ACHILLES TENDON RUPTURE

“Achilles”, (Brad Pitt, in “Troy”, Warner Bros, 2004)

“He dropped to his knees with a scream, the dark cloud of death enveloped him, as he sank, he clutched his innards to him with his hands. When Hector saw his brother slump to the ground, his eyes were dimmed with tears…

… Achilles next struck Tros through the liver with his sword. The liver slithered out and drenched his lap with dark blood. Darkness enveloped his eyes as he lost his life. Achilles then attacked Mulius and stabbed him through the ear with his spear, so forcefully that the bronze point exited through the other. Next he struck Echeclus to the head with his hilted sword, the whole blade running warm with his blood. Inexorable destiny and purple death closed Echeclus’s eyes. Deucalion was next. Achilles pierced his forearm with the bronze point of his spear just were the sinews of the elbow are attached. Deucalion waited for him, his arm weighed down by the spear and looked death in the face. Achilles struck the man’s neck with his sword and sent both head and helmut flying off together. The marrow spurted out of his vertebrae as he lay there stretched out on the ground.

…The Trojans withdrew from battle and gathered together to assess the situation. Nobody dared sit down and rest, out of fear they held their meeting on their feet, since all had been aghast at Achilles reappearance after long absence from the war. The discussion was begun by wise Polydamas, the only man among them who looked into the future as into the past.

“It is my opinion that at this distance from the walls we should withdraw into the town now before daylight catches us in the open by the ships. So long as Achilles was in dispute with Agamemnon the Greeks were easier to fight…but now I am terrified of swift footed Achilles…believe me we must retreat to Ilium, you have seen what he can do. For the moment the blessed night has checked him. But tomorrow as he charges out again in full armour and catches us here, well, I don’t need to tell you the rest. The man who gets away from him and reaches sacred Ilium can thank his stars. Its Trojan flesh the dogs and vultures will be feasting on. ”

The Iliad, Homer 8th Century B.C.E

From the moment Achilles burst forth onto the beaches of Troy the Trojans faced a terrifying enemy. As he was “god-like” no mortal man could harm him. Achilles at birth was dipped into the river Styx, of the underworld, by his mother in order to make him immortal. She almost succeeded in her aim but when she immersed him into the waters, she held him by one heal and this part of his body remained mortal.

The terrified Trojans were powerless against Achilles. The only thing that eventually saved them from his wrath was a lucky arrow strike to his “mortal” heel from the bow of Paris. If the Trojans had not heeded the wise words of Polydamas to retreat, , the only slim hope that they might have held, failing another lucky arrow strike, would have been that Achilles ruptured his mortal tendon during one of his in his explosive “swift footed” charges.

ACHILLES TENDON RUPTURE

Introduction

Achilles tendon rupture is a serious soft tissue injury that will have significant morbidity if not detected early. Many cases are misdiagnosed in the first instance as ankle sprains.

Pathology

The Achilles tendon, named after Achilles of Homer’s Iliad, is the largest and strongest tendon in the human body.

It is formed from the tendinous contributions of the gastrocnemius and soleus muscles coalescing approximately 15 cm proximal to its insertion.

It inserts into the calcaneal tuberosity.

The gliding ability of the Achilles tendon is aided by a thin sheath of paratenon rather than a true synovial sheath. The sheath of paratenon is composed of a visceral layer and a parietal layer.

The blood supply of the Achilles tendon arises from its osseous insertion, its musculotendinous junction, and multiple infiltrating mesosternal vessels between these. Vessels are most sparse at 2-6 cm proximal to the heel insertion (ie, the watershed area, in vascular terms). Due to the relative lack of blood supply in this area, the tendon is less resilient to repetitive trauma and has a higher tendency for irritation, degeneration, and rupture at this point.

Precipitating events include:

● A sudden contraction force applied to the dorsiflexed foot.

● Direct trauma.

● Following Achilles peritenonitis with or without tendinosis.

Previous steroid injections may be a predisposing factor.

Clinical Features

Ruptures most commonly occur over the age of 30 years.

Symptoms:

● Rupture or partial tearing usually occurs in association with a sudden “take off” by the patient as in running or jumping.

● There is very sudden and severe pain in the tendon. Patients will often describe a sensation of having been “struck” by something in the back of the leg.

 Patients may describe an audible “snap”.

Signs:

● Swelling, bruising and localized tenderness at the point of rupture.

● Patients with complete rupture will have a palpable gap along the Achilles tendon around 2-6 cm above its calcaneal insertion.

● There is a limp and the patient will be unable to stand on his/her toes.

● The patient may have some weak plantar flexion, (due to action of tibialis posterior and the long toe flexors) even with complete rupture of the Achilles tendon.

● Thompson’s test:

With the patient prone and the knees flexed to 90 degrees, both calves are compared. The calf muscles are squeezed and the response observed. Normally there will be plantar flexion of the foot.

In complete ruptures of the Achilles tendon there is no plantar flexion of the foot. This is termed a “positive” Thompson’s test.

Right heel shows normal, plantar flexion response to calf squeezing, whilst the left shows no plantar flexion suggesting a complete rupture of the Achilles tendon.

Investigations

In clear-cut cases imaging may not be necessary and diagnosis can be made on clinical grounds.

In less certain cases or delayed presentations (where typical signs are more difficult to ascertain), or in cases of partial tendon injury imaging should be done.

This can be by ultrasound or MRI.

Ultrasound

● This is the best “first up” imaging option. It is quick, relatively cheap, but more “operator dependent”.

MRI

● MRI is more sensitive when trying to detect incomplete tendon ruptures.

● It is better able to discern other pathology such as peritenonitis, bursitis and tendon thickening and other chronic degenerative changes

However it is a much more expensive investigation and is not “routinely” done.

Management

All cases will need orthopedic referral.

Treatment for complete ruptures may be operative or non operative.

Operative treatment:

● Operative treatment gives better results with earlier return to normal activities and there will be less chance of recurrence of the injury.

Nonoperative treatment:

● Nonoperative treatment may be indicated for patients who are elderly especially if inactive or with significant co morbidities, such as diabetes, vascular disease, neuropathies, or serious systemic illnesses.

● These patients will be at significantly increased risk with operative treatment including infection, wound breakdown, repair dehiscence and general perioperative complications.

● Partial tears are usually treated conservatively, unless the patient is an “elite” athlete.

Immobilization:

Following operative treatment or in non-operative treatment a plaster cast is applied with the foot in slight plantar flexion for 6 weeks non weight bearing, followed by a further 6 weeks of partial weight bearing.

Physiotherapy:

All cases will require intensive physiotherapy follow-up.

Dr J. Hayes 16 July 2005.