16 Achilles Tendon Disorders in Athletes

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MedicineAmerican Journal of Sports

2002; 30; 287Am. J. Sports Med.Anthony A. Schepsis, Hugh Jones and Andrew L. Haas

Achilles Tendon Disorders in Athletes

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Current Concepts

Achilles Tendon Disorders in AthletesAnthony A. Schepsis,* MD, Hugh Jones, MD, and Andrew L. Haas, MD

From the Department of Orthopaedic Surgery, Boston University Medical Center,Boston, Massachusetts

ABSTRACT

Achilles tendon disorders are among the more com-mon maladies seen by sports medicine physicians.Understanding the anatomy and biomechanics of theAchilles tendon and contiguous structures is essentialto the diagnosis and treatment of Achilles tendon over-use injuries. Posterior heel pain is multifactorial andincludes paratenonitis, tendinosis, tendinosis with par-tial rupture, insertional tendinitis, retrocalcaneal bursi-tis, and subcutaneous tendo-Achillis bursitis. Each ofthese entities is distinct, but they often occur in com-bination. Although most cases of this disorder are suc-cessfully treated nonoperatively, a small subgroup of

recalcitrant cases may benefit from surgical interven-tion. Complete ruptures in active, athletic personsshould be treated operatively in most cases and resultin predictably good outcomes. There may be somecases that escape early recognition and require a re-constructive procedure to salvage a potentially severefunctional deficit.

ANATOMY

Since the time of Homer’s Iliad, the name of Agamemnon’sgreatest warrior, Achilles, has been attached to the tricepssurae tendon. As knowledge of the specific anatomy of this

tendon was crucial to Achilles’ opponents’ success, so suchknowledge is equally crucial to the orthopaedic surgeon inthe management of Achilles tendon-related maladies, bothacute and chronic in nature.

The Achilles tendon is a confluence of the gastrocnemiusand soleus muscles. The gastrocnemius muscle is com-posed of a medial and lateral head. The medial head arisesfrom behind the medial supracondylar ridge and adductor

tubercle on the posterior surface of the femur. The lateral

head arises from the lateral surface of the lateral condyleof the femur, proximal and posterior to the lateral epicon-dyle. Each of these heads has additional attachments fromthe posterior capsule of the knee joint and from theoblique popliteal ligament.29 The soleus muscle lies deepto the gastrocnemius muscle, arising from the posteriorsurface of the upper tibia along the soleal line, the poste-rior aspect of the proximal third of the fibula, and from theintermuscular septum.

The medial and lateral heads of the gastrocnemius mus-cle gradually coalesce and incorporate into a broad, robusttendon in the posterior aspect of the lower leg. This tendongradually narrows and becomes more rounded as it ex-

tends distally. The soleus muscle forms a broad tendonabout midway down the leg, in a position deep to thetendon of the gastrocnemius. This tendon glides freelydeep to the gastrocnemius muscle in its more proximalextent, thereby allowing independent movement of thetwo muscles.

The tendinous components of these two muscles are variable. The gastrocnemius component is the longer por-tion, contributing 11 to 26 cm. The soleus, in contrast, isshorter, containing a tendinous component from 3 to 11cm in length. The width of the tendon at its point of insertion into the calcaneus varies from 1.2 to 2.5 cm.29

Approximately 5 to 6 cm proximal to the calcaneal in-

sertion, the independent tendons of the gastrocnemiusand soleus fuse to become one tendon. At about 12 to 15 cmproximal to the insertion of the tendon, at about the levelthe soleus muscle begins to contribute fibers to the Achil-les tendon, rotation of the tendon begins. This rotationbecomes more marked in the terminal 5 to 6 cm of thetendon. The tendon spirals approximately 90° with themedial fibers rotating posteriorly and the posterior fibersrotating laterally.

The tendon inserts on the posterior surface of the cal-caneus distal to the posterior-superior calcaneal tuberos-ity.23 Deep to the tendon, proximal to the point of inser-tion, between the tendon and the calcaneus, is theretrocalcaneal bursa. The posterior wall of the bursa is

* Address correspondence and reprint requests to Anthony A. Schepsis,MD, Sports Medicine Orthopaedic Surgery, Boston University Medical Center,Doctors Building, Suite 808, 720 Harrison Avenue, Boston, MA 02118.

No author or related institution has received financial benefit from researchin this study.

0363-5465/102/3030-0287$02.00/0THE A MERICAN JOURNAL OF SPORTS MEDICINE, Vol. 30, No. 2

© 2002 American Orthopaedic Society for Sports Medicine

287


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formed by the tendon itself. Anteriorly, the bursa is bor-

dered by a 0.5- to 1.0-mm thick cartilaginous layer on the

posterior aspect of the calcaneal tuberosity. Proximally,

the bursa is bordered by a synovial lining that separates

the bursa from the proximal fat pad.97 This fat pad rests

anterior to the tendon and occupies an area bordered

anteriorly by the flexor hallucis longus muscle, posteriorlyby the Achilles tendon, and caudally by the superior as-

pect of the calcaneus. Superficial to the tendon lies a

subcutaneous tendo-Achillis, or retrotendo-Achillis bursa

between the tendon and the overlying skin.

Snow et al.109 evaluated the Achilles tendon insertion

and its relation to the plantar fascia. They found that the

neonate has a thick continuation of fibers of the tendinous

insertion into the plantar fascia. This continuity gradually

diminishes with age and the thick continuation of fibers of

the neonate becomes solely a connection of superficial

periosteal fibers in the middle-aged foot. The foot of the

elderly patient appears to have separate insertions alto-

gether, with periosteum between the Achilles tendon and

the plantar fascia. This finding indicates that, in the man-

agement of heel pain, stretching regimens of the Achilles

tendon and plantar fascia appear to alleviate insertional

stresses rather than relieve stresses on a contiguous

structure connecting the Achilles tendon and plantar

fascia.

The Achilles tendon is not encased in a true synovial

sheath but is encased in a paratenon made up of a single

layer of cells. This paratenon anteriorly consists of fatty,

mesenteric-like areolar tissue. This tissue is richly vascu-

larized and is responsible for a significant portion of the

blood supply to the tendon.20 This supply comes through a

series of transverse vincula, which function as passage-

ways for blood vessels to reach the tendon. In addition tothese mesotenal vessels, the blood supply to the tendon

comes from two other sources: the musculotendinous junc-

tion and the osseous insertion. Angiographic studies have

shown that the area of most tenuous blood supply is 2 to 6

cm proximal to the insertion in the calcaneus.24 Addition-

ally, the number of intratendinous vessels and the relative

area occupied by these vessels is lowest 4 cm from the

calcaneal insertion.104

Although not classically considered part of the Achilles

tendon, the plantaris muscle anatomy should be discussed

because of its intimate relationship with the Achilles ten-

don and its frequent use in operative management of

chronic Achilles tendon tears. The plantaris muscle orig-inates from the lowest part of the lateral supracondylar

ridge, the adjacent area of the posterior surface of the

femur, and the knee joint capsule. The tendon of the

plantaris crosses obliquely from lateral to medial in a

depression in the soleus muscle. It continues its course

distally between the gastrocnemius and soleus muscles,

emerging on the medial side of the Achilles tendon 12 cm

from the Achilles insertion to the calcaneus. Cummins et

al.29 studied 200 cadaveric specimens and noted four pat-

terns of insertion of the plantaris tendon. The plantaris

tendon inserts most commonly (47%) via a fan-shaped

expansion into the medial aspect of the insertion site of

the calcaneal tuberosity of the Achilles tendon. Occasion-

ally, thin slips of fascial strands may extend from the

plantaris tendon to the medial border of the Achilles ten-

don. In the second most frequent pattern (36.5%), the

plantaris tendon inserts into the calcaneus 0.5 to 2.5 cm

anterior to the medial border of the Achilles tendon.

The third most common pattern (12.5%) demonstrates

a broad insertion along the dorsal and medial surfacesof the Achilles tendon. In the least common finding (4%),

the plantaris tendon inserts into the medial border

of the Achilles tendon from 1 to 16 cm proximal to the

Achilles insertion into the calcaneus. The plantaris tendon is

absent in 7.05% of people as tabulated from the literature.29

BIOMECHANICS

The gastrocnemius muscle and soleus muscle, via the

Achilles tendon, function as the chief plantar flexors of the

ankle joint. In walking as well as in running and jumping

activities, this musculotendinous unit provides the pri-

mary propulsive force for locomotion. Whereas the gas-

trocnemius muscle functions primarily as a plantar flexor

at the ankle, the soleus muscle has a postural role as well,

preventing the body from falling forward during standing.

Contraction of this musculotendinous unit also functions

to flex the knee and supinate the subtalar joint.

The gastrocnemius and soleus musculotendinous unit

function during the second and third intervals of the

stance phase of the gait cycle.114 During the second inter-

val, extending from 15% to 40% of the gait cycle, the

activity in the posterior calf musculature is mainly di-

rected at controlling the forward movement of the tibia

over the planted foot. At about 34% of the gait cycle, heel

rise begins. The third interval of the gait cycle extends

from 40% to 62%. During this interval there is rapidplantar flexion of the ankle joint due to concentric contrac-

tion of the triceps surae muscle.78 Komi et al.54 performed

an in vivo evaluation of the Achilles tendon force during

ambulation. They demonstrated that after heel strike

there is an initial silent period of force in the Achilles

tendon, and that there is a rapid increase in force leading

to a peak at the end of the push-off phase. This is

consistent with the triceps surae muscle activity dem-

onstrated by Mann78 during the third interval of the

stance phase of gait.

At the end of the stance phase in normal walking, mus-

cle tension through the Achilles tendon is estimated at

250% of body weight.

99

Studies using both implanted elec-trodes and biomechanical force analysis have demon-

strated that the Achilles tendon force during running ap-

proaches 6 to 8 times body weight, a load close to the

ultimate strength of the tendon.5,24

The 90° spiral of the Achilles tendon is believed toexplain some of the seeming elastic qualities of the ten-

don. When landing from a jump, the body will remain

upright while the foot attains a plantar flexed position due

to activity in the triceps surae muscle. On landing, the

strain is absorbed by the Achilles tendon, which produces

a recoil effect.97

Because of the Achilles tendon’s insertion into the cal-caneus, the tendon can be exposed to forces secondary to

288 Schepsis et al. American Journal of Sports Medicine




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subtalar motion. This is particularly notable in the hyper-

pronated or cavus foot and in runners who pronate. It is

believed that a hyperpronated or cavus foot may lead to a

greater chance of rupture of the Achilles tendon because of

the diminished shock absorption associated with these

malalignments.5 James et al.45 have implicated this func-

tional overpronation as a causative factor in noninser-tional Achilles tendinitis as well. The foot pronates during

the midstance phase, leading to an internal rotation force

on the tibia. With extension of the knee, an external rota-

tion force is applied to the tibia. It is believed that during

midstance with the foot pronated and the knee in exten-

sion, there are contradictory rotational forces that present

themselves across the Achilles tendon and are directed

toward the Achilles tendon insertion.24,45,89,104 Arndt et

al.7 demonstrated that activation of the triceps surae mus-

cle results in a tensile force, leading to plantar flexion.

They showed that an eversion moment could be created by

isolated activity of the lateral head of the gastrocnemius

muscle; however, all other patterns of firing of the triceps

surae muscle led to an overall inversion moment.7 This

inversion moment may contribute additionally toward the

increased stress across the Achilles tendon during the

period of midstance with the foot pronated and the knee

extended.

ACHILLES TENDON OVERUSE INJURIES

The term “ Achilles tendinitis” has previously been usedfor any pain in the posterior part of the heel. This term is

misleading because it implies an inflammatory pathologic

process within the tendon itself. It has been well estab-

lished that there are several pathologic conditions that

cause posterior heel pain.9,26,34,58,59,61–63,67,106 The lit-erature is confusing in regard to the classification of Achil-

les tendon overuse injuries. For example, there are many

terms given for the same type of pathologic entity denot-

ing inflammation of the paratenon (such as tenosynovitis,

tenovaginitis, peritendinitis, or paratenonitis). Further-

more, various pathologic conditions sometimes coexist (for

example, paratenonitis with tendinosis), making the dis-

tinction between these various classifications somewhat

vague. The authors prefer a modification of the classifica-

tion as set forth by Puddu et al.,101 which is presented in

Table 1.

With more than 10% of the American adult population

participating in running today, as well as increasing par-ticipation in other running and jumping sports, posterior

heel pain and Achilles tendon injuries are among the more

common entities seen by sports medicine physicians.

Contributing Factors

In runners, the most common cause of Achilles tendon

injuries is training errors, including sudden increase in

training mileage or intensity, or both, a change of terrain

(particularly hill running), an increase in interval train-

ing, or a solitary intense run. Biomechanical factors have

also been shown to come into play with these inju-

ries.17,25,28 A cavus foot as well as a flat foot with exces-

sive pronation has been implicated. The motion of the

hindfoot going from a supinated to a pronated position and

then back during the running gait cycle creates a “whip-ping ” action on the Achilles tendon, which creates shearforces across the Achilles tendon, placing particularly high

eccentric stresses on the medial side of the tendon. Mal-

alignment factors above the ankle, such as genu varum,

can also contribute to increased stress on the Achilles

tendon.

Paratenonitis

The paratenon of the Achilles tendon is composed of a

single layer of cells that has a variable structure. This

layer is better termed a “tenovagium” rather than tenosy-

novium, which implies a double-layered sheath lined bysynovial cells.25 The ventral paratenon consists of fatty

mesenteric-like areolar tissue that is rich in blood vessels

that nourish the tendon. Paratenonitis is accompanied by

diffuse discomfort and swelling within the tendon. In

acute cases, the tendon appears “sausage-like” because of its diffusely swollen, edematous condition, and crepitation

is often noted (Fig. 1).62 This is commonly encountered

acutely in marathon runners. Usually there is palpable

tenderness on both sides of the tendon, but the medial side

is more commonly involved than the lateral side. In some

cases, tender nodules form within the paratenon, repre-

senting localized hypertrophy and connective tissue pro-

liferation. The involved area may either be over a segmentof several centimeters or it can involve the entire tendon

sheath from the insertion to the muscle. Paratenonitis

may result from abnormal biomechanics, but it can occa-

sionally occur because of extrinsic pressure causing fric-

tion between the Achilles tendon and its adjacent sheath,

often from poor-fitting shoes, although this is more likely

to cause subcutaneous tendo-Achillis bursitis. Although

symptoms are typically aggravated by activity and re-

lieved by rest, runners often complain of stiffness and pain

at the beginning of their run and then are able to “runthrough” the discomfort. However, if left untreated, symp-toms may increase to the point that running is no longer

possible.

TABLE 1Classification of Achilles Tendon Disordersa

ParatenonitisTendinosis

Partial ruptureParatenonitis with tendinosis

Degeneration

Partial tearsCalcification

Insertional tendinitisRetrocalcaneal bursitisHaglund’s deformity

Tendo Achilles bursitisComplete rupture

AcuteNeglected

a According to the classification of Puddu et al.101

Vol. 30, No. 2, 2002 Achilles Tendon Disorders in Athletes 289




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Tendinosis

Although painful areas of the Achilles tendon are com-

monly called “ Achilles tendinitis,” this term is actually amisnomer. Histologically, these areas of the tendon are

characterized by a degenerative noninflammatory processthat is best termed “tendinosis.”25 These areas in thetendon consist of mucinoid or fatty degeneration with a

disorganized collagen structure. These degenerative

changes in the tendon seem to be related to the normal

aging process and will usually eventually be present in all

persons to some degree.113 These changes do not neces-

sarily progress to clinical symptoms. Interestingly, these

histologic changes may be seen in young patients as well.

The symptoms of Achilles tendinosis may be secondary to

microtrauma or failure of this degenerative tissue, leading

to partial tears and subsequent symptoms. Kannus and

Jozsa50 have demonstrated the degenerative changes that

are found in ruptured tendons soon after their spontane-ous failure. Tendons that are subjected to high eccentric or

stretching stresses, such as the Achilles tendon, seem to

be most susceptible. Therefore, abnormalities within the

tendon itself that lead to symptoms should best be termed

Achilles tendinosis. Puddu et al.101 have documented his-

tologically that long-standing degeneration can exist in

the absence of clinical symptoms but may become symp-

tomatic with heavy training, leading to localized pain,

tenderness, and thickening in the tendon. The onset of

symptoms is usually gradual, but well localized to an area

within the mid-third of the tendon. A nodule develops

within the tendon and is more commonly seen on the

medial side, where the tendon experiences its highest

eccentric and shear stresses. This area is also the most

hypovascular zone of the tendon. In many cases, the onset

of symptoms is related to a partial rupture or series of

microruptures in the area of degeneration.69 A history of

transient sharp pain or repeated episodes of sharp pain

within the tendon while running should alert the physi-

cian to the possible presence of a partial rupture. Thesepatients will have a localized medial thickening of the

tendon (Fig. 2). The pain is usually exacerbated by loaded

dorsiflexion of the foot, and there is often limited dorsi-

flexion.105 In rare cases, heterotopic ossification can occur

within the tendon itself.70 In the authors’ experience, mid-dle-aged men who suddenly increase their activity level or

resume strenuous activity after a long period of inactivity

seem to be most susceptible to developing micro or partial

ruptures within an area of preexisting tendinosis. If the

degenerative process is extensive, leading to repetitive

partial ruptures, the tendon may actually elongate and

not function well in continuity with a paradoxical increase

in passive dorsiflexion.90 Å ström and Rausing 10 studied aseries of 342 operative cases of tendinosis (81% were male

patients). A partial rupture was found in 23%, tendinosis

in 49%, and no macroscopic abnormalities in 28% of the

tendons. They found that the lesion was more common in

the distal part of the tendon; predisposing factors were

physically active lifestyle, age slightly below middle-age,

and, particularly, local steroid injection before surgery.

Retrocalcaneal Bursitis

Retrocalcaneal bursitis is a distinct entity hallmarked by

pain that is anterior to the Achilles tendon and just supe-

rior to its insertion on the os calcis. The retrocalcaneal

Figure 1. Acute paratenonitis: note the diffuse, circumferen-tial swelling involving the entire tendon sheath, from theinsertion up to the musculotendinous junction. Crepitus willbe noted on palpation with ankle movement as well.

Figure 2. Tendinosis with chronic partial rupture. An asym-metrical, nodular thickening of the tendon, more commonlyseen on the medial (tension) side of the Achilles tendon.





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bursa, which lies between the anterior aspect of the ten-

don and posterior aspect of the os calcis, becomes in-

flamed, hypertrophied, and adherent to the underlying

tendon. This may be associated with a prominence of the

posterosuperior angle of the os calcis. Patients with retro-

calcaneal bursitis will have a positive two-finger squeeze

test. Pain is elicited by applying pressure both mediallyand laterally with two fingers just superior and anterior to

the Achilles insertion at about the level of the posterosu-

perior angle. This entity should be distinguished from

inflammation of the subcutaneous tendo-Achillis bursa

lying between the posterior aspect of the tendon and the

skin that occurs secondary to an abrasive heel counter or

high-heeled shoes. When this entity is bilateral, the clini-

cian should always exclude the possibility of a systemic

inflammatory disease. There is an association of retrocal-

caneal bursitis with rheumatoid arthritis seen in up to

10% of patients with this disease.120

Many studies have been made of the morphologic vari-

ations of the posterior calcaneal seen in association with

retrocalcaneal bursitis. The three most common varia-

tions in the shape of the superior tuberosity of the calca-

neus are hyperconcave, normal, and hypoconcave. Al-

though prominence of the posterior tuberosity has been

associated with retrocalcaneal bursitis, it is well known

that it is not uncommon to find retrocalcaneal bursitis in

runners without any associated calcaneal deformity. Com-

pression of the bursa between the calcaneus and the Achil-

les tendon occurs every time the ankle is dorsiflexed, and

in a runner the repetitions are countless, particularly with

uphill running where ankle dorsiflexion is increased.

Thus, it is not surprising that long-distance runners who

use uphill running as a training method frequently de-

velop this clinical entity. Other biomechanical abnormal-ities that are associated with the development of retrocal-

caneal bursitis include rearfoot varus and a rigid plantar

flexed first ray.

The retrocalcaneal bursa is a significant structure that

is horseshoe-shaped and 4 mm in width and 8 mm in

depth.99 Its anterior surface is composed of fibrocartilage

and its posterior boundary blends in with the paratenon.

It contains 1 to 2 mm of bursal fluid. In some cases, the

fluid in the bursa can actually become ballottable. There is

usually some element of contiguous inflammation in the

sheath or at the Achilles tendon insertion. The pain is

typically aggravated by dorsiflexion of the ankle.

Haglund’s Deformity

Prominence of the posterosuperior lateral aspect of the

calcaneus causing irritation of the bursa (both the retro-

calcaneal and the adventitial bursa), particularly from a

poor-fitting shoe, has been termed “Haglund’s deformi-ty.”107 This entity often goes hand-in-hand with retrocal-caneal bursitis and frequently there is an element of in-

sertional tendinitis as well. The term “pump bumps” hasalso been used to describe this condition. Often this pump

bump is asymptomatic, but it may become symptomatic

from a poor-fitting shoe or an irritating heel counter. This

tender prominence is typically present on the lateral side

of the Achilles tendon insertion, not directly on its central

portion. Although this is more commonly found in women

who wear high-heeled shoes, in the athletic population it

is sometimes found in hockey players who wear a rigid

heel counter that causes irritation. The patient population

that has this superolateral bone prominence tends to be

younger than the patients with retrocalcaneal bursitis.These patients likewise often have an element of retrocal-

caneal bursitis, tendo-Achillis bursitis, as well as inser-

tional tendinitis. Multiple studies have attempted to de-

lineate Haglund’s deformity radiographically by looking at the height, length, and the angular relationships of the

calcaneus. In our experience, none of these views have

been very helpful or reliable in making a diagnosis or

planning treatment, and the authors cannot recommend

one particular radiographic view as being consistently

helpful in demonstrating this bony prominence.

Numerous biomechanical risk factors have been associ-

ated with Haglund’s deformity, including a high-archedcavus foot, rearfoot varus, rearfoot equinus, and trauma to

the apophysis in childhood.28,45,55 It is important in these

cases to look for associated retrocalcaneal bursitis, as well

as insertional Achilles tendinitis.

Insertional Tendinitis

Patients with insertional tendinitis have a true inflamma-

tory reaction within the tendon. These patients have di-

rect tenderness over the Achilles tendon insertion, often

associated with calcification or spurring within or in jux-

taposition to the tendon just above its insertion on the

superior aspect of the calcaneus. It must be emphasized,

however, that the Achilles tendon does not actually attachto these spurs since it is contiguous with the whole poste-

rior wall of the calcaneus. There is a high association

of insertional tendinitis with retrocalcaneal bursitis or

Haglund’s deformity. The athlete typically complains of pain directly at the insertion of the Achilles tendon that is

initially worse after exercise but may eventually become

constant. As in other conditions with the Achilles tendon,

it is frequently aggravated by hill running and interval

training. Training errors are also common in this group

when there is a sudden increase in mileage and improper

stretching techniques. Insertional tendinitis is also seen

in heel runners. Running on hard surfaces also tends to

aggravate the pain.On physical examination, the tenderness is localized at

the Achilles tendon insertion. Insertional tendinitis is fre-

quently aggravated by passive dorsiflexion. Loss of pas-

sive dorsiflexion is common in this group.105 Radiographs

frequently demonstrate calcification or ossification com-

ing off the superior portion of the calcaneus and the upper

part of the insertion of the Achilles tendon. These changes,

however, are often seen incidentally as part of the normal

aging process, and clinical correlation is paramount before

assuming that the patient’s symptoms are secondary tothese abnormalities shown on radiographs. Often, these

radiographic changes can be seen bilaterally, although the

patient’s clinical complaints may be only for one side.





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Patients with insertional tendinitis are usually older than

patients with paratenonitis or Haglund’s deformity.

Imaging

Plain radiographs are only occasionally of any value in

determining treatment for any of these predominantly softtissue injuries. In rare cases of long-standing tendinosis

with or without partial rupture, ossification may be seen

within the tendon. Plain radiographs are more helpful

in evaluating patients with retrocalcaneal bursitis,

Haglund’s deformity, and insertional tendinitis, not onlyto delineate the morphologic characteristics of the postero-

superior aspect of the calcaneus, but also to look for any

ossification or osteophytes at the Achilles tendon

insertion.

The two imaging techniques that best demonstrate ab-

normalities within the Achilles tendon are ultrasonogra-

phy and MRI.86 Sonography seems to play a larger role in

European countries, particularly in Scandinavia, whereas

MRI appears to be the test of choice for most clinicians in

the United States. These imaging techniques seem to be

most helpful in delineating abnormalities within the

Achilles tendon itself, as well as imaging of the retrocal-

caneal bursa. Ultrasonography is much less expensive

than MRI and also allows for dynamic examination. It is,

however, very examiner-dependent, and reliability ap-

pears to correlate with the experience of the examiner.

Kälebo et al.49 compared sonographic findings in 37 pa-

tients who subsequently underwent surgery for Achilles

tendon disorders. In particular, they looked at the reliabil-

ity of diagnosing partial ruptures of the Achilles tendon

and found that ultrasound had a sensitivity of 0.94, a

specificity of 1.00, and an accuracy of 0.95. Paavola et al.96found that ultrasonography was reliable in delineating

focal lesions within the Achilles tendon, but they con-

cluded that it was inaccurate for differentiating partial

rupture from a focal area of tendinosis. They did note,

however, that ultrasonography was not completely reli-

able for diagnosing paratenonitis and tendinitis unassoci-

ated with a lesion within the tendon itself. For diagnosing

retrocalcaneal bursitis, they found ultrasonography to be

accurate in six of eight cases.

Magnetic resonance imaging has been shown to be ex-

tremely helpful in the preoperative evaluation of Achilles

tendon overuse injuries. This modality is extremely sen-

sitive to pathologic changes that occur within the tendonas a result of tendinosis, partial rupture, or both. Partic-

ularly in smaller areas of intrasubstance degeneration

that are not clinically palpable, MRI can help localize foci

that require exploration and debridement. Marcus et al.80

noted an excellent correlation between MRI and patho-

logic findings at the time of surgery, which has also been

our experience.106 Magnetic resonance imaging is ex-

tremely sensitive to pathologic changes within the tendon

(Fig. 3). Again, clinical correlation is paramount, as areas

of increased signal seen on MRI may in some cases repre-

sent incidental areas of asymptomatic degeneration simi-

lar to those seen in the menisci or the supraspinatus

muscle that may not be clinically significant. Our exami-

nation protocol includes 2-mm slices taken in both T1- and

T2-weighted images in the axial and sagittal planes.

In patients with paratenonitis, even in chronic cases

with significant thickening and fibrosis of the paratenon,

MRI has not been reliable in demonstrating pathologic

changes within the sheath, and we have found that sur-

gical correlation is poor in these circumstances.106 In

these cases, MRI is only helpful in ruling out abnormali-

ties within the tendon itself. Retrocalcaneal bursitis dem-

onstrates a high signal within the retrocalcaneal bursaand is best seen on T2-weighted images (Fig. 4). It is also

helpful for delineating contiguous changes within the ten-

Figure 3. Axial MR image of the midsubstance of the Achil-les tendon in a patient with tendinosis. Note the areas of highsignal within the tendon (arrow).

Figure 4. Retrocalcaneal bursitis. Sagittal MR image dem-onstrating high signal within the retrocalcaneal space asso-ciated with an osteophyte and prominence of the posteriorsuperior angle of the calcaneus (arrow).





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saline and, if available, ultrasound guidance can be help-

ful to ensure proper placement of the needle. A corticoste-

roid solution should not be used for this procedure.

The authors, as well as others, have found that the use

of injectable steroids is contraindicated as it may lead to

tendon rupture; however, we have found that in refractory

cases of retrocalcaneal bursitis, a one-time steroid injec-tion directly into the retrocalcaneal bursa is sometimes

helpful. Extreme care must be taken not to inject any

steroid solution into the tendon, and it is important that

only one injection be used. In an occasional case, one may

be able to aspirate bursal fluid from the bursa itself before

injection of corticosteroid. Although the use of steroid in-

jection in refractory cases before resorting to surgery can

be tempting, multiple studies have delineated the delete-

rious effects of injecting the corticosteroid solution into the

Achilles tendon. Å ström and Westlin11 studied a group of patients who had a partial rupture and a history of chronic

Achilles tendon symptoms. In a logistic regression analy-

sis, only preoperative steroid injections in men were pre-

dictive of a partial rupture. Furthermore, in highly com-

petitive athletes who have been known to use anabolic

steroids, either oral or injectable, it has been reported that

the use of anabolic steroids produces a stiffer tendon that

absorbs lower loads before failure and fails with less

elongation.43

Surgical Management

Although nonoperative management of Achilles tendon

overuse injuries is usually successful in getting patients

back to activity, there will be a small group of patients

who continue to be symptomatic, despite the measures

previously outlined. In particular, competitive and seriousrecreational runners who would like to continue running

may seek a surgical solution after other measures have

failed. Preoperative planning and exact delineation of the

cause of the symptoms is crucial. Often these entities

occur in combination (for example, paratenonitis with ten-

dinosis, or retrocalcaneal bursitis with insertional tendi-

nitis). In our initial review of 45 surgical cases, we found

7 patients (15%) actually had a combination of retrocalca-

neal bursitis along with more proximal paratenonitis or

tendinosis, or both.105

In our surgical treatment method, we use a longitudinal

approach made 1 cm medial to the Achilles tendon to avoid

the sural nerve. The length of the incision varies according to the extent and site of primary abnormality. In most

cases of paratenonitis or tendinosis, the incision spans

from the musculotendinous junction to just above the in-

sertion. In cases of retrocalcaneal bursitis, where expo-

sure of the retrocalcaneal bursa and the posterior aspect of

the calcaneus is necessary, it is essential to have exposure

from both sides. Our original approach was to perform a

skin incision that continued transversely from medial to

lateral below the Achilles insertion in a J-shaped fashion.

Subsequently, we have converted to a more conventional

double-incision technique, making a smaller longitudinal

lateral incision on the lateral side of the retrocalcaneal

bursa and carefully avoiding the sural nerve. This second

incision should leave a skin bridge of at least 4 cm; we

have not had problems with skin necrosis using this tech-

nique. Dissection should be carried directly down to the

Achilles paratenon, and a full-thickness flap should also

be created by dissecting between the Achilles tendon and

the paratenon, and not above this layer. This is para-

mount to preserve blood supply to the skin flap, particu-larly in older patients. In cases of chronic paratenonitis,

the tendon sheath is usually found to be hyperemic, thick-

ened, and adherent to the underlying tendon (Fig. 5). By

sharp dissection, the involved tissue is freed from the

underlying tissue and excised. We are careful not to excise

the anterior portion of the paratenon or disturb the ante-

rior fatty tissue for fear of jeopardizing the blood supply to

the tendon. A complete circular dissection could also po-

tentially lead to extensive postoperative fibrosis.

In cases of tendinosis or partial rupture, or both, often

the thickened area of the abnormality is obvious. In more

central or subtle cases, the tendon should be carefully

inspected and palpated for areas of thickening, defects, or

softening. This is where preoperative MRI can be very

helpful in delineating areas of tendon degeneration or

rupture that are not clinically palpable (Fig. 6). If there is

no clinically palpable defect or nodule within the tendon

and a well-done MRI does not demonstrate any echogenic

signal changes within the tendon, an exploratory splitting

incision within the tendon is usually not warranted.

In those patients where the tendon substance is in-

volved, a longitudinal splitting incision is made within the

tendon at the site of the abnormality. The foci of symp-

tomatic degeneration should be completely excised. Histo-

Figure 5. Chronic paratenonitis. The paratenon is markedlythickened and fibrotic, requiring sharp dissection off the ten-don. Care should be taken not to disturb the anterior softtissues.





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logically, this will usually represent areas of mucinoid

degeneration. The abnormal scar tissue has a different

consistency, usually harder and nodular, and appears dis-

organized in reference to the surrounding normal tendon.

All abnormal tissue should be excised.

Maffulli73 recommends exploration by three to five lon-

gitudinal tenotomies with excision of the abnormal tissue.In another study by Maffulli et al.,75 they described a

percutaneous technique using a No. 11 blade inserted

parallel to the long axis of the tendon fibers in marked

symptomatic areas and then plantar flexing and dorsiflex-

ing the foot, creating a 3- to 4-cm area of tenolysis ob-

tained through this percutaneous incision. This is re-

peated four to five times in the surrounding quadrants of

the tendon.

When a longitudinal splitting incision is made in the

tendon, care should be taken to use a minimal amount of

suture in closing the tenotomy. The use of excessive syn-

thetic absorbable sutures can initiate an extensive fibrotic

reaction in the tendon, creating fibrosis and thickening.

106

Maffulli et al.75 recommend not closing the longitudinal

tenotomies at all.

In cases of extensive tendinosis or partial rupture, or

both, the decision as to when to perform a reinforcement of

the tendon remains controversial. In our retrospective

long-term study,106 the area of partial rupture did not

require reinforcement in most cases. In fact, many of the

patients with these symptoms will have marked thicken-

ing of the tendon so that after debridement the tendon

may have a more normal diameter in comparison with the

contralateral, unaffected side. Based on our clinical expe-

rience, we have developed an algorithm for surgical man-

agement of tendinosis or partial ruptures of the Achilles

tendon. In cases of moderate deficiency (20% to 40%), we

would reinforce the tendon with either a turn-down flap or

a plantaris patch. In cases where there is 50% to 75%

involvement of the tendon, augmentation is necessary.

This can be either in the form of a direct augmentation

with the use of autograft (such as semitendinosus or gra-

cilis tendon graft) or, more recently, we have used allo-graft tendon with less morbidity and equally good results.

If more than 75% of the tendon is involved and there is

very little normal substance left, autogenous tendon

transfer or reconstruction with the use of allograft is in-

dicated. Mann et al.79 reported on seven patients in whom

they performed a transfer of the flexor digitorum commu-

nis tendon for chronic rupture of the Achilles tendon. They

believe there is an advantage in using this tendon instead

of the peroneus brevis because it brought in a richer vas-

cular supply, allowing retention of plantar flexion as well

as a more biomechanically correct insertion into the cal-

caneus. They believe the use of the peroneus brevis muscle

changes the balance between the invertor and evertor

muscles. In their study, however, all patients had gross

incontinuity of the tendon, and most patients were in their

6th and 7th decades of life.

Hansen40 has recommended the use of the flexor hallu-

cis longus muscle for treating prerupture syndrome of the

Achilles tendon. He recommends splitting the Achilles

tendon and inserting the muscle belly of the flexor hallucis

longus muscle to improve the blood supply to the Achilles

tendon. We believe that this procedure helps correct the

vascular insufficiency in the tendon. Concerns must be

raised about the transfer of the flexor hallucis longus

muscle in an athlete, particularly in a runner, as there is

an effect on the flexion strength of the first interphalan-

geal joint. The biomechanical imbalance created by thisprocedure, although relatively minor, could potentially

have a significant impact in an athletic person.

In most of our patients, the involvement was well below

50% of the diameter of the tendon, and the biomechanical

implications of a more major surgical procedure with ten-

don transfer may seriously jeopardize the patients’ returnto athletics and running. However, if the majority of the

tendon is involved, tendon augmentation or transfer

should be used. These patients have usually already been

forced to a lower activity level, being functionally disabled,

even with activities of daily living. At the present time, we

more commonly perform tendon augmentation using tibi-

alis or semitendinosus tendon allograft rather than ten-don transfer.

In patients with retrocalcaneal bursitis, the retrocalca-

neal bursa should be completely excised. Again, it cannot

be overemphasized that exposure is essential from both

sides of the tendon, and a second longitudinal lateral

incision is necessary. The bursa is usually found to be

hyperemic, thickened, and in some cases filled with fibrin-

ous loose bodies and bursal fluid. In most patients, the

bursa was found to be scarred and adherent to the ante-

rior surface of the Achilles tendon (Fig. 7). After excision of

the retrocalcaneal bursa, the posterior superior angle of

the os calcis should be generously excised using a 0.5-inch

flat osteotome. The ostectomy should be started just su-

Figure 6. Clinical case of tendinosis. A longitudinal splittingincision has been made, revealing extensive diffuse muci-noid degeneration within the tendon.





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perior to the insertion of the Achilles tendon fibers on the

os calcis and performed in approximately a 40° to 50°angle to the long axis of the tendon, up to the posterior-

superior surface of the os calcis (Fig. 8). It is critical to

expose the area between the anterior surface of the tendon

and the posterior os calcis as distally as possible. Since the

Achilles tendon has an extensive insertion all the way

down to the inferior aspect of the calcaneus, this does not

jeopardize the Achilles tendon insertion. Most failures of

this procedure are related to an inadequate ostectomy.106

The edges should be carefully smoothed to remove any

sharp ridges and the ankle should be brought through a

complete range of motion to ensure that there is no longer

any impingement of the os calcis on the anterior surface of

the Achilles tendon. Enough bone should be removed so

that there is clearance the size of one finger between the

posterior aspect of the os calcis and the anterior aspect of the Achilles tendon with dorsiflexion of the foot. Some

authors have described the use of a lateral incision only,

as the primary prominence of the posterior superior os

calcis is located laterally.89,90 Although some authors,

such as Keck and Kelly,52 have described simple excision

of the retrocalcaneal bursa without ostectomy in patients

without a bone prominence, most authors, including us,

advocate a generous ostectomy in all cases of retrocalca-

neal bursitis. A ridge of bone is often left at the distal

insertion site that must be carefully removed with a ron-

geur, curette, and rasp so that no irritating prominence

remains above the distal insertion. Most cases of failure

referred to us were secondary to an inadequate ostectomy,often performed through a single incision.

In cases of Haglund’s deformity, the ostectomy shouldbe more generous on the lateral than on the medial side,

and the primary incision should be lateral. In addition, the

superficial adventitial bursa needs to be removed as well,

taking care not to devascularize the skin flap. This pump

bump condition is not frequently seen in athletes and

usually can be treated conservatively. Hockey players are

the one group of athletic patients in which we have most

frequently found this condition. The rigid heel counter of

the skate is the causative factor.

Insertional tendinitis is usually seen in older athletes.

We tend to treat these patients conservatively for a longerperiod, even resorting to a period of immobilization in a

short-leg walking cast, and, in most cases, symptoms will

resolve. Often, a “fish hook” osteophyte is seen with orwithout ossification of the distal Achilles tendon. In some

cases, this osteophyte may actually fracture and cause

pain. Again, it is important to be certain that this is

actually contributing to the pain, as it is often seen as an

incidental radiographic finding. Local inflammation sec-

ondary to this osteophyte also occurs in conjunction with

degeneration and erosion of the central portion of the

Achilles tendon in this area, which contributes to the pain

as well. If surgery is necessary, the soft tissues must be

handled very carefully, particularly in an older popula-

tion. Although Baxter and Thigpen12 recommended a cen-

tral longitudinal incision, most authors, including us, pre-

fer a longitudinal incision either placed medially or

laterally, or in some cases, in both positions. A small

splitting incision is made within the tendon at the inser-

tion and any spurs and areas of degeneration are debrided

(Fig. 9). Involvement of the retrocalcaneal bursa and some

prominence of the posterior os calcis is common in these

patients, and these entities should be addressed as well.

Complete detachment of the tendon, debridement, and

reattachment should be avoided. Again, excessive suture

material in closing the splitting incision within the tendon

should also be avoided.

Figure 7. Chronic retrocalcaneal bursitis. The bursa ismarkedly thickened and adherent to the tendon.

Figure 8. Ostectomy for retrocalcaneal bursitis. A wide, thinosteotome is used to perform a generous ostectomy of theposterior superior angle of the calcaneus starting right at theinsertion and angled at approximately 45°.





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Postoperative Regimen

In cases of paratenonitis only, range of motion exercises

are instituted immediately to prevent scarring and fibro-

sis. A removable boot walker is used, but the patient is

allowed to remove the boot for gentle range of motionexercises. Weightbearing is usually limited for the first 2

to 3 weeks to control soft tissue swelling and to aid wound

healing. In those cases where there is a small area of

tendinosis, a boot walker will be used for approximately 4

to 6 weeks and range of motion is begun after good wound

healing is present. Weightbearing is also limited for the

first 4 to 6 weeks. Where there is an extensive area of

tendinosis requiring augmentation or tendon transfer, pa-

tients are treated with a complete rupture regimen. Pa-

tients are initially placed in a short-leg cast in a relaxed

plantar flexed position and serial casting is performed at

weekly intervals for the first 3 to 4 weeks postoperatively

to bring the patients up to a neutral position. They arethen placed in a boot walker, at which time range of

motion exercises are begun, avoiding aggressive dorsiflex-

ion for the first 8 weeks postoperatively. In cases of retro-

calcaneal bursitis, range of motion can be begun immedi-

ately and a boot walker is used for 2 weeks with protected

weightbearing, and then weightbearing is resumed with

the walker being replaced with a heel lift. Patients with

insertional tendinitis tend to be older, and wound healing

is a major concern. Therefore, we recommend placing pa-

tients in a boot walker for 4 to 6 weeks and keeping them

nonweightbearing during this time. When good wound

healing is evident after the first 2 weeks, range of motion

exercises are begun.

Early emphasis in the postoperative treatment regimen

should be on regaining passive dorsiflexion. This is

achieved with passive stretching, both in the nonweight-

bearing and weightbearing positions with the knee ex-

tended as well as flexed. A graduated program of swim-

ming and stationary bicycling, along with isometric,

isotonic, and eccentric strengthening in the later stages isprescribed. Light jogging is usually permitted between 2

and 3 months postoperatively, unless there was extensive

tendon involvement, in which case we discourage any

running until at least 4 to 5 months postoperatively. Ini-

tially, a softer running surface such as a track is recom-

mended. Mileage is gradually increased, and the patient is

initially discouraged from doing hill workouts or interval

training. Return to a competitive level usually is not until

5 to 6 months postoperatively, and may be longer in cases

of extensive tendon involvement.

Alfredson et al.2 performed a prospective study of 13

patients with chronic Achilles tendinitis who underwent

surgical treatment. The authors were interested in return

of calf muscle strength. They concluded that 6 months of

postoperative rehabilitation for chronic Achilles tendinitis

was not enough for patients to recover concentric and

eccentric plantar flexion muscle strength compared with

the noninjured side. However, in their series, the patients

were immobilized in a cast for 6 weeks postoperatively. In

a further study, the same authors3 prospectively looked at

the calf muscle strength in patients who were immobi-

lized in a cast for only 2 weeks, followed by an aggres-

sive rehabilitation program. Again, they found that the

concentric strength as well as the eccentric strength

return is very slow, taking up to 1 year, and even at that

point there was still concentric strength deficit. We

counsel patients, particularly if they have extensivetendon involvement, that any running activities may

not be possible for 6 months, and complete recovery may

take up to 1 year.

Results

In our initial surgical series105 we reviewed 45 surgical

cases in 37 patients. Overall, there were 87% satisfactory

results. Interestingly, 92% of the patients with involve-

ment of the paratenon or tendon, or both, had a satisfac-

tory outcome, as compared with only 71% of patients with

retrocalcaneal bursitis. In this early study, it was appar-ent that many of these patients had had an inadequate

ostectomy. In our subsequent study, looking at 79 cases in

66 patients, 80% of whom were competitive or serious

recreational runners, overall there were 79% satisfactory

and 21% unsatisfactory results.106 The percentage of sat-

isfactory results in the paratenonitis group was best

(87%), and the percentage in the tendinosis group was the

worst (67%). Satisfactory results were found in 75% of

patients with retrocalcaneal bursitis and in 86% of pa-

tients with insertional tendinitis. Furthermore, in 7 of the

45 cases (16%) with longer than 5-year follow-up and

initially satisfactory results, patients’ results deterioratedwith time and reoperation was required. This scenario

Figure 9. Insertional tendinitis with loose osteophyte ex-posed through a midline longitudinal splitting incision at theinsertion.





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was most commonly seen in the older male runner with

tendinosis who, despite adequate debridement at the

time of the initial operation and a period of symptomatic

relief, had slow recurrence of the degenerative process

within the tendon and the development of symptomatic

tendinosis. We were able to obtain 2-year follow-up in

five of the seven cases after revision surgery, with onlythree of the five patients able to return to long-distance

running.

In a larger series, Nelen et al.91 treated 170 patients

surgically and had follow-up on 143 tendons in 91 pa-

tients, only in those patients with paratenonitis or tendi-

nosis, or both. In 50 patients with tendon involvement,

they resected the diseased tendon only with a side-to-side

repair of the tendon. In the other 24 cases of tendinosis,

reinforcement was performed with a turn-down flap. They

reported a satisfactory surgical outcome in 82 of 92 cases

(89%) of paratenonitis. A satisfactory outcome was ob-

tained in 19 of 26 patients (73%) with debridement and

side-to-side repair, and in 21 of 24 cases (87%) with aturn-down flap in cases where there was extensive de-

bridement. Johnston et al.46 reported on 17 patients who

underwent surgery, all of whom were able to return to

unrestricted activity after an average of 31 weeks of reha-

bilitation. Maffulli et al.75 reported on the surgical out-

come of 14 athletes with central degeneration and tendi-

nosis who underwent surgery. Only 5 of these patients

(36%) had an excellent or good result, despite reexplora-

tion in 6 of the 14 patients. The average duration of

symptoms, however, from onset of symptoms to surgery

was 87 months. It was their conclusion that surgery in

this condition should be performed at an earlier stage. It is

our policy that, if symptoms have been recalcitrant toconservative measures for at least 6 months and there is

actual tendon involvement, and if the patient is a surgical

candidate, surgery should be performed at that time. It is

well known that any intrinsic tendon healing that occurs

after tendon injury will be relatively complete by 6

months.

Complications include skin necrosis, infection, exten-

sive fibrosis in and about the tendon, and permanent loss

of motion or strength, or both. Complications can be

avoided by meticulous handling of the soft tissues, avoid-

ing extensive use of suture material in or about the ten-

don, performing an adequate ostectomy in cases of retro-

calcaneal bursitis, and instituting range of motion

exercise at an early stage of rehabilitation. Rolf and

Movin103 reported a complication rate of 13% in 58 pa-

tients treated surgically. These included two superficial

and two deep infections, two deep vein thromboses of the

lower leg, one total rupture and one hypertrophic scar.

Although a satisfactory surgical outcome can be achieved

in most cases, patients with extensive tendinosis, partic-

ularly older male runners, should be warned of the high

rate of recurrence as well as a possibility that they may

not return to a strenuous running program. In most cases,

however, surgery does offer a solution in well-selected

cases.64

ACHILLES TENDON RUPTURES

Diagnosis

Since Ambrose Pare98 first described Achilles tendon rup-

ture in 1575, there is evidence that the incidence of Achil-

les tendon rupture is increasing in western society.48,67,82

This may be associated with an increase in athletic par-

ticipation in a predominantly sedentary, white collar pop-

ulation. Leppilahti et al.67 suggest that the incidence may

have increased from 2 in 100,000 in 1986 to 12 in 100,000

in 1994.

Typically, Achilles tendon rupture occurs most com-

monly in men in their 4th and 5th decades, with an aver-

age age of between 30 and 40 in many studies; such

ruptures account for 40% of all operated tendon rup-

tures.21,22,41,43,48,53 Rupture in association with racquet

or ball sports or other athletic activity has been noted

in 75% to 80% of cases.16,21,33,48,67,82,93,111,112 Möller

et al.82 have commented that the age distribution is bi-

modal, with a maximum incidence of sports injuries in the4th decade of life followed by a second but lower peak of

other injuries in the 8th decade. Achilles tendon ruptures

are less commonly seen in women. The male-to-female

ratio has been reported by most authors in the range of 5:1

to 6:1.13,16,21,43,44,53,67,81 Additional risk factors for rup-

ture include prodromal symptoms seen in 15% to 20% of

patients with ruptures,110 a history of previous corticoste-

roid injection,76 gout,13 and treatment with flouroquin-

olone antibiotics.81,84,85 Several authors have noted a

greater incidence of left-sided ruptures and an association

with type O blood group.21,41,48,67 In a recent study, an

association between high longitudinal arches with less

pronation of the ankle and less varus of the forefoot wasnoted.66 The authors hypothesized that an underpronat-

ing foot and ankle, which are linked with poor shock

absorption, increases stress on the Achilles tendon, plac-

ing a torsional force on the tendon in midstance and push-

off that may cause an ischemic “wringing out” at or nearthe avascular zone.

The mechanism leading to rupture is not fully under-

stood; however, the interplay of intrinsic pathologic

changes within the tendon and extrinsic factors combine

to result in acute musculotendinous injury. Intrinsic fac-

tors include pathologic degenerative changes in the region

of the rupture as found in more than 50% of 292 patients

in the study of Jósza et al.

48

; corresponding rupture typi-cally occurs in the hypovascular region of the tendon 4 to

6 cm proximal to its insertion. Recurrent microtrauma to

this region with subsequent inability to heal has been

proposed as the cause. Against this are the relative pau-

city of prodromal symptoms, suggesting a silent degener-

ative process, and conflicting histologic data, failing to

show an association between degenerative change and

rupture.43 Corticosteroids, oral or injectable, have been

implicated in collagen necrosis, and flouroquinolone anti-

biotics have been suggested to be toxic to tenocytes and to

inhibit matrix formation.76,81,85

The role of extrinsic factors in Achilles tendon rupture is

also significant. Acceleration/deceleration mechanisms





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have been noted in up to 90% of sports-related injuries.110

Inglis et al.43 proposed a malfunction of the normal pro-

tective inhibitory neuromuscular pathway of the muscu-

lotendinous unit in the fatigued or poorly trained athlete,

a theory that is supported by data suggesting that rupture

typically occurs 30 minutes or more into the athletic en-

deavor. Biomechanical factors may also contribute, asnoted by Å ström and Rausing 10 and Leppilahti et al.66

Clearly, the cause is multifactorial, with a complex inter-

play of contributing factors.

The clinical history of Achilles tendon rupture is fre-

quently typical, with the athlete describing an audible

snap and sudden pain, as if being kicked or hit from

behind. Many clinical tests have been described to detect

acute rupture.74,94,108,117 A recent study attempted to

validate several of these tests and found that the calf

squeeze test described by Thompson117 and Simmonds108

was the most reliable, with a 93% sensitivity.73 The pal-

pable gap test was the least sensitive, with a value of 73%

with the patient awake, improving to 81% under anesthe-

sia. All tests had a high negative predictive value, and we

have found a combination of these two tests to be highly

reliable. Imaging is generally not indicated except when

tendinous avulsion is suspected, which, in our experience,

is uncommon. Magnetic resonance imaging and ultra-

sound are sensitive and specific; however, they do not

influence surgical planning in acute cases and, in our

opinion, are not warranted except perhaps in the rare case

when clinical findings are equivocal. Perhaps somewhat

surprisingly, a reported 20% of ruptures are missed by

primary treating physicians.43

Treatment Options

There has been much debate over the relative merits of

operative versus nonoperative management of acute

Achilles tendon ruptures. A lack of defined universally

accepted outcome measures, a multitude of different re-

parative techniques, and a similarly diverse range of post-

operative immobilization and rehabilitation protocols

have made comparison of results difficult.

In the early 20th century, closed treatment was widely

accepted as the standard of care; however, the increasing

functional demands of the athletic population and im-

proved surgical technique have caused operative treat-

ment to gain popularity in recent times. Patient selection

remains the most important factor decision. Operativetreatment, particularly with early functional rehabili-

tation, seems to confer better functional outcome with

accurate restoration of tendon length and a lower re-

rupture rate.13,16,21,32,44,124 Against this are the re-

ported complication rates associated with open treat-

ment and the acceptable functional results of closed

treatment in the less-demanding athletic

population.21,37,43,65

Nistor,93 in a randomized prospective trial of 105 pa-

tients, noted 2 deep infections and 2 reruptures compli-

cating operative treatment versus 5 reruptures in the

closed treatment group. After evaluation of subjective and

objective plantar flexion strength and power using func-

tional tests and a dynamometer, the author concluded

that operative surgical treatment conferred no great ad-

vantages and that closed treatment was therefore prefer-

able. Of note, only nine patients in this series participated

in competitive sports.

Beskin et al.13 evaluated 42 patients who underwent

primary repair using a number of techniques including direct repair, plantaris tendon augmentation, and pero-

neus tendon augmentation. No reruptures were noted,

with a 7% minor wound complication rate. Better results

were noted in the three-bundle technique, but rehabilita-

tion was not uniform and, in the latter group, consisted of

early functional treatment.

Augmented repair has also been described. This may be

performed with local tissue, such as a fascial turn-down

from the proximal tendon, plantaris muscle, peroneus bre-

vis muscle, or with synthetic material.32,68,71,116 Fernán-

dez-Fairén and Gimeno32 reviewed the results of repair

augmented with a polyethylene terephthalate mesh syn-

thetic graft that permitted immediate mobilization with

weightbearing in the 3rd week. Twenty patients were

high-level amateur athletes and nine were professional

athletes. Average flexion strength was 96% of the normal

side, as measured with a dynamometer.

Gerdes et al.36 studied the efficacy of repair using a

fascial turn-down technique. Biomechanical cadaveric

studies were performed and strength was compared with

two interrupted Kessler sutures, revealing a 35% increase

in strength to failure. In a small series of seven patients,

immediate postoperative weightbearing was allowed in a

cast for 6 weeks. Five patients had excellent results at 1

year and one had a good result; all athletes returned to

their previous levels of activity. Plantar flexion strength

measured 94% of the contralateral limb.Cetti et al.21 reviewed 111 patients in a nonrandomized

prospective study in 1993. There were 10 major complica-

tions (9%; 4% with deep infection) in the operatively

treated group and 18 (16%) (8 were reruptures) in the

nonoperative group. Repair was performed with an end-

to-end Bunnell suture, and cast immobilization with non-

weightbearing was implemented postoperatively. Al-

though hospitalization was longer in the operative group,

return to work was 2 weeks earlier. Perhaps more impor-

tantly, 63 patients (57%) returned to sports at the same

level, versus 32 (29%) in the nonoperative group. The

authors also reviewed the literature on 4083 Achilles ten-

don ruptures treated operatively and noted a difference inrerupture rate after operative and nonoperative treat-

ment (1.4% to 13.4%) and also a lower overall rate of

complications (3.5% to 18.1%). Simple end-to-end repair

without flaps or augmentation had a trend toward a lower

rerupture rate (0.65%) and decreased wound complica-

tions. Various methods have been used to objectively eval-

uate functional recovery, and in those studies in which a

dynamometer was used, mean plantar flexion strength

after surgery was 87%, versus 78% with nonoperative

treatment. Similarly, return to sports at preinjury levels

was 62% versus 51%.

Inglis et al.43 studied 79 patients, 48 of whom were

treated operatively and 31 nonoperatively. Complications





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in the former group included two superficial infections, no

reruptures, and only two dissatisfied patients. This con-

trasts with the results in the nonoperative group where,

although immobilization ranged from 5 to 9 weeks in

short- and long-leg casts, there were 9 reruptures and only

9 of 23 patients were satisfied. Strength/power/endurance

measured objectively were 101/88/91 versus 73/62/64, allsignificantly less in the nonoperative group. Furthermore,

in 17 cases that were operated later in the study, endur-

ance was 20% less. The authors noted that their compli-

cation rate had decreased with surgeon experience, and in

1981 they reported on a series of 159 patients with a

complication rate of 12.5%.44 Kellam et al.53 reported a

rerupture rate of 3% and an incisional complication rate of

13%, with 92% of the patients returning to previous levels

of participation. Wills et al.124 reviewed complications in

the literature and noted a trend toward a decreasing op-

erative wound complication rate with time. Arner and

Lindholm,8 in their 1959 series, reported a 30% complica-

tion rate, whereas in a recent study of repair using several

techniques in 101 patients, of whom 91 were athletes, a

complication rate of 6.9% was noted. The authors also

described a standardized scoring protocol for evaluation of

outcome.

Percutaneous repair was first described by Ma and Grif-

fith72 in 1977 in an attempt to avoid the potential wound

complications of open repair while obtaining the advan-

tages of operative apposition of the tendon ends and res-

toration of tendon length. FitzGibbons et al.33 reported on

the follow-up of 14 patients after percutaneous repair,

noting two sural nerve injuries and no other significant

complications; however, a 13% loss of power was seen on

isokinetic testing at 180 deg/sec. Subjectively, satisfactory

results were noted in recreational athletes, with all of them returning to preinjury activity levels.

Bradley and Tibone16 reported on a series of 12 percu-

taneous repairs and compared these with a series of 15

patients treated with an open technique using a gastroc-

nemius muscle flap as described by Lindholm.68 Two re-

ruptures (13%) occurred in the percutaneous group, but

otherwise no differences were noted in subjective or objec-

tive outcome as measured isokinetically. No complications

were noted and the authors concluded that percutaneous

repair should be reserved for the recreational athlete. Ma

and Griffith,72 in their original series of 18 patients, had

no wound complications, but they reported a rerupture

rate of 12%; plantar flexion power, assessed objectively,ranged from 72% to 94% of the contralateral limb. Hock-

enbury and Johns42 suggested that percutaneous repair

may not be strong enough to allow an aggressive rehabil-

itation program. In a cadaveric study, they performed

biomechanical studies on five specimens with a percuta-

neous technique and compared the results with those after

a direct end-to-end Bunnell suture technique. They found

a 60% incidence of sural nerve entrapment and 50% rela-

tive strength in the percutaneous group. In our opinion,

the difficulty in accurately restoring musculotendinous

length by closed means does not significantly outweigh the

reduced incidence of wound necrosis and potential sural

nerve injury in the athletic population. In a further at-

tempt to avoid the reported 25% wound complication rate

associated with open repair, Esemenli et al.31 described a

combined open and percutaneous technique using a mod-

ification of the fascial turn-down technique, avoiding an

open incision directly over the site of repair. The follow-up

was 2 years, but there were only three cases with no

reported reruptures.The biomechanical strength of several repair techniques

has been evaluated in cadaveric models.123 In an analysis

comparing Bunnell suture with modified Kessler and in-

terlocking suture, investigators found the interlocking su-

ture to be significantly stronger.42 In a further biome-

chanical evaluation of the percutaneous technique, the

authors demonstrated significant gapping at the repair

site in addition to a high rate of sural nerve entrapment

and concluded that percutaneous repair did not provide

sufficient initial strength to allow aggressive rehabilita-

tion. Mortensen and Saether83 compared a continuous

six-strand suture technique with the Mason and Bunnell

techniques and found significantly greater tensilestrength and gapping resistance. Our concerns with the

more complex suture techniques previously described, as

well as the three-bundle technique described by Beskin et

al.,13 is the bulkiness of these repairs, with higher wound

complication rates noted in some clinical series and the

potential for devascularization of the tendon with multiple

complex grasping sutures.

We believe that surgical repair is indicated in the ath-

letic population primarily to restore functional length of

the musculotendinous unit. Closed and percutaneous

methods are not incompatible with this dictum; however,

achievement of these ends without open means is far less

predictable. For this reason, we advocate repair using asimple modified Kessler suture with No. 5 nonabsorbable

and a running epitendinous 2.0 absorbable suture, avoid-

ing any knot placement or bulky suture material directly

beneath the incision. We prefer a medial incision with the

patient prone and we routinely use a tourniquet. The

contralateral limb is free-draped to allow a comparison of

resting tension with the normal limb. Careful handling of

soft tissues is mandatory for success, and we attempt to

close the paratenon over the repair after release of the

tourniquet. Appropriate intraoperative tensioning of the

repair is essential and is performed with the knee flexed to

90°. In this position, the gently plantar flexed foot shouldreturn to neutral after release. A comparison with tension

on the contralateral side is always helpful.

Various augmentation techniques have been described,

including local gastrocnemius muscle fascial augmenta-

tion as described by Lindholm,68 peroneus brevis muscle

transfer as described by Teuffer,116 and plantaris muscle

augmentation as described by Lynn.71 In addition, recon-

structive techniques using flexor digitorum longus and

flexor hallucis longus muscles have been de-

scribed.79,121,122 Although these may offer a biomechani-

cal advantage in terms of permitting a more aggressive

rehabilitation program, we do not believe that they are

required in acute cases if an adequate primary repair can

be obtained without the potential for greater wound com-





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plications, as noted by Cetti et al.,21 and potential donor

site morbidity.

Before the 20th century, treatment of Achilles tendon

rupture was primarily nonoperative; however, with the

work of Arner and Lindholm,8 surgery became increas-

ingly popular. However, the significant complication rate

associated with operative treatment in the 1960s and1970s led Lea and Smith60 to review 56 patients treated

nonoperatively with casting. They recommend this treat-

ment for all patients with acute rupture, citing experimen-

tal evidence of tendon regeneration when sectioned. The

authors also argued that rerupture could be avoided by

casting for 8 weeks rather than 6 weeks. Fourteen pa-

tients had greater than 6° of increased dorsiflexion andnone were professional or college athletes. No consensus

exists concerning the duration of cast treatment, weight-

bearing, or the length of cast (that is, above the knee

versus below the knee), although the cadaveric studies of

Davis et al.30 suggest that short-leg cast immobilization is

sufficient.

We recommend closed treatment only for those patients

with limited functional goals and also for those patients

with concurrent medical conditions that preclude ade-

quate wound healing, such as arteriosclerosis, diabetes,

limb edema, or dermatologic problems. In these patients,

we prefer immobilization in a short-leg cast with the foot

in equinus for 4 weeks, followed by a walking cast or boot

walker in neutral plantar flexion, permitting a gradual

increase in weightbearing to 8 weeks and then adding a

2.5-cm heel rise to the shoe for the following 4 weeks.

Rehabilitation

The postinjury rehabilitation of Achilles tendon ruptures,whether treated operatively or nonoperatively, remains

controversial. Traditionally, treatment has consisted of

cast immobilization for a period of 6 to 8 weeks with

immobilization of the ankle initially in equinus, with sub-

sequent return of the foot to neutral plantar flexion over

the following 3 to 4 weeks. Some authors have advocated

treatment in a long-leg cast; however, this is not sup-

ported by the biomechanical cadaveric studies of Davis et

al.,30 who demonstrated minimal tension in the tendo-

Achillis with the ankle in 25° of plantar flexion, irrespec-tive of knee position.

Experimental work in animals has confirmed that the

benefits of loading the healing musculotendinous unit areimproved vascularity, decreased collagen cross-linkage,

and increased size and number of collagen fibrils. In ad-

dition, appropriate loading has been shown to improve

fiber orientation, with corresponding enhanced biome-

chanical properties when compared with immobiliza-

tion.87,111 The detrimental effects of immobilization have

been well documented. Häggmark and Eriksson39 demon-

strated gross morphologic wasting and histologic changes

in the soleus muscle with atrophy of type 1 fibers in

athletes immobilized for 6 weeks. Neumann et al.92 dem-

onstrated kinematic and neuromuscular alterations in

gait 12 months after surgery for tendo-Achillis rupture,

with subsequent immobilization for an average of 9 weeks.

Other potential complications of immobilization include

arthrofibrosis, adhesions, venous thromboembolism, and

pressure necrosis from casts or splints.

Given this experimental evidence for the advantages of

early mobilization, practitioners have subsequently ap-

plied these principles clinically. Clearly, the main con-

cerns with early mobilization are the potential for increas-ing the incidence of wound complication and early

rerupture, which might outweigh any potential long-term

benefits. As such, the initial strength of the surgical repair

must be sufficient to withstand an aggressive rehabilita-

tion program.

Early reports describing limited range of motion with

restricted weightbearing were favorable.22,111,118 More

recent protocols have advocated progressively earlier

weightbearing in functional orthoses.77,112 Using these

regimens, return of o

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16 Achilles Tendon Disorders in Athletes