A Closer Look At Treatment Options For Neglected Achilles Tendon Ruptures
Achilles tendon rupture occurs frequently and if it is neglected, there may be significant long-term disability. Early diagnosis of an acute rupture and prompt initiation of treatment will generally lead to optimal results. Acute Achilles tendon ruptures may be misdiagnosed up to 25 percent of the time.1 In other cases, patients may not seek immediate medical care if they are able to ambulate and the pain is tolerable. It may be weeks or months before the patient receives a referral or decides to pursue treatment. Ultimately, continued functional impairment and alterations in gait cause the patient to seek medical attention.
An Achilles rupture is considered chronic if treatment is delayed greater than four weeks.2,3 Contraction of the gastrocnemius-soleus complex may occur as early as three to four days after rupture.4 As a result, any delay in diagnosis and treatment will worsen the outcome and treatment options become more limited.
Pertinent Diagnostic Principles
Patients will often complain of pain along the posterior lower leg and present with an antalgic gait. They often report difficulty with stairs, complain of weakness and instability, and are unable to jog or run.
The physical exam may reveal a palpable gap. However, with delayed presentation, one may palpate a bulbous segment. This bulbous segment represents disorganized, irregular scar tissue and, over time, as the calf muscle contracts, the fibrous scar tissue stretches and heals in an elongated position. As a result, one will note weakness due to a loss of mechanical efficiency of the triceps surae complex.5
On the clinical exam, there is increased dorsiflexion with weakened plantarflexory strength in comparison to the contralateral limb. There is often calf atrophy and the patient is unable to perform a single leg heel raise. The Thompson test, in which the patient lies prone with his or her feet hanging over the edge of the exam table and the clinician squeezes the calf muscle to stimulate contraction, may not be as reliable. Thompson and Doherty noted that in chronic Achilles tendon ruptures, the tendon might adhere to surrounding structures, leading to a weak plantarflexion response when one squeezes the calf, leading to a false negative finding.6
Physical exam findings are fairly consistent and are often all that is needed for acute Achilles tendon ruptures. However, in the case of a chronic rupture, magnetic resonance imaging (MRI) is helpful in determining the extent of injury. Magnetic resonance imaging is an essential component of the surgical plan as the distance between tendon ends will have a direct impact on the surgical decision.
Essential Treatment Considerations
One should consider surgical management for active individuals. The treatment should restore the continuity of the tendon with as close to normal length-tension relationship. When it comes to neglected ruptures, the large gap between tendon ends often makes end-to-end repair impossible. In a series of patients treated four to 12 weeks from the time of injury, Porter and colleagues found an average gap of 3 to 5 cm between the tendon ends after removal of the fibrous scar tissue.7
Surgeons often repair smaller gaps (less than or equal to 2 cm) with an end-to-end technique.8 One may also attempt an end-to-end repair for gaps up to 3 cm. In these cases, surgeons may perform tendon mobilization by placing a Krackow locking stitch at the proximal segment and applying distal manual tension. However, the surgeon is cautioned against repairing the tendon with excessive tension and therefore should not hesitate to perform a fascial advancement to close the gap.9,10