Achilles Tendon Rupture

Acute Ruptures of the Achilles Tendon tend to occur more in men of the ages 30-40. They are usually the poorly conditioned “weekend warriors”. Most of the time this injury is sustained during a sporting activity in which the patient experiences a “pop” and feels like he’s been kicked in the area. Pain, weakness and difficulty walking then ensues.

This injury can also occur in patients of other demographics following a misstep or fall. When this is the case, there may have been an underlying diseased Achilles tendon which is predisposed to the tear.

How is it diagnosed?

A clinical examination is usually sufficient to make the diagnosis. A step would be prominent, and this is usually 4-6 cm from the insertion point. The step or gap would be more prominent if it is a complete tear, as partial ones may not be as obvious. A test known as the Simmond-Thompson test is performed to gauge the amount of plantarflexion – an impaired one sporting less.

Is an MRI necessary?

An MRI is not strictly necessary. However, it gives us added information regarding the size of the tear and is useful to gauge how diseased the torn ends are if surgery is being planned for. This would determine the type of surgery which may be performed.

Is open surgery the only option available?

Open surgery is preferable if the torn ends are diseased and need to be debrided. Depending on the size of the gap left behind, adjunct procedures may be needed to close the gap. If the ends are not diseased, it is possible to perform a minimally invasive technique to effectively repair the tendon. The advantage of this is that there is less scarring and risk of morbidity.

Is surgery absolutely necessary to begin with?

Surgery is not mandatory. There are studies which suggest that the end result and risk of re-rupture is similar between cases treated conservatively and those which had undergone surgery.

However, the time taken for healing and return to mobility and indeed sports would definitely be longer. Additionally, high-level athletes would want to restore the appropriate tension so as to regain strength.

We recommend that frail, elderly and sedentary patients be treated conservatively with functional bracing/ casting, and surgery for the younger active patient who wants to return to early mobilisation and sports.

Figure 1. Percutaneous Repair of Tendo Achilles Rupture.

What about chronic ruptures?

Chronic ruptures are defined as those which have persisted beyond 3 months. They may have been missed, neglected or failed conservative management. An MRI is useful to plan the surgical management which may be required. The surgery which is required in such cases would often require adjuncts such as a lengthening procedure of the tendon in order to bridge the gap or a tendon transfer.