How To Address The Neglected Achilles Tendon Rupture

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

   Following a complete rupture, symptoms may parallel the former with an addition of inappropriate posterior group tensioning, including weakness and over lengthened tendon healing. Patients may complain of unsteady gait, difficulty with step climbing, a limp with ambulation and difficulty with heel rise. Classically, this is why the patient seeks treatment. The patient may notice weakness from the previous baseline and a difference from his or her contralateral limb. Not infrequently, the patient does not recall the actual rupture or simply did not realize its severity and failed to seek guidance.

   The physical exam may show a palpable gap or conversely a bulbous segment where irregular regeneration has occurred, depending on the length of delay of the presentation. Increased dorsiflexion in comparison to the contralateral ankle with diminished plantarflexion strength is common. Pain may or may not be present. Propulsion is ineffective and one often sees a calcaneal gait. Gastrocsoleus muscle atrophy may also present as the deep flexors serve to plantarflex at the ankle instead of the gastrocsoleal muscle group. This combines with scarring to create a wasting effect.

   The physical exam is sufficient when there is an acute Achilles rupture. However, when there is a neglected rupture, obtaining magnetic resonance imaging (MRI) can be helpful in determining the extent of Achilles tendon damage. If there is a partial rupture of less than 50 percent of the tendon on transverse or cross sectional views, one should exhaust conservative efforts as they can facilitate dramatic improvements.

   When examining Achilles tendinopathy (non-rupture patients), Magnussen and colleagues assessed the literature and determined eccentric rehabilitation for three to six months can have positive outcomes.10 One can expect success rates with conservative care to range between 30 to 50 percent when less than 50 percent of the tendon is affected.11,12 Achilles tendon rehabilitation addresses inflammation, weakness, flexibility and biomechanical malalignments.

   If the MRI reveals greater than 50 percent cross sectional tendon involvement and there is accompanying pain and/or disability, one may consider surgical repair. When functional deficit and weakness exist, MRI is not as critical and one can make decision to proceed to surgery clinically.

   However, even in the presence of over-lengthened tendon healing and functional failure, obtaining a MRI can assist with determining the extent of involved tendon derangement and can facilitate procedure choice. Also, the MRI serves to confirm viability of the flexor hallucis longus (FHL) tendon in case of transfer.

   We do not recommend corticosteroid injections for the Achilles tendon for the known risks of collagen weakening and ultimate rupture. Relative contraindications to surgical intervention include: arterial insufficiency; superficial infection; inadequate soft tissue envelope; and poor medical condition. One must also consider age and functional demands.

   Ultimately, the decision to perform surgery for a neglected Achilles tendon rupture is based on a discussion with the patient to determine functional goals and the known risks involved. Surgical complications can be expected following an Achilles repair. Paavola and co-workers reported an 11 percent complication rate in 432 patients.11 Their complications included skin necrosis, superficial wound infections, seroma formation, hematoma, scarring, sural nerve irritations, tendon rupture and deep vain thrombosis.

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