Section: CME Category: Surgery Trauma & Sports Medicine

Achilles Tendon Ruptures

Marie Williams, DPM, DHL

Marie Williams, DPM discusses the etiology and mechanism of injury of Achilles tendon ruptures. Dr Williams discusses clinical findings as well as comparing non-surgical and surgical treatment options for Achilles tendon ruptures.

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Goals and Objectives
  1. Define the etiology and mechanism of injury of Achilles tendon ruptures
  2. Distinguish the clinical findings and diagnosis of Achilles tendon ruptures
  3. Formulate a treatment plan for Achilles tendon ruptures
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  • Lecture Transcript
  • TAPE STARTS – [00:00]

    Speaker: The next speaker coming to the podium is one of my great friends and true awesome person is Marie Williams and Marie is going to speak to us about Achilles rupture. For those of you who don't know Marie, she is probably the humblest podiatrist person you will have ever met. If you don't know her, she happens to be in the National Basketball Hall of Fame for women. She is an amazing athlete. She still plays. She won another gold model in the most recent games, right? And then she told me this morning just I'm passing that she also received an honorary doctor from her undergraduate just recently. So it is with great pleasure that we welcome Marie Williams to the podium. Give her a warm welcome.

    Marie Williams: Well, thank you. Okay, so the test questions will be 600 questions at the end, you must stay. I'm teasing. I'm not going to test you about anything. I'm going to talk to you about subject that everyone knows pretty much about. And I actually love the questions by the way because it keeps you guys on your toes, right? But Achilles tendon ruptures are very much a commonplace, believe it or not in our profession. So I'm going to go over some of the basics, very basics. It's a very basic lecture for you. So I just want you to understand the etiology and mechanism of the injury, look at some of the clinical findings and diagnosis for Achilles tendon ruptures and some of the treatment plans and/or how to develop a treatment plan. So remember it's a spontaneous rupture of the Achilles usually most commonly without any real history of any medical problems or calf or heel pain. Some of the heel pain can be mildly painful posterior heel, don't think about it and then all of the sudden they have this pain in the back, will talk about that. Most commonly and then between the third and fifth decade of life and it's actually something that shows that men sustain this 14% more than women.

    00:02:11

    I don't know if it's going to be changed down the road, but it's commonly placed problem in the male population and yet I see many females with Achilles tendon ruptures because maybe more active in sports and all those exercises and Zumba and all that stuff. But also professional athletes that are playing like basketball, football, some are career-ending injuries. Also you might see this from the Weekend Warriors, somebody who is going out, hasn't played sports in the long time and now they are out playing football or basketball. My favorite case was a 65-year-old female, grandma playing football with her sons, went for a long diving catch and she felt like one of her kids hit her on the back of the leg. The common complaint is that there is pain in the back of the leg where somebody punched them or hurt them. This is just a picture of that but one of my patients actually said, I was out, I was there, I was playing and I felt someone kicked me in the leg. I turned around with my fist ready to punch the guy for kicking me in the leg and there was nobody behind me. So remember when they have that kind of emotion is probably a ruptured tendon and I smile and go you probably ruptured your Achilles. And I'm like 100% on when they give you that history. This is just an anatomical picture of the common spot where the tendon ruptures but it can rupture off the heel which I will talk about and/or that 2 to 6 cm area, the watershed area. It's the largest strongest tendon in the human body. It's formed from the tendinous combination of both the gastroc and soleus and it is approximately 15 cm, starts proximal 15 cm above the heel.

    00:04:05

    And then it has a spiral twist between 30 and 150 degree twist until it inserts into the calcaneal tuberosity. I never understood that twist until I saw somebody who ruptured their tendon and the tendon twisted like a rope but it didn't actually tear all the way. It looked like a line of thread just popped in the middle and it didn't actually cut in half, but it was still a ruptured tendon because the twist was completely disrupted. So you have this gliding ability of the Achilles tendon which is aided by this thin paratenon. It's not a synovial sheath because it's not a tendon that attaches to joint. It arises from an osseous insertion and also it has a musculotendinous junction with multiple infiltrating mesosternal vessels which cross the layers of the anterior paratenon. It's highly vascular until it's not. You start to lose your vascularity around that 2 to 6 cm area and therefore it's where you've high tension and rupture rates that are increased. Achilles tendon ruptures in the area of the poorest blood supply arch the called the watershed area, 2 to 6 cm proximal to the insertion of the calcaneus. The mechanism of injury is usually a sudden forced plantar flexion, unexpected dorsiflexion and violent dorsiflexion of a plantarflexed foot. Basketball player, football player, tennis player, someone running fast, things like that. Sometimes in car accidents but not really that's rare. More in the action mode of sports or walking. I had a recent patient come in and she was very dehydrated.

    00:06:03
    And I think dehydration can lead to a lot of these where they are not really hydrating after exercise or during exercise and then you get weakness to that tendon. We will talk more about that. So about the etiologies and adverse influence of oral or topical corticosteroids. How about the guy that has been getting injection into his heel because he has posterior heel pain around the Achilles and someone keeps putting steroids in there and eventually the tendon tears and they don't understand why? And that's very highly suspect to be doing something like that and there are other alternatives to that type of treatment. Antibiotics, quinolones were the only real antibiotics that were creating a lot of these problems but now there is a literature out there about tetracyclines and typical Z-PAK, Zithromax, so be cautious of that. There is exercise induced hypothermia and there is also mechanical abnormalities, a very high cavus foot with equinus that could be a possible mechanism to give you a part of the etiology as the problem. Symptoms of course are sudden increase in pain around the Achilles tendon. There is weakness, poor balance. These are things that can cause ruptures. Most of the time, as I said, people come to you, they tell you that they felt like someone kicked them or punch them in the back of the leg and/or they were shot in the leg. They just feel like something happened but no actual twist or turn to the foot and/or ankle. There is all these tests. I mean Thompson test is probably the one I use the most, little squeeze test in the back. I actually use two things. I use that and I use the palpable dell and you can feel it. The Kager's triangle and Toygar's angle are used but I mean they are kind of just an incidental, oh look, there is -- it's the soft tissue, now you can see this soft tissue density in the back of the leg and now with the advent of MRI, you don't even have to really use these topical test many times.

    00:08:11
    This is just the Thompson test where you squeeze the back of the calf and you get plantar flexion on the unaffected side and where the affected side, there is no movement or motion and yet they have good range of motion. If you ask them to move their ankle and dorsiflex and plantar flexion -- as matter of fact, dorsiflexion they had, now they have because the tendon is torn. So they go I don't understand but I can move my ankle great. You are like okay, great, that's really not a good thing. So you can see the palpable dell. On physical exam, there is usually pain, swelling, ecchymosis, palpable gap, weakness on active plantar flexion. They usually can't stand on their toes. I don't recommend doing that any way. If you know that that's what it is, don't ask them to stand on their toes. They are not going to be very happy with you. Hyper dorsiflexion is one of the signs that I actually know that I'm very -- 90% certain in my own diagnosis that it's a rupture and/or partial rupture. The O'brien needle test, I don't do but just for educational purposes, you just put a small gauge needle in the insertion perpendicular through the skin into the tendons. Most people won't let you do this. This is just for educational purposes and you can actually see the needle on the opposite direction of the tendon during passive ankle joint dorsiflexion and it confirms that the tendon is intact or not. Ultrasound and MRIs. Now, there is a section in this area where -- first of all ultrasounds are really incredibly helpful especially if you get someone with a pacemaker. You don't want to send someone to go get an MRI if they have a pacemaker. Makes you look a little silly and then they tell you, doctor, I have a pacemaker and I know I'm not supposed to get that. You are like oh, yeah, that's right. So let's do an ultrasound. But these imaging tests, ultrasound and MRI are very classic. I left this slide in because there is one error in the slide now. I think it wasn't in the past. It says on the very bottom, it says MRIs and it talks about limited clinical value and inability to offer dynamic testing.

    00:10:27

    MRI is not routinely indicated in patients with tendon rupture. False. It was because what happened was MRIs are super expensive and you are like what you are doing anyway. You can feel it, you can see it. MRIs are very much a good tool to do. It's not not-indicated. As a matter of fact, if you are ever asked, did you the do the MRI and you said no, it's not. It's usually asked, where is the MRI report? How do I know it's ruptured? How do you know it's ruptured? This is your actual proof that you know what you know. So I do MRIs on everybody even when I know it's completely ruptured. Number one, you can see the distance on MRI, you can get a lot more data, any other tendons that are torn or any other problems, soft tissue injury or whatever. Radiographs don't really help you although you do see soft tissue swelling, increased ankle dorsiflexion, calcification sometimes in the tendon itself. You may see avulsion fracture of the calcaneus and/or Haglund's deformity. But that only helps you or guides you in what you are going to do next. This is just an MRI T1 weighted as well and you can see here where there is a complete disruption of the Achilles. In [indecipherable] [00:11:45] 1990 did a classification of Achilles tendon rupture, we all have classification of some type. One, two, three and four. And it usually is classified by partial tear, complete rupture with the defect less than 3 cm, a complete rupture between 3 and 6 cm and then the last one complete rupture with the defect greater than 6 cm. So it's just if you need to have it classified, this is the classification that's commonly used.

    00:12:14

    Treatment options. You have the nonoperative therapy. It's used for the elderly cast immobilization, functional bracing like CAM boot or something like that. Surgery, open surgery. There is also open surgery with augmentation and without augmentation for the young athletes and patients that are very active. Age is not my personal requirement for surgery. I've done as old as 80 in active people. And then there is percutaneous repair and that's used for either the people you don't want to open up, elderly, maybe cosmetic reasons. I'm not a percutaneous Achilles tendon user, so I don't really talk about that as like the absolute way to go but it is an option and you should have that in your treatment plan. So here is the nonoperative treatment and basically you have some of the researches shows that when you do cast immobilization alone, you have high re-rupture rate, almost up to 12% with muscle atrophy and weakness. Sometimes you get joint stiffness around the ankle joint, possible DVT because you have them immobile for so long. They can get ulcers atrophy and also with the functional bracing in addition with post casting, you have a less of re-rupture rate. But overall, the re-rupture rate in nonoperative Achilles is high. I had a patient in his 80s. He had peripheral vascular disease, calcification in not only his tendons but his arteries more than his tendon. And I decided, okay, the only thing I'm going to do for him is treat him by simple CAM boot.


    00:13:59

    80 years old and I gave him a cane. He lived another six years, the happiest guy in the world without any complications. No wounds, no worries. And he was able to get around. So you have to look at your patient. You have to decide what's most ethical for that guy. Even though for me, absolutely, I would have him up and running and strengthened in very short order with the treatment that I do but I was not willing to risk him nonhealing. So the goal is to restore the preinjured strength and function. Well, that's a very big statement because I don't know about any of you have done these but usually they still limp, they feel a little weak, they can't push off, they scar, the tendons are thick. These are some of the problems, right? And so you are trying to -- actually the goal was to restore the preinjured strength and function. I think we have come in this present day close to being able to do that with a lot of modalities that we have which I will go over with you. Advantages of the surgery include less re-rupture rate, less 0 to 5%, it's a higher percentage of patients that can return to sports and activity much faster with less scar and increased power and endurance. The disadvantage is that it's surgery which includes going to the OR. Sometimes the costs are higher and you may have wound complications and/or suture infection, skin slough, adhesions and maybe if you are not careful, sural nerve injury and so these are some of the things that maybe considered complication of disadvantage to going to surgery. I do open repair. There is a medial incision. You use a tourniquet. I'm going to go over this but the medial incision is good because you can actually visualize the plantaris if you need to use the plantaris as actual augmentation. You want to avoid the sural nerves. So that's one of the best ways. I tend to go midline or midline medial for my incision. It reduces adhesions.

    00:16:06

    If you go midline alone, sometimes you have scar and adhesion but I'm going to show you how we can prevent that. This is just an example where the sural nerve is drawn out. This is a bit midline maybe midline medial and then you can see as you open it up, you have a nice paratenon. What you will always see is this little area of hematoma. You don't even have to look, you will know that that's where the rupture is. You can see this paratenon opening. Preserve that paratenon. It is the vascularity to the tendon. Once you open it up, you will start to see the hematoma formation and then you will see these two ends of the tendon that look like mop. They tuck like a mop, an end of mop. You want to get these as close end to end as you can and there is all types of suture repairs. You have the Krackow, you have this [indecipherable] [00:17:00]. I'm going to go over the couple. These are more for you personally if you are doing testing or anything like that but you can see this is the Krackow. That's the one of better sutures in my hands for repair. You can see this is how -- it's basically a running baseball stitch which now has a fancy name. Of course, anything with a fancy name has more importance. So there you go. Anyway, that's the stitch. You can see it's locking and it's very strong and so pull out of that is very strong. As you go, you can see end-to-end and there is end-to-end repair. Make sure you are closing that paratenon, very, very important that the paratenon is closed and you don't disrupt it and basically that's a closure. This is another type. It's a basically a box stitch. You have the Bunnell stitch. This just shows you how you can actually tie the two ends together with a knot on the side. You want to put this in equinus so you actually getting end-to-end tendon and slowly take them out equinus. Here is the [indecipherable] [00:18:08] where you are actually taking the central strip if you don't have the length to actually put end to end repair, so you have internal graft.

    00:18:19

    You have the Lindholm where you are taking the double strip and I just want to go back to that. I don't use any of those now because of the augmentation materials that I use. I have two studies. This one I wanted to mention and the reference is in the end of the lecture but it was a study that showed best suture method for the strength of the Achilles rupture. They took three groups. They had Bunnell type, they had Bosworth type and they had anchor method with sutures. Now, you have to think, first I go, okay so how do you do an anchor method with middle tendon rupture at the 2 to 6 cm where you don't have any near bone. So the actual tendon repair was with the short rip, a short tear where you can almost get that piece close to bone. If not, you could at least anchor that proximal portion to bone. That was the anchor system. So there was no significant difference in group A and B with whether it was what type of procedural suture that you did whether it was the Krackow or Bosworth or the Bunnell. It didn't really matter how you were sewing it. The actual pull-out strength didn't really have any significant difference. So I know in my hospital everyone is like you must do a Krackow. It's the strongest. Well, this proves that's not really true. And by the way, it wasn't suture type either. So they were equal whether they had the same suture and/or the same type of closure. But what had strength was the anchor system and I'm going to show you that. Again, there was a greater tensile strength when you were able to anchor the tendon to the bone in any one of the anchor systems.

    00:20:02
    Some actual validity to tendon-to-bone anchor. Percutaneous repair. This is for completeness sake. I've not done these very often and I'm better off -- for me personally I like to open it, see it, repair it and close it. So this is just for you to know that there is now companies that have techniques for you. Several companies where you can actually grab the tendon percutaneously and have the suture coming through. You are just putting the tendon together without looking. And I wouldn't really tell you that I'm an expert in that area. There is advantages to percutaneous surgery on people who you don't want to go into surgically and open them up and worry about a wound. End-to-end versus augmented repair of an acute tendon rupture. I'm an augmented type surgeon. I will use the Krackow end-to-end with augmentation. These are just example of someone with the Krackow. There is advantage and disadvantages. Dr. Lee wrote an article in 2007 when we were starting to use a lot of the augmented materials to actually evaluate these. We used the material called Graftjacket, now we call it -- there is many acellular dermis products on the market. It doesn't really matter which one you use. Acellular dermis is very strong and there is a lot of other ones on the market. But you can see that initially the disadvantages of getting autologous graft and stuff will, he said, increase the surgical time, increase the surgical difficulty and then decrease the strength at the donor site. And so what they did was they started to use these augmented tissues and it was technically not very difficult and your return to activity was less than 15 weeks and it was a very favorable way of treating them without re-rupture.

    00:22:09
    I use this acellular dermis on all of my ruptures. I use a very thin one so that it's not really bulky. At first, I used the bulky ones. I found that the skin dehisced a bit. There was too much pressure on the skin line. And the strength was equal, so I will show you some of that. So here is just a quick open versus percutaneous. On the percutaneous side, you have the lower rate of wound infection or damage to the nerves and definitely an improved cosmetic appearance as opposed to an open where you have more adhesions, you have risk of surgery that will possibly injure the nerve, delayed wound healing, hematoma and possible skin necrosis. And there is ways you can prevent all of that. Here is just an example of Achilles tendon rupture. They come in, it's very thick. You honestly don't have to really send them anywhere. You know it's ruptured. You feel it. They tell you it's rupture as they felt it coming on the way when they didn't have any one behind them. So this is an interesting case because when I opened it up, the tendon looked like it wasn't really in half but it was all rolled up like shrunk up in a little ball. So I unrolled it. I actually had to cut it, the dead portions of the tendon and then repair it. So then after I did that, I used an acellular dermis and then on top of that what I do now is I augment it with an amnion material because I think that you get less scar, increased strength and less swelling. And my postop recovery and pain recovery is unbelievable. So I use a combination. Everyone teases me like what else can you put in there. If I find something that would help it faster up, I will put it in there. So I use a combination a lot. So that's just an example of that. Here is another one where you actually -- all pretty much looked the same where they are really in pieces and then you are going to now get them end-to-end.

    00:24:06
    I put my acellular dermis. This is a very thin acellular dermis. It's probably 0.5 cm thick. It's 2 x 4 hand Graftjacket from Wright Medical. I'm not being paid to say that. I'm just saying that. That's what it is. It's really thin, very strong and I've been getting better results with that. This is an Achilles tendon rupture where it ripped up right off of the bone and now we are going to anchor it because the anchor system as I said showed really strong construct. So I will use a knotless system and there is all type of anchor system, tendon-to-bone, that I like. I drill two holes and I actually do bury the suture. This is just an example of that being buried in and then of course, there is actual procedure that I use. This is like dial in. I'm going to use this to dial in the tension, very simple. And the tendon, you can wash the tendon, glide right into the bone and I really like that repair. I've also used other knotless systems where you can actually roll it in like fishing rod. I will show you that too but you see how I augmented always with an acellular tissue and then I close it. Again, here is another one where you had a heel spur rupture where I had a large posterior fragment, I will show you that, and then a tendon rupture right off of that spur. This is me lifting that spur up and out of the wound. That's just a fragment of bone and once you did that and now you had the end-to-end piece of tendon. And this is another knotless type system where you drill holes into the calcaneus. You actually clamp the Achilles with a thread where you actually -- this is the drill and then you are now loading your suture on to your pin and then that's going to actually dial right into the bone and it's a really nice system, very strong.

    00:26:10
    There is another article, it didn't show up in the slide where it shows that again it didn't matter what sutures you use, end-to-end wasn't as strong as bone-to-tendon. And there is the actual system where you are taking that thread and now you have it well tied to the tendon and now it dives deep into the bone without any knot. So the knotless system is the one that I like the best. And then I also augmented and there is that small little graft tissue that I used and I also put some amnion in there. Now, this is never a popular lecture for anyone who sells these types of thread. This is fiber wire. There is a lot of them out there. I'm pretty much an anti -- I've seen many complications. Let's just put this way, I've seen many complications of these threads and many years later, I've had a patient come to me with the draining abscess of their knee where they had a patellar tendon repair. And I kind of opened up the abscess and all of the sudden I was just pulling this material out because it doesn't absorb and slowly over time caused reaction. So this is a reaction to actual fiber wire which caused the tear in the tendon. So the guy had this looks like a very bad infection. It was infected. What was really interesting is when I opened it up, look at the hole that was created in the tendon and he had no function of the tendon. He had scar and pain and that was the reaction to that tissue. So I took all that out and then of course I cleaned up the tendon and I repaired him end-to-end and actually wrapped the tendon to actually give its strength and he had very little scar. He had no more reaction. Of course, I didn't use any -- I used all nonabsorbable thread and he went on to full healing but it was months and nobody could diagnose him except that he had an open draining wound. Very interesting.

    00:28:07
    So this is just that repair. Now, this one I knew it's reinforced with bit thicker tissue, but over the hole where the wound was, where the skin was weak, I've said to myself, this is probably going to dehisce because it's really weak point. So I put a graft material there that I knew is good for wound care as well. So it's sort of like killing two birds with one stone. I think it worked really well because it did dehisce in that one spot and then I had this tissue that would granulate for wounds. So it really did help. So I just want to show that was a double repair. Postoperatively, old treatment was, you know, it was going to take three months to really get back into activity. There are many articles on that. If you did keep them immobile for a short period of time up to six weeks, then begin range of motion, you had very little re-rupture rate. My postoperative care, this is the physical therapy treatment in that type of patients but mine is very different and I want to show you that. Mine is three weeks nonweightbearing in the CAM boot or a cast to your choice. And then in the next three weeks, I do a partial weightbearing in the CAM boot. Because of my graft material, it was so strong and after three weeks, tendon healing really starts to really take place and become more solid. And then I start active range of motion in postop six weeks. In six to eight weeks, I return him to full weightbearing. I sent him to physical therapy where they do gravity exercises. So they are in the machine where they are running in the machine, antigravity machine and I get them to full strength. Believe it or not, by 12 weeks, three months, they are back to activity and actions. So it's really kind of much more fast and rewarding result for patients and they love that, that they can get back quick and easy, especially when they are told Achilles tendon ruptures are nightmare and you are done, no more Weekend Warrior for you. But we get them back into action.

    00:30:19
    So that's basically my postop treatment. There is a lot of references on types of Achilles tendon ruptures and things for your own for later. And also there is another one we will add to this down the road. This is the article that came out with the biomechanical study of the rupture of the tendons and basically point of interest about suturing because everybody has their method of suturing. There is this better. And when you put it on study level, it doesn't really make a difference. Just get the two ends together and augment it. Thank you.

    Speaker: Marie.

    Marie Williams: Oh yes.

    Speaker: Just one comment. I think you should add statins to your list of potential drugs that cause Achilles injuries. And one question, in your experience -- at least in mine, most of the patients have preexisting equinus. What's your gap threshold once you clean out the tendon ends before you might consider an augmentation like an FDL or fascia lata graft or even maybe gastroc resection where you are pulling the proximal end down?

    Marie Williams: That's a great question. So the way I do that is I actually -- when you are trying to get it together and you are not, I've very rarely used any -- I tend to use plantaris to help augment that and/or my graft tissue which is stronger than any of the human body tissue like the fascia lata or anything. So I will use an augmentation that I will make as part of the tendon and then down the road, that will then regenerate as part of the tendon.

    00:32:03

    So I have filled the gaps with the augmented tissue and that's how I will do it.

    Speaker: Any comments on partial tear treatment?

    Marie Williams: I'm sorry what's that?

    Speaker: Any comment on partial tear of the Achilles tendon, what your treatment protocol is and do you use any of those injectable amniotic products?

    Marie Williams: Absolutely. I use injectable amnion quite often, especially in the partial tear or the tendinosis and the way I do that is I will put them -- I will inject them, percutaneously all through the tendon and I will put them in the CAM boot for two to three weeks and believe it or not within about three weeks, I have incredible pictures of this where the tendon actually looks like a normal tendon. The thickness and the swelling around the tendon actually become more realigned and the research on that I just showed you that when you have partial tear of the tendon, you have these pieces that are thick and bold up. And when you start to put the amnion tissue in it, it doesn't matter -- I'm chorion-free amnion person. What happens is the tendon fibrils will realign and that's what the augmentation of those amnions do. So they take the scar away, they replace that tissue and that's why the tendon that's very thick and bold is now become back to normal in a very short order. So that's basically how I treat that. Any other questions before I go?

    Speaker: It's not absorbable, the 2-0, you said your suture material.

    Marie Williams: My suture is always absorbable. I have had too many complications unless it's knotless system that comes in the system with the nonabsorbable suture, all my sutures are repaired with 2-0 Vicryl.

    Speaker: What's your rule with the Strayer in addition to this higher up as well as using FHL tendon for augmentation?

    Marie Williams: Basically, I will do that if there is a lot of equinus but it has to be significant. And I do not use any other tendon -- I don't use the FHL tendon. I do not remove good healthy tendon since we have these materials that augment. I honestly have not in the past 15 years used any other tendon but my augmentation materials, particularly acellular dermis Graftjacket like material. Thank you.





    TAPE ENDS - [34:40]