Acute and Chronic
Ruptures in Athletes
Jonathan Thompson, DPMa,b,*, Bob Baravarian, DPMc,d
Achilles tendon injuries are one of the most common injuries in athletes. The Achilles
tendon is the largest and strongest tendon in the human body and is composed of the
gastrocnemius and the soleus muscles1to create a musculotendinous complex
(triceps surae) that crosses the knee, ankle, and subtalar joint. The Achilles tendon
is subjected to extensive static and dynamic loads and can be subjected to loads 2
to 3 times the body weight with walking and up to 10 times the body weight with
certain other athletic activities.2,3The Achilles tendon is the most injured tendon of
athletes in the lower extremities and has been noted to be the most common tendon
to rupture spontaneously.4
The Achilles tendon is in the superficial posterior compartment of the leg and is formed
from tendinous continuations of the 2 muscle bellies of the gastrocnemius and soleus
muscles, inserting primarily on the central middle portion of the posterior calcaneus as
well as providing fibers that extend around the heel to blend in with the plantar fascia.5
The plantaris tendon (absent in 7%–20% of individuals) is located medial to the
Achilles tendon apparatus and inserts medial and anterior to the Achilles complex.5,6
The Achilles tendon receives its main blood supply to the midportion of the tendon
from the paratenon, more proximally from the recurrent branch of the posterior tibial
artery and the local small muscular branches and distally from the rete arteriosum cal-
caneare supplied by the posterior and fibular arteries.5,7,8The Achilles tendon is
The author has nothing to disclose.
aUniversity Foot and Ankle Institute, Private Practice, 1101 Sepulveda Boulevard, Suite 104,
Manhattan Beach, CA, USA
bUniversity Foot and Ankle Institute, Private Practice, 2121 Wilshire Boulevard, Suite 101,
Santa Monica, CA 90403, USA
cUniversity Foot and Ankle Institute, Private Practice, 2121 Wilshire Boulevard, Suite 101, Santa
Monica, CA 90403, USA
dSanta Monica Orthopedic Hospital, 1250 Sixteenth Street, Santa Monica, CA 90404, USA
* Corresponding author. University Foot and Ankle Institute, Private Practice, 1101 Sepulveda
Boulevard, Suite 104, Manhattan Beach, CA.
E-mail address: firstname.lastname@example.org
? Achilles tendon rupture ? Athletes ? Rehabilitation
Clin Podiatr Med Surg 28 (2011) 117–135
0891-8422/11/$ – see front matter. Published by Elsevier Inc.
almost entirely composed of type I collagen and approximately rotates 11?to 90?in
a medial direction in that the medial fibers proximally come to lie in a posterior position
distally.1This anatomic construct provides potential energy and mechanical advan-
tage with rotational contraction; however, in doing so, it potentially “strangulates”
this portion of the tendon known as the watershed area, making it the most common
site of rupture.9,10This area of lowest vascularity is approximately 2 to 6 cm proximal
to the insertional area.9–11Lagergren and Lindholm10originally described this zone of
reduced vascularity in the midportion of the tendon1,7,11and subsequent studies have
supported their findings.7,9,12Although there remains some dispute regarding the
zone of least vascularity,1,11,13it is generally expected that the blood flow is dimin-
ished with increasing age, with gender (decreased in men), and during certain physical
loading conditions.11,13Astrom and Westlin11evaluated the blood flow of Achilles
tendons by comparing 35 patients, most of them competitive runner athletes, with
40 healthy volunteers using Doppler flowmetry and concluded the following: (1) blood
flow was evenly distributed throughout the Achilles tendon in both groups, (2) blood
flow values progressively declined when tension/contraction increased, (3) values
were significantly lower at the distal insertional areas, and (4) symptomatic Achilles
tendons had an increase in blood flow to the area. The Achilles tendon lacks a true
synovial sheath or lining like other tendons and is surrounded by a peritendinous struc-
ture called the paratenon. The paratenon is a multilayered structure that covers the
tendon and is composed of an outer layer of which the deep fascia is a portion, the
mesotenon, and a very thin and delicate epitenon layer that directly surrounds the
tendon.5The sural nerve and lesser saphenous vein course in the posterior midline
of the leg and need to be accounted for during surgical repair.
There is a paucity in the literature with few reported studies documenting the preva-
lence of Achilles tendon ruptures in the general population and let alone in the athletic
population. The incidence of ruptured or spontaneously ruptured Achilles tendons
seems to be growing; however, it cannot be determined if this incidence is from
a growing population or an increasing percentage of the population. Rates of Achilles
tendon rupture have been reported from 2 to 18 ruptures per 100,000.1,14,15A large
study in Scotland was published in 1999 of a total of 4201 Achilles tendon ruptures
between 1980 and 1995, which analyzed data on age- and gender-specific incidence
rates, and demonstrated similar rupture rates of 4.7 per 100,000 in 1981 and 6 per
100,000 in 1995.16The investigators also determined that the peak incidence in
men was from age 30 to 39 years but in women the risk increased after the age of
60 years, and the incidence after the age of 80 years was greater in women than in
men.16Most studies demonstrated thatAchilles tendon ruptures have occurred during
sporting-related activities. A study by Postacchini and Puddu17showed that in 44% or
12 of 27 cases the rupture occurred during athletic activities. Cetti and colleagues18
reported that 83% (92/111) of patients in a study injured their tendons during activities.
A Scandinavian study of badminton players demonstrated that 58 of 111 patients
(52%) with Achilles ruptures were playing badminton at the time of injury.1,19A
Hungarian study analyzed 749 patients from 1972 to 1985 who were diagnosed and
surgically treated for 832 acute tendon ruptures (both upper and lower extremity
ruptures).20Of the 292 cases, 59% Achilles tendon ruptures occurred during sport-
related activities in contrast to 2% of other tendon ruptures.20There were no profes-
sional athletes included in this study; however, the ruptures occurred most often in
participants of recreational soccer (33.5%), track and field (16.2%), and basketball
Thompson & Baravarian
(13.3%). Furthermore, the investigators also demonstrated that (1) there was a higher
prevalence of Achilles tendon ruptures (53.7%) and reruptures (71%) in those with
blood group O, (2) most patients commonly ruptured their left Achilles tendon, and
(3) most ruptures demonstrated histopathologic alterations on examination.20Parekh
and colleagues21documented 31 cases of Achilles tendon ruptures in the National
Football League (NFL) between 1997 and 2002. The average age and time in the
league was 29 years (average age of NFL players is 26 years) and 6 years, respec-
tively.21About 32% of players (10/31) never played in the NFL again, and those who
returned showed a reduction in their performance of more than 50%.21There was
no study that compared Achilles tendon rupture occurrence rates between profes-
sional and recreational athletes. Most studies demonstrated that recreational athletes
and furthermore the “weekend warrior” athletes are more prone to ruptures and have
increasing rupture rates secondary to a partial sedentary life combined with intermit-
tent activities compared with professional athletes who are consistently exercising. It
is postulated that regular exercise allows the tendon diameter to thicken and the
tendon to become stronger and, in theory, decreases the chance of rupture compared
with inactivity, which results in an atrophied Achilles tendon.22Other factors that
potentially differentiated the 2 groups of athletes are that the professional athletes
are generally younger, are healthier with less associated comorbidities, have poten-
tially lower body mass indexes, and have regular access to physical therapy and
a controlled athletic training program.
described to be associated with multiple disorders, including, but limited to, inflamma-
tory conditions, autoimmune disorders, collagen abnormalities,1,23–26infectious
process, exposure to antibiotics (fluoroquinolones),27,28systemic or injectable steroid
use,29–32repetitive microtrauma, tendon variations, decreased blood flow with
advanced age,33,34abnormal pronation and mechanics, ankle equinus, and Achilles
calcification.35Some investigators have proposed a possible mechanical theory,
whereby injury to the tendon leads to weakening and incomplete regeneration, versus
a vascular theory, whereby decreased tendon vascularity secondary to age and/or
trauma leading to chronic tendon degeneration.34,36It has been debated if a previous
history or current symptomatic Achilles tendon increases the risk of Achilles rupture or
if most cases are truly spontaneous. Achilles tendon disorders are more prominent in
participants of running sports and has been noted to be symptomatic in 7% to 11% of
in other studies. One of the larger studies by Kvist39demonstrated that approximately
53% of 455 athletes who developed Achilles tendon disorders were involved in running
sports.40Because the Achilles tendon is unique compared with other tendons in the
body in that it lacks a true synovial sheath it can be a potential for somewhat confusing
terminology. Achilles tendon disordersare nowgrouped togetherinto what is known as
Tendinosis is differentiated from tendonitis in that there is degeneration of the tendon
without inflammation or evidence of intratendinous inflammatory cells.1,42This distinc-
tion is important not only to understand the pathologic condition but also to dictate
the proper and appropriate treatment. Puddu and colleagues44in 1976 defined this
terminology and classified Achilles tendon disease into 3 categories: (1) pure peritendi-
nitis or inflammation of peritendinous tissue with normal tendon, (2) peritendinitis with
tendinosis or inflamed peritendinous tissue and degenerative changes of the tendon
Achilles Tendon Ruptures in Athletes
and (3) tendinosis or normal peritendinous tissue with degenerative changes of the
without anyhistoryof previous pain or swelling toAchillesarea) hadevidence ofdegen-
Achilles tendon and another at the paratenon) in 163 patients with chronic Achilles ten-
dinopathy among which 75% were athletes. Degeneration or tendinosis was demon-
strated in 90% of biopsied specimens from symptomatic parts of the tendon and in
only 20% from nonsymptomatic portions, and it was found that the paratenon was
mostly normal or revealed slight changes.45Partial tendon ruptures were found in
19% of patients and always in the area of tendinosis,45which may indicate a predispo-
have been asymptomatic.46However, Mafulli and colleagues47in a study performed
bilateral percutaneous muscles biopsies in the triceps surae of 12 asymptomatic
athletes within 36 hours of trauma of the affected and normal side and found no signif-
icant differences in histochemical analysis, muscle abnormalities, or fiber areas;
however, the uninjured side demonstrated slight increase in capillary density.
The diagnosis of acute Achilles tendon ruptures is usually straightforward and
commonly diagnosed with appropriate patient history taking and clinical examina-
tion.1,48–51Patients present with pain and swelling in the posterior ankle and describe
a traumatic event or a feeling of being kicked at the back of the heel.1The patients may
have heard an audible popping sound52and may have difficulty with normal ambula-
tion or walking uphill or climbing stairs.53–55On examination there is often calf atrophy
when compared with the contralateral leg, loss of Achilles tendon congruity or
palpable gap,51weakness of ankle joint plantar flexion, and inability to do heel rai-
ses.49Multiple investigators (Simmonds,56Thompson and Doherty,57Matles,58
O’Brien,59Copeland60) have described clinical tests to diagnose Achilles tendon
ruptures. The most commonly used clinical test was originally described by Sim-
monds56and popularized by Thompson and Doherty.57Patients are made to lie in
a prone position with their feet hanging over the edge of the table, and the examiner
squeezes the largest muscle portion of the calf complex to simulate a contraction/
shortening of the Achilles tendon complex, which should normally produce a plantar
flexion of the foot. An “abnormal” or positive Thompson test result is observed
when there is a lack of plantar flexion response. Another reproducible test was
described by Matles,58which involves having the patient lying prone on the table
with the knee flexed at 90?and the examiner evaluating the “resting tension” position
of the feet. With an Achilles tendon rupture, the foot shows less plantar flexion and
may even be positioned neutrally or slightly dorsiflexed compared with the uninjured
leg. Maffulli50evaluated the sensitivity, specificity, and predictive values of the calf
squeeze test, palpable gap, Matles test, O’Brien needle test, and Copeland sphygmo-
manometer test of 174 complete Achilles tendon tears. All tests showed a high posi-
tive predictive value; however, the calf squeeze (Thompson test) and Matles tests
were found to be significantly more sensitive (0.96 and 0.88, respectively) than the
other tests.50Achilles tendon ruptures have been described to be misdiagnosed
approximately a quarter of the time,53,61and other potential diagnostic modalities
include radiographs, ultrasonography, and magnetic resonance imaging (MRI).
Standard radiography is usually not indicated; however, a lateral ankle view allows
the practitioner to rule out a posterior calcaneal avulsion fracture62and possible
Thompson & Baravarian
distortion of Kager triangle63as well as evaluation of Toygar sign.1Ultrasonography
and MRI are useful in differentiating between a partial and complete rupture and allow
a more detailed evaluation of the tendinous structure with a chronic rupture. Ultraso-
nography is inexpensive, easy to use, allows dynamic imaging, and is able to measure
the residual gap between tendon ends.49,64Ultrasonography in an uninjured Achilles
tendon demonstrates hypoechogenic bands of parallel fibrillar lines contained
between 2 hyperechogenic bands in the longitudinal plane and round or oval shape
in the transverse plane.1,61,64Ultrasonographic images of a ruptured tendon demon-
strate discontinuity of normal fibrillar pattern, gap between torn ends, and an acoustic
vacuum.1,49,64,65Hartgerink and colleagues65evaluated 26 suspected Achilles tendon
ruptures with ultrasonography and compared the results of this test with surgical
results and demonstrated that ultrasonography was accurate in distinguishing full-
thickness tears from partial-thickness tears or tendinopathy with a sensitivity of
100%, a specificity of 83%, an accuracy of 92%, a positive predictive value of
88%, and a negative predictive value of 100%. Some investigators believe that there
are some pitfalls with ultrasonography, including false diagnosis of high-grade tear if
plantaris tendon remains intact64and difficulty in differentiating between all tendinous
pathologies including partial ruptures of the Achilles tendon,66and MRI should be
used in these cases. MRI using sagittal and axial images with T1- and T2-weighted
sequences are recommended for the evaluation of Achilles tendon injuries, with
normal tendon demonstrating low signal intensity (black) on all images.1,64A ruptured
tendon shows a signal disruption on T1-weighted images and high signal intensity
consistent with hemorrhage/edema with retraction of torn ends with a complete
rupture on T2-weighted images.1,64MRI allows adequate evaluation of the size of
partial and intrasubstance tears, potential gapping of ruptured ends, and the amount
of tendon degeneration/scar tissue.67
There remains some controversy in the literature regarding whether nonoperative or
operative treatment be pursued in the acute rupture of the general population depend-
ing on age, time or delayed presentation, activity level, and associated comorbid-
ities.68Operative repair has associated risks, including inherent complications from
surgery and anesthesia, which have to be accounted for. Studies advocating nonop-
erative approaches have demonstrated similar results as operative procedures and
might be better indicated for high-risk patients.69,70Professional and collegiate
athletes are generally younger and healthier and have the means for a more appro-
priate or timely diagnosis. Multiple studies have demonstrated that overall operative
repair provides earlier return to sporting activities and less rate of rerupture.18,71–74
A prospective and randomized study by Cetti and colleagues18of 111 patients who
were randomly assigned to either an operative or a nonoperative group found that
the operative group had a significantly higher rate of resuming sport activities, lesser
calf atrophy, more ankle joint range of motion (ROM), and lesser rerupture rates than
the conservative group, and is the focus of this article.
Conservative options can be divided into serial casting with gradual decrease in
gravity equinus position and splinting devices/boots and early ROM. Multiple casting
and rehabilitation protocols are available and are surgeon dependent. An accepted
conservative regimen uses either an above-the-knee cast or a below-the-knee cast,
with the ankle in plantar flexion (gravity equinus) for approximately 4 weeks.69Serial
cast changes then begin, gradually reducing equinus for the next 4 to 8 weeks and
Achilles Tendon Ruptures in Athletes
eventually transitioning to a walking boot with a heel lift while starting ROM exercises
and a rehabilitation program. Gradual return to regular tennis shoes with a step-down
heel lift is used as well.23It is important to implement physical therapy with passive
and active ROM exercises. Some investigators argue for early ROM to enhance
tendon healing process and to diminish side effects from immobilization. Advocates
of early ROM with splint devices argue that this technique provides a speedier
recovery and early ambulation.71
The Achilles tendon rupture can be severely debilitating and time consuming in the
athletic population. The goal of surgical repair is to allow the athlete to return to pre-
injury and activity levels with return of normal function, strength, and ROM. A variety of
surgical repairs are described in the literature, including open repair, percutaneous
repair, and mini-open repair techniques. Open repair can include end-to-end repair
with or without graft augmentations and be combined with tendon lengthening, turn-
down flaps, or tendon transfers. A retrospective analysis by Ateschrang and
colleagues75in 104 (20 of them athletes) patients who underwent open augmentation
after Silfverskio ¨ld procedure for acute Achilles repair determined that 19 of 20 or 95%
versus only 48 of 84 or 57% were able to return to original sport activity.
The patient can be given general, regional, or local anesthesia and is placed in prone
position on the operating room table. The affected leg as well as the contralateral leg
can be prepped and draped for comparison of proper length/tension of the Achilles
tendon. Approximately a 6- to 10-cm incision is placed centrally or made at a more
advocated posterior-medial midline of the leg to avoid the sural nerve. Dissection is
carried down through subcutaneous tissue and fat with minimal dissection or under-
mining until the crural fascia and the overlying tendon can be visualized. The crural
fascia and paratenon can then be incised and carefully reflected off the tendon and
should be identified to ensure proper anatomic layered closure. The tendon is visual-
ized, and once the cleaning or removal of the hematoma formation near rupture ends
(Fig. 1) is performed, one can attempt to tie or “bundle the horse hair” ends.
Unhealthy-appearing tendon ends should be cleaned and debrided before reapprox-
imation of tendon. Sometimes the proximal portion of the rupture tendon “retracts”
and should lightly be stretched for a short period to promote elongation. Then it
must be determined if there is adequate tendon available to reapproximate and repair
the rupture ends. Adequate length is evaluated to ensure that a tendon lengthening,
turndown or rotational flap, and/or transfer procedure is not indicated. If satisfied,
then the end-to-end reapproximation can be carried out.
Fig. 1. Complete Achilles tendon rupture with retraction and hematoma formation of the
Thompson & Baravarian
Simple end-to-end repair is most commonly performed via the Bunnel, Kessler, and
Krackow techniques.76All of these suturing techniques are acceptable for the repair of
the Achilles tendon; however, the Krackow method has been shown to be superior in
biomechanical and cadaveric studies and has the advantage of allowing 4 threads
(and 2 knots) across the rupture site if desired.77The size and type of suture available
on the market is variable and is usually the surgeon’s preference. More recently #2 or
2–0 FiberWire (Arthrex, Naples, FL, USA) has become more popular, and a recent
study compared Prolene (Ethicon, a Johnson and Johnson company New Brunswick,
NJ, USA), Ticron (Covidien, Mansfield, MA, USA), and FiberWire.78The investigators
determined that FiberWire has a greater cross-sectional area of similar size and is
10% stronger than Prolene and 25% stronger than Ticron in knotted tensile strength.78
It should be noted that common to all suturing types the location of failure seems to be
located at the knot site regardless of the type of suture used. Some investigators rein-
force with simple interrupted sutures across rupture site. The rupture should be
repaired with the foot in a position similar to the contralateral side resting in equinus
position. The paratenon and crural fascia can be reapproximated as well, and then
skin closure via suture or staples is done and dressings are applied.
End-to-end repair with augmentation can be performed with additional autografts,
allografts, and synthetic grafts. The most common and easiest autograft to harvest
is with the plantaris tendon, which is usually intact after a rupture and easily available
through the same surgical wound. The tendon iscut from its insertion on the calcaneus
and stretched or “fanned out” and can be placed over the rupture site with absorbable
sutures.79–81Akgun and colleagues79performed 36 acute Achilles tendon end-to-end
repair with Krackow technique combined with plantaris augmentation in which 31 of
36 patients participated in sporting activities and returned to preinjury sport activities
after a mean of 17 weeks (range 14–20 weeks). In contrast, Aktas and colleagues82
demonstrated no significant difference in the American Orthopeadic Foot and Ankle
Society hind foot clinical outcome scores between the group that underwent single
end-to-end repair and the group that underwent end-to-end repair with plantaris
tendon. Furthermore, the nonaugmented group demonstrated a slight decrease in
local tenderness, scar adhesions, and tendon thickness.82
There have been a variety of biologic scaffolds described in the literature and favor-
able arguments include added strength of repair without sacrificing secondary struc-
tures or more dissection to allow early ROM postoperatively.83–85Various scaffolds
and their cellular makeup, biomechanical strength, and biocompatibility have been
described for augmentation in the repair of ruptured Achilles tendons.86These scaf-
folds include, but are not limited to, TissueMend (Stryker, Kalamazoo, MI, USA),
Restore (Depuy Orthopaedics, Warsaw, IN, USA), GraftJacket (Wright Medical Tech-
nology, Arlington, TN, USA), Conexa (Conexa Reconstructive Tissue Matrix, Tornier,
Edina, MN, USA) and Dacron (DuPont, Wilmington, DE, USA) vascular graft. There
are limited prospective and randomized trials regarding the use of these grafts in
Achilles tendon repairs. TissueMend has been noted to have significantly higher
DNA count than most other matrices.87A human cadaveric study of 8 matched pairs
evaluated simulated Achilles ruptures repaired with end-to-end repair with Krackow
technique and 1 limb augmented by human dermal allograft (GraftJacket) and
concluded that the augmented limb had significant strength and stiffness.83However,
there have been no follow-up studies. The graft is usually “wrapped” around the
ruptured ends and sutured in place (Fig. 2). Every surgeon should be encouraged to
Achilles Tendon Ruptures in Athletes
educate themselves on the differences between these scaffolds, such as the source,
tissue type, and inherent properties, to help differentiate between them.
Turndown or rotational flaps
Fascial turn down flaps of the proximal gastrocnemius fascia have also been advo-
cated. The most common being the single strip or Silfverskio ¨ld procedure and the
double strip or Lindholm procedure, and these fascial slips are made approximately
3 cm proximal to the rupture site and rotated 180?and flapped down to cover and rein-
force rupture site.88It should be noted that doing a turndown flap requires a longer
proximal skin incision with more dissection that increases the potential for wound
healing issues and sural nerve injury. A study by Pajala and colleagues89described
66 acute Achilles tendon ruptures in 2 groups, one received end-to-end repair with
Krackow locking suture and one group underwent end-to-end repair with augmenta-
tion described by Silfverskio ¨ld, and found that it took approximately 25 minutes longer
and the incision was 7 cm longer in the augmented repair with no significant advan-
tages regarding ankle score, isolated calf muscle strength, and rerupture rates.
Because the author is dealing with the athletic population, tendon transfers in acute
ruptures have been avoided and have been reserved for possible delayed ruptures,
chronic ruptures, or reruptures when indicated secondary to the increased dissection,
surgical time, and potential morbidity when sacrificing another tendon. In the case that
a surgeon feels more comfortable or if indicated, the author recommends using
possible plantaris tendon overlay graft or turn down flaps as mentioned earlier. Pero-
neal tendon transfers for acute Achilles tendon ruptures were described by Perez
Teuffer90in the 1970s and later popularized by Turco and Spinella62,91in 1987. It has
Fig. 2. Sutured onlay graft around ruptured ends.
Thompson & Baravarian
been indicated to use these transfers in acute, chronic, and reruptured Achilles tendon
injuries. After end-to-end apposition is performed for the acute rupture, then peroneal
brevis tendon is detached from the base of the fifth metatarsal brought through to the
posterior compartment and tunneled through the distal Achilles tendon in the medial
direction and then drawn proximally along the medial Achilles tendon and secured.62
Turco and Spinella91performed a follow-up study in 55 athletes who sustained acute
Achilles ruptures in which they found no early evidence of rerupture rate and also
that the tendon transfer had minimal loss of strength. Gallant and colleagues92
concluded that there was only mild objective weakness in eversion strength (14.9%
ankle instability, or activities of daily living when comparing the peroneal brevis tendon
transfer limbs with the normal contralateral side in 8 patients.
Minimal incision techniques
Minimal incisional and percutaneous techniques were introduced and advocated to
Ma and Griffith93first described a percutaneous technique using multiple stab incision
of 18 acute Achilles tendon ruptures to minimize postoperative complications and
reported no complications of sural nerve injury. The anatomic path of the sural nerve
be noted that percutaneous repairs are not completely benign and every surgeon
percutaneous repair described in the literature to decrease potential sural nerve injury
by placing percutaneous incisions more in the midline or medial position.97,98Marti-
nelli94described percutaneous repair on 50 acutely ruptured Achilles tendon. In this
study, 30 patients practiced amateur or professional sports and were able to return
to preinjury sporting levels after 120 to 150 days.94The mini-open technique using
the Achillon System (Newdeal, Lyon, France) was introduced to decrease wound
complications with smaller incisions.99–101Favorable arguments for mini-open tech-
nique are allowing for early postoperative ROM and rehabilitation to assist proper
tendon healing with the reduction of scar adhesions and allowing athletes an earlier
return to sporting activities.100Rippstein and Easley100used the mini-open technique
and Achillon device to repair acutely ruptured Achilles tendons in 89 consecutive
patients. Of these patients, 75% participated in sporting activities (5 elite athletes) 1
to 3 or more times per weekend, and all patients returned to sporting activities within
1 year, with an average return to sporting activities at 6 months.100The average Amer-
suturingsystem onthecontralateral limb.In thisstudythe investigatorsfound thelatter
technique to be biomechanically stronger.
A study by Ceccarelli and colleagues99compared acutely ruptured Achilles tendons
in 12 paitents who underwent repair via modified Ma and Griffith percutaneous proce-
dure and in 12 who underwent repair using minimally invasive procedure with the
Achillon system and found similar results in the time taken to return to work and sports
and similar American Orthopedic Foot and Ankle Society Score values.
Rehabilitation of acute repairs
There are a variety of postoperative rehabilitation protocols after acute repair of the
Achilles tendon regarding when to initiate ROM, rehabilitation and strengthening,
Achilles Tendon Ruptures in Athletes
and weight bearing. Mortensen and colleagues103prospectively randomized 71
patients who had acute repairs of the Achilles tendon into a group that underwent
conventional postoperative management with a cast for 8 weeks and a group that
underwent early restrictive ROM with a below-the-knee brace for 6 weeks and
concluded that the early ROM group was more satisfied, developed less scar adhe-
sions, had less initial loss of ROM, and returned to sporting activities sooner. The
median percentages of strength and heel rise index of the repaired limbs compared
with the normal contralateral limbs were similar in both groups.103Suchak and
colleagues104randomized 110 patients into 2 groups of weight bearing and non–
weight bearing for 4 weeks after an initial 2 weeks of non–weight-bearing casting.
The early weight-bearing group demonstrated improved scores in physical and social
functioning with fewer limitations in daily activities at 6 weeks; however, no significant
differences were noted at 6 months.104Aoki and colleagues105allowed early ROM and
partial weight bearing with transition to full weight bearing by 16 days in 22 athletes
with end-to-end repairs of acute Achilles ruptures. The investigators reported an
average period of 13 weeks for returning to the sport.105Mandelbaum and
colleagues106performed the Krackow modified suture technique in 29 athletes who
sustained Achilles tendon ruptures and implemented early ROM and rehabilitation
programs; 90% of patients demonstrated full ROM at 6 weeks and 92% returned to
sport participation by 6 months.
It seems that early ROM most likely allows for earlier return to normal activities of
daily living and recreational and sporting activities without a significant increased
morbidity or increased rerupture rate regardless of operative technique and is prob-
ably the most important aspect that needs to be addressed when dealing with an
athletic patient. If a surgeon can provide a solid repair and institute an early ROM
and protective weight-bearing protocol, the time missed could be decreased.
CHRONIC, DELAYED, AND RERUPTURE OF ACHILLES TENDONS IN ATHLETES
Chronic or delayed Achilles tendon ruptures in the athletic population are extremely
rare. It has been described in the literature that ruptures presenting after 4 to 6 weeks
of the injury can be classified as chronic or delayed ruptures.53,61,107,108MRI is war-
ranted for more precise evaluation in any patient with a concern of a suspected
chronic rupturefor better evaluation of the tendinous structure. Itis generally accepted
that operative repair is recommended for chronic ruptures, delayed ruptures, or rerup-
tures of the Achilles tendon; however, there is no consistent surgical procedure
recommendations provided in the literature.108The general goal in any ruptured
tendon is to attempt end-to-end anastomosis of the ruptured site; however, this
attempt becomes more difficult in the ruptures that are presented with delay or in
those that are neglected. Accordingly, multiple classification schemes and algorithms
have been described to help guide and give surgical recommendations for surgical
repair.53,107–110There are limited prospective randomized trials to compare these
surgical proposals in the general or athletic populations. In delayed ruptures, the
tendons usually become a solid mass of scar tissue and it can be difficult to determine
healthy or viable tendon and corresponding layers. The surgeon must debride and
clean until potentially healthy and functional tendon remains, which obviously results
in increase in gapping of the tendon and makes it difficult to oppose the ends. The
surgeon must use other potential procedures that include, but are not limited to,
lengthening via inverted V-to-Y or tongue-in-groove procedures, turndown rotational
flaps, tendon augmentation or bridging, and tendon transfers. Often there requires
a combination of the above-mentioned procedures.
Thompson & Baravarian
Myerson107and Kuwada109attempted to simplifythe operativeprocess andprovide
recommendations based on this resultant gapping. The classification by Myerson107
(Table 1) recommends the following: type 1 defect that is no more than 1 to 2 cm
long can be repaired by an end-to-end anastomosis and a posterior compartment fas-
with possible flexor hallucis longus (FHL) tendon transfer, and type 3 defect that is
tears and can be managed with conservative casting, type II lesions are complete
ruptures smaller than 3 cm and can be repaired via end-to-end repair, type III lesions
and/or synthetic grafts, and type IV lesions are complete ruptures larger than 6 cm and
Abraham and Pankovich111first described the V-Y advancement for end-to-end
repairs of Achilles tendon ruptures in an attempt to allow anastomosis between the
2 ruptured ends. The inverted “V” incision is placed at the musculotendinous junction
with the arms approximately 1.5 times the length of the tendon defect and were found
to close up to 6-cm gaps in the tendon ends.111Parker and Repinecz112introduced
a tongue-in-groove procedure (Fig. 3), which they found was easier to perform, and
were able to achieve 50% more length. Single and double turndown flaps can also
be used as described earlier for the repair of acutely ruptured Achilles tendon and
are not rediscussed.
Tendon transfers have been well described in the literature for acute ruptures,
chronic ruptures, and/or reruptures and most commonly use the plantaris,79peroneus
brevis,52,62,90,91flexor digitorum longus (FDL),43,113and FHL61,113,114tendons. The
plantaris tendon is the easiest to harvest; however, most of the time, in chronic
ruptures, this tendon has been incorporated into the scarred tendinous mass and is
unidentifiable. The peroneus brevis tendon has been described earlier and can be
used in similarly for the repair of chronic ruptures. FHL has been advocated over
the FDL for Achilles tendon transfers and augmentation because of its anatomic prox-
imity, stronger and longer tendinous structure, and lower-lying muscle belly that can
be incorporated into the rupture site for added vascularity and strength.61,113,115It
is understood that any tendon transfer results in loss of strength, but it is difficult to
determine how much of this loss will functionally affect the athlete during sporting
activities because there is a lack of published data in the literature as well as difficulty
in performing prospective randomized trials with this type of injury and athletic popu-
lation. Frenette and Jackson116determined that there was no disability or activity
Neglected Achilles tendon ruptures
Size of Defect (cm)Recommended Procedure
1–2Simple end-to-end anastomosis, can apply tension to “stress relax”
myotendinous junction before tying suture for additional length
2–5V-Y myotendinous lengthening with end-to-end anastomosis,
consider flexor hallucis longus (FHL) tendon transfer if warranted
>5FHL tendon transfer combined with V-Y advancement if needed,
turndown flaps, author advocates FHL tendon transfer over flexor
digitorum longus or peroneal tendon transfer
Data from Myerson MS. Achilles tendon rupture. Instr Course Lect 1999;48:226, 227; with
Achilles Tendon Ruptures in Athletes
limitation in 4 athletes who sustained complete laceration of the FHL without repair.
The FHL tendon transfer seems to be gaining popularity and has been described
and modified by multiple surgeons.107,114,115The FHL tendon can be harvested via
a single incisional technique or double incisional technique. The single incisional tech-
nique uses the same incision with more anterior dissection through posterior fascia
that is incised to identify and mobilize the FHL tendon that is cut as distally as possible
(Fig. 4). The FHL tendon should be easily identified and freed with careful visualization
of the neurovascular bundle as the tendon is dissected distally. The double incisional
technique requires a secondary incision over the midfoot to identify the FHL near the
level of the knot of Henry, which is then incised and retracted through the proximal
wound. The single technique has the advantage of not using a secondary incision
or dissection and possible neurovascular compromise in the foot incision but provides
a potential shorter tendon available for transfer that might require screws and/or
anchors for fixation into the calcaneus depending on the surgeon’s preferred tech-
nique (Fig. 5). The 2-incision technique allows for a longer tendon for transfer and
augmentation and possibly allows for wrapping around both ruptured ends depending
on the technique. An average of additional 3 cm with secondary midfoot incision and
harvesting just proximal to the knot of Henry has been described.116Furthermore,
Wapner and colleagues115demonstrated that an additional 10 to 12 cm can be found
with transecting the tendon distal to the knot of Henry when compared with a proximal
posterior harvesting technique. Once the FHL tendon is harvested, the tendon can be
transferred in a variety of ways. The 2-incision approach allows for a longer tendon
graft, and the graft can be transferred to the calcaneus in a medial-to-lateral direction
through a posterior superior calcaneal drill hole. The graft is then proximally fashioned,
and if enough tendon remains, it can be weaved through the proximal and distal
Kuwada’s classification of Achilles ruptures
Type Recommended Treatment/Procedure
Type I: <50% tear Cast immobilization for 8 weeks
Type II: defect<3 cmSimple end-to-end anastomosis
Type III: defect 3–6 cmEnd-to-end anastomosis and autogenous or
Type IV: defect>6 cm (includes delayed
Requires gastrocnemius recession for
increased length, end-to-end anastomosis
with free tendon graft or synthetic graft
Data from Kuwada GT. Classification of tendo Achillis rupture with consideration of surgical repair
techniques. J Foot Surg 1990;29:362.
Fig. 3. Open repair with tongue-and-groove lengthening procedure.
Thompson & Baravarian
rupture ends of the Achilles tendon.117The single incisional approach results in
a shorter tendon length and is transferred from a superior- to inferior-directed calca-
neal tunnel placed anterior to the Achilles insertional area. The tendon is brought
through the osseous tunnel via suture (whip stitch or other suture technique) and
out the plantar aspect of the foot and held in tension as an interference screw is placed
through the superior hole to secure the tendon in place. Some investigators advocate
suturing the FHL muscle belly over the rupture site to provide increased strength and
Fig. 4. FHL tendon exposure with single incision approach.
Fig. 5. FHL transferred to the calcaneus. Note that the low-lying muscle belly of FHL can be
used to reinforce and provide vascularity to the repaired ruptured tendon.
Achilles Tendon Ruptures in Athletes
vascularity. Onlay allograft or synthetic grafts can be wrapped around the tendon once
the earlier-mentioned procedure is performed, but this graft adds bulk to the tendon
and can make layered closure and wound healing difficult.118
Postoperative care and rehabilitation for chronic Achilles tendon ruptures generally
require a more conservative approach with longer immobilization and protective
casting period. The optimal immobilization and rehabilitation period is still debated.36
Functional ankle foot orthosis and patellar tendon–bearing braces that limit ankle joint
dorsi flexion and allow early ROM and protective weight bearing can be used well in
this patient population.
Acute and chronic Achilles tendon ruptures in the athletic population are one of the
most challenging and time-consuming conditions to deal with for both the athlete
as well as the surgeon. These ruptures are becoming more prominent in the medical
community, most likely with the increasing number of recreational, amateur, and
professional athletes competing in sporting activities. Surgical repair seems to be
the standard of care for treatment, especially in this subset of population.
New surgical approaches, including percutaneous and mini-open techniques, are
being introduced to potentially diminish perioperative complications, and the advent
of early protective ROM and rehabilitation has shown a potential for earlier return to
sporting activities for patients with acute Achilles ruptures.
Delayed or chronic ruptures are rare in the athletic population and usually require
more extensive surgical approaches with possible tendon lengthening, turndown
flaps, tendon augmentation with graft substitutes, and/or tendon transfers. The FHL
tendon seems to be more favorable than other tendons available for transfer
secondary to its close proximity to the Achilles tendon, in-phase muscle activity,
longer and stronger tendinous structure, and low-lying muscle belly for potential incor-
poration into the repair site for increased strength and vascularity. There remains no
clear and identifiable postoperative protocol for rehabilitation and this rehasbilitation
regimen remains the surgeon’s preference; however, a few studies have determined
that early protective ROM has allowed an early return to physical activities. It is hoped
that follow-up studies would be performed to define or redefine surgical recommen-
dations and postoperative protocols for the athletic population.
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