, place the index and middle fingers
of both hands over the head of the fibula (That's just below the
knee on the outside of the leg). Using a firm and rapid motion,
manipulate the head of the fibula anteriorly (towards the front
of the leg). A slight shift or pop may or may not be noted.

2. Next, with the patient sitting and the hip and knee extended
(straight) place traction on the foot with the ankle slightly
plantar flexed (toes pointing down and away from the leg).
Continue traction for 30-45 seconds. Then dorsiflex the ankle
(move the foot/toes towards the shin). Complete a series of
range of motion of the ankle with the patient.

3. Repeat as needed.

In cases of chronic Achilles tendonitis, patients who do not
respond to heel lifts, manipulation and anti-inflammatory
medications require a lengthening procedure of the Achilles
tendon with or without a partial resection of the posterior
heel. In cases with minimal hypertrophy of the heel, lengthening
of the tendon will suffice. Lengthening of the Achilles tendon
may be performed through three 0.5cm incisions but does require
a period of casting. Full recovery may take 6-18 months.



Achilles Tendon Ruptures

Chronic Achilles tendonitis is not a symptom to be ignored
based upon the knowledge that Achilles tendonitis is often a
precursor to an Achilles tendon rupture. A rupture of the
Achilles tendon can be a debilitating injury. The actual rupture
of the tendon is described by most patients as feeling as if
they were hit in the back of the leg. An audible pop is often
described. Most ruptures occur 2-4cm proximal to the insertion
of the tendon into the calcaneus (heel bone).

The repair of Achilles tendon ruptures may be conservative or
surgical. Orthopedic and podiatric literature abounds with
articles that compare the merits of conservative vs surgical
care of Achilles tendon ruptures. Re-rupture of the tendon is
not uncommon regardless of the method of correction although,
statistically, re-rupture does seem to occur less in those
patients that undergo surgical repair. These findings may also
reflect the nature of patient that would be a surgical
candidate. Typically we would assume that those patients that
were in poor health (eg elderly, diabetic, immune compromised)
would not become surgical candidates and therefore may
contribute to the increased rate of re-rupture seen in those
treated with conservative care.

Recent articles have advocated a surgical approach for repair of
ruptured Achilles tendons that employs both an open and
percutaneus technique of repair. The most popular method was
described by M. Kakiuchi of The Osaka Police Hospital in 1995.
This technique involves the use of an open procedure at the site
of rupture to enable debridement of the ruptured tendon.
Kakiuchi also employs a closed technique to suture the tendon to
allow for proper healing.

About the author:
Jeffrey A. Oster, DPM, C.Ped is a board certified foot and ankle
surgeon. Dr. Oster is also board certified in pedorthics. Dr.
Oster is medical director of Myfootshop.com and is
in active practice in Granville, Ohio.