Management of Chronic Ruptures of the Achilles Tendon
Achilles tendon rupture is not a common injury but it is being seen more often now, particularly among middle-aged men who are so-called weekend-warriors or weekend athletes. Often, the injury occurs but the patient doesn't see a doctor until about four to six weeks after the injury. At this point, the rupture is considered to be a chronic rupture. This delay could be because the injury wasn't all too bad and the patient didn't realize that he had damaged the tendon or, if it was more severe, it could have just been neglected or even misdiagnosed.

The signs and symptoms of an acute Achilles tendon rupture include a sharp sudden pain in the calf and this makes it fairly easy to make the diagnosis, although up to 20 percent can be misdiagnosed. Chronic rupture, on the other hand, may not cause much pain and can be easily misdiagnosed. The patients may still have satisfactory range of motion, although a limp may be noticeable.

Unlike treatment of acute ruptures (ruptures that have just happened), where doctors often disagree on the best methods, chronic ruptures are almost always treated with surgery.

The Achilles tendon plays a major role in walking and maintaining foot and ankle stability; it runs down the back of the lower leg to the heel. With a chronic rupture, the tissue can become quite thick and immovable, making it hard to move the ankle properly. Because the diagnosis is easy to miss at this point, there are several tests that may make it easier to spot. These include, the calf squeeze test. With the patient prone on the examination table, with feet over the edge, the physician squeezes the calf. If the Achilles tendon is intact, it will pull on the foot, causing it to flex.

Another test, the Matles test, is performed with the patient still prone but with the legs bent at a 90 degree, or right, angle. If the tendon is intact, the foot should stay straight. The O'Brien needle test is more invasive. With the patient still prone, a needle is inserted into an area near the Achilles tendon; the foot is then held by the physician and bent forward and backward. The movement should make the needle move with the movement of the tendon if the tendon is intact. Another test, using a blood pressure cuff, a sphygmomanometer, has also been used. The physician wraps the cuff around the patient's calf and pumps up the cuff to 100 mm Hg of pressure. The reaction of the foot, while the calf has the pressure on it, will indicate if the tendon intact.

X-rays are helpful, but can also be used to rule out other problems, besides the tendon rupture or in addition to the rupture. Ultrasound is also useful but isn't always accurate. Magnetic resonance imaging (MRI) can also be done as well.

When managing a chronic Achilles tendon rupture, physicians have the option of conservative, nonsurgical approach, or surgery. With the conservative approach, improvement usually is slow and the results, according to research, seem to be less successful than surgery. Patients who go with the conservative approach often benefit from bracing.

If using surgery to correct the tendon rupture, there are different types of surgery to consider, depending on the rupture. If the rupture is no more than an inch (1 to 2 centimeters), it can likely be fixed with an end-to-end repair, while wider ruptures need to have the tendon lengthened or even supplemented by using tendon tissue.

Another type of surgery,a tendon alignment, is done by joining the ends of the ruptured area, while another method, using turndown flaps uses a flap that covers the rupture.

Using tendon tissue from another part of the body, from the fifth toe, for example, can also be used. Grafts from donors and synthetic grafts are also being used for these repairs.

The surgeries just described all needed traditional incisions and surgical techniques, but surgeons are now looking at endoscopic surgery for tendon repair as well. This type of surgery is becoming increasing popular because they require only a few tiny incisions, through which the surgeon manipulates the tools, using a camera to see inside the body. This type of surgery, called minimally invasive surgery has many advantages, including shorter healing times.

Management after surgery is very important to keep the integrity of the repairs. Although there don't seem to be any long-term studies that look at the management after surgery, the current thought is that patients need to begin moving and using their foot as soon as possible after surgery. The foot would be immobilized, usually in a plaster cast, for two weeks, followed by a splint for another few weeks. At six weeks, the patient should gradually be able to begin using the foot as usual.

The authors of this article write that tissue engineering may be the future of chronic Achilles tendon rupture repair, with several studies that are ongoing now. In conclusion, they write that although the ruptures aren't common, they can be debilitating and need to be managed effectively for the best possible outcome.
Nicola Maffulli, MD, MS, PhD, FRCS(orth) and Adam Ajis, MRCSEd. Management of Chronic Ruptures of the Achilles Tendon. In The Journal of Bone and Joint Surgery. June 2008. Vol. 90. No. 6. Pp. 1348-1360.