Keys To Diagnosing And Treating Achilles Tendon Ruptures

Jeffrey Bowman DPM MS

At his muscled peak playing the Greek God Achilles in the film Troy, Brad Pitt suffered the same doom as the hero he portrayed. Pitt reportedly tore his Achilles tendon during filming, resulting in a significant delay in filming. In the classic story, Achilles' mother Thetis dipped Achilles in the river Styx by his heel, making him invincible except for the small area that was not submerged. The Trojan prince Paris ended up killing Achilles with an arrow. The arrow struck the only vulnerable area on his body. From this epic tale, we have the Achilles tendon.

The Achilles tendon is the strongest tendon in the body yet like the hero, it has vulnerability. The watershed area of the Achilles is approximately 4 cm proximal to its insertion in the calcaneus. This is an area of avascularity and decreased thickness to the tendon, resulting in higher susceptibility to tear and rupture.

As for the diagnosis of Achilles tendon ruptures, stabbing pain is usually associated with a traumatic event and the sensation of being hit in the back of the heel. There is usually a palpable defect in the tendon and associated decrease in plantarflexion. Magnetic resonance imaging (MRI) is the gold standard for a true diagnosis.

Conservative treatment is for partial tears, sedentary or older patients, and non-surgical candidates. Treatment consists of gravity equinus casting for six to eight weeks with a gradual decrease in the equinus angle. Patients progress to heel lifts in shoegear. Based on my experience, conservative treatment has a higher incidence of re-rupture.

Surgical treatment for Achilles tendon ruptures is the gold standard. The most popular treatment modality is primary repair of the tendon ending with suture techniques with or without graft reinforcement. There are fascial reinforcements from the gastrocnemius aponeurosis or flexor and peroneal tendons.

Allogenic grafting has increased in popularity to reinforce the suturing technique of choice. No definitive studies have placed one suturing technique over the other.

Clinicians often use orthobiologics to increase healing potential and decrease recovery time. Platelet rich plasma (PRP) has been in widespread use for both assisting the healing of ruptures and for the treatment of Achilles tendonopathy. One would draw the patient's blood, which spins down in a centrifuge to collect the blood platelets. The physician re-injects this blood back to the site of injury to improve healing. Studies support PRP and its use on many inflammatory problems.1,2

Recurrence of injury due to loss of tendon strength is a common complication. Wound dehiscence and infection can occur, but one can avoid these with good incision planning and technique. As with much of trauma, the diagnosis and treatment of Achilles tendon ruptures is relatively straightforward.

The moral of this story is prevention. Teach all active patients proper stretch techniques and preach to them the importance of stretching before and after activity. This will cut down on the weekend warrior injuries we see.

1. McCarrel TM, Minas T, Fortier LA. Optimization of leukocyte concentration in platelet-rich plasma for the treatment of tendinopathy. J Bone Joint Surg Am. 2012; 94(19):e1431-8.
2. Xiong X, Wu L, Xiang D, et al. [Effect of platelet-rich plasma injection on early healing of Achilles tendon rupture in rats]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2012; 26(4):466-71. Chinese.

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