How To Address The Neglected Achilles Tendon Rupture

Bradly W. Bussewitz, DPM, and Terrence M. Philbin, DO

Given the common presentation of neglected Achilles tendon ruptures, these authors discuss signs and symptoms, and keys to diagnosis. They also survey the literature and offer their perspectives on excision with direct repair and performing a flexor hallucis longus transfer.

A neglected Achilles tendon rupture is one that has gone without treatment for more than four weeks.1 It is common to see neglected Achilles tendon ruptures in foot and ankle practices around the country.

   Why is this the case? There are two reasons. Acute Achilles tendon ruptures are occasionally missed or misdiagnosed in emergency rooms and urgent care centers. Alternately, the patient may not bother to seek care due to the fact that the pain is often tolerable and the limb still functions well enough for ambulation.

   It may be weeks or months before the patient is referred or decides to seek treatment from a foot and ankle specialist. Most of the patients presenting with Achilles tendinopathy, whether they do so post-rupture or not, are individuals who maintain an active lifestyle, recreationally or competitively.2 Achilles tendinopathy is described as pain, limitation of activities and swelling related to tendon degeneration.3 In regard to the incidence of Achilles rupture, it reportedly occurs in 18 out of 100,000 people, mostly athletic men in their 20s and 30s.4

   The Achilles tendon is the strongest and thickest tendon in the human body. However, the amount of force placed across it at times can unfortunately lead to rupture. Currently, many surgeons advocate surgical repair in the acute setting. Surgical repair offers decreased re-rupture rates in comparison to non-operative care. Researchers have documented rates as high as 10 to 30 percent with conservative efforts along with decreased functional outcomes.5

   Researchers have shown that non-operative treatment can lead to a decrease in plantarflexion and decreased stamina in comparison to a surgically repaired Achilles.6 Early weightbearing is crucial to facilitate proper healing and full functional return, and surgical repair allows earlier range of motion.

   The suspected mechanism for rupture is excessive muscle contraction with a lack of inhibition, most often occurring on an already degenerative tendon. The Achilles tendon can be damaged with or without rupture. Various authors have suggested several possible causes for Achilles tendinopathy. These potential causes include overuse, decreased blood supply and collagen change with age, muscle imbalance, insufficient flexibility, and malalignment.

Essential Diagnostic Insights

The presenting symptoms vary depending on multiple factors. The rupture may be a partial rupture, including multiple foci of “micro-tears.” In this subset, tendon healing/remodeling has likely faltered, leading to pain and/or a soft, non-functioning tendon. Both lipoid and mucoid degeneration can occur with the former having fatty deposits and the latter having a soft grey/brown appearance.7

   The healing mass may itself become painful at a bulbous segment, which one would usually note around the midsubtance or watershed area, 2 to 6 cm proximal to the Achilles insertion. Clinicians can observe abnormal (nonparallel) neovascularization and varicose nerve fibers where poor healing has occurred.8

   Also bear in mind that neurotransmitters such as glutamate have recently been isolated in elevated concentrations in pathologic tendon tissues and may relate to pain in a degenerative Achilles.9 Similar to a complete rupture, this variant may also have a strength deficit during propulsion.

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