Achilles Tendon Rupture

AnatomyAchilles tendon anatomy


Gastrocnemius tendon 10-25 cm long

- soleus 3-10 cm

- inserts superior calcaneal tuberosity

- fibres spiral 90°

- fibres that lie medially in proximal portion become posterior distally

- allows elastic recoil & energy storage


Plantaris present in 90% population

- medial to T Achilles


Poor blood supply midportion

- mesotenal vessels

- fewest at 2-6 cm

- other blood supply from osseous insertion




Usually age > 40 years

- M:F = 12:1

- occasional sportsman

- 75% during sports




Calf contraction with forced dorsiflexion in setting of tendon degeneration


Combination of


1.  Repetitive microtrauma

2.  Hypovascularity

- occurs at watershed of vascular supply 

- an area of hypovascularity 5 cm proximal to tendon insertion



- corticosteroids - oral or injected

- anabolic steroids

- flouroquinolone / ciprofloxacin (especially elderly)

- gout

- hyperthyroidism

- tendinitis (10% ruptures have preexisting achilles tendon disorder)

- cavovarus OR planovalgus foot


Mechanical Overload

- footwear (low heel, inadequate shock absorption)

- sudden training increase

- cross training


Classification of Tendon Inflammation


1. Paratenonitis 

- inflammation of paratenon

- swelling, pain, crepitation, tenderness, warmth


2. Paratenonitis with tendinosis


3. Tendinosis 

- intratendinous degeneration due to atrophy

- aging, microtrauma, vascular compromise

- swelling absent

- +/- palpable nodule


Rupture Site


1.  Watershed area

- 5 cm proximal to insertion

- most common


2.  Insertion

- common with insertional tendonitis


3.  Musculotendinous juntion

- avulsion of medial or lateral head

- may present with chronic weakness


Medial Head Gastrocnemius RuptureMusculotendinous Gastrocnemius Rupture 2


NHx (if neglected)


Weakness / wasting

- difficulty with push off

- compromised running / jumping / stairs 

- can still walk with use of FHL / FDL / T posterior / Peroneals


Calf Wasting Left Leg




Sudden pain in calf

- with audible snap

- on unaccustomed exercise

- especially tennis / squash




MAJOR SIGNS (AAOS Clinical Practice Guidelines 2010)

Positive Thompson Test (90% sensitivity and specificity)

- patient prone

- squeezing calf doesn't produce plantarflexion of ankle


Thompson Sign Normal PreThompson Sign Normal Post 

Palpable gap (70% Sensitivity and Specificity)


Achilles Tendon Rupture 1Achilles Tendon Rupture 1


MINOR SIGNS (more difficult to elicit acutely) 

Weak PF

- unable to perform single heel raise 


Increased DF comparted to contralateral side


Chronic tear

- gap fills with scar tissue

- gap not palpable

- excessive DF compared with other side


TA rupture increased DF



Only indicated if associated bony tenderness 




Cheap, dynamic, fast

- operator dependant

- check reduction of tendon ends with plantarflexion


Acute Achilles Tendon Rupture UltrasoundAcute Achilles Tendon Rupture Reduced with Plantarflexion





- incomplete rupture 

- signs of degeneration

- clinical uncertainty (two major signs not present) 

- measurement of gap in chronic cases / preoperative planning for reconstruction


MRI TA rupture chronic


Operative v Non-operative Management




1.  Complications 

- infection & skin necrosis with operative

- ? re-rupture with non operative


2.  Function

- strength & patient return to activity / sports

- ? better function with non operative




Khan et al JBJS Am 2005

- 12 trials involving 800 patients

- operative treatment associated with lower RR (.27; CI .11 - .64) of rerupture

- higher risk of complications (RR 10.6; CI 4.82 – 23.2) 



Willits et al JBJS Am 2010 

- 144 patients randomised trial operative v non operative

- concept of accelerated functional rehabilitation in both groups

- 2 weeks NWB

- weight bear in aircast with 2 cm heel raise up to 8 weeks

- able to actively DF / PF below neutral

- no significant difference in rerupture rate or loss of motion / power at all time indices

- 13 complications in operative versus





- elderly, DM, PVD, smokers

- non athlete




Equinus front slab 

- need to do within 24 hours

- try to close gap before haematoma forms

- change to full cast at 1 week

- debatable if need long leg cast v short leg

- 2 weeks


Functional Rehabilition

- heel raise 2 cm and air cast

- FWB for further 6 weeks

- active ROM below neutral


Achilles Tendon Boot and heel raise





- rate unknown

- likely in order of 5%

- likely some minimal loss of plantarflexion strength


No risk of infection / wound breakdown




Achilles tendon ruptureAchilles tendon repairKrackow suture



- young, active

- athlete 





- ? delay for one week to allow swelling to reduce



- prone

- prep both feet to check tension


Posteromedial approach

- avoids sural nerve and short saphenous vein

- don’t place scar directly posteriorly / less scar discomfort

- full thickness skin to paratenon


Open paratenon and dissect off tendon

- want to repair at end of case on dorsum of tendon

- this reduces skin adhesions

- incise paratenon in the midline anteriorly / increases tissue available for closure


Tendon repair

- Bunnell Suture  / Krackow suture x 2 with high strength suture / fibre wire

- one in proximal and one in distal tendon ends

- tie via two knots with foot fully plantar flexed

- augment with circumferential 4.0 prolene to minimise bunching



- not usually needed acutely


Paratenon repair

- closure posteriorly to aid glide

- prevents adherence to scar

- use 3.0 vicryl


Careful skin closure

- LA with adrenalin

- front slab short leg


Post operative

- accelerated rehab as above

- jog at 3/12

- sports at 6/12




Wound breakdown


Debride, manage infection

- vac dressing

- free muscle flap (usually gracilis) + SSG

- fasciocutanous flap (radial or lateral thigh) has better wear characteristics




Case 1


Previously non operative management / new onset severe pain with bump

- intrasubstance / incomplete tear


Tendoachilles Nonoperative ReruptureAchilles Tendon Rerupture0001Achilles Tendon Rerupture0002


Case 2


Acute pain 8 weeks post non operative management rupture

- ultrasound demonstrates scar tissue

- no reduction with plantarflexion


Achilles Tendon Scar TissueAchilles Tendon Scar Tissue No Reduction Plantarflexion


Reconstruction / Augmentation




Unable to primary repair / chronic setting




< 3cm 

- turndown


Achilles Tendon Turndown


3 - 5 cm 

- VY lengthening


Achilles Tendon VY Turndown


VY Advancement


> 5 cm 

- FHL / FDL / peroneal transfer

- free gracilis graft

- allograft


Chronic TA rupture reconstruction with graft


Large gaps

- turndown + FHL

- FHL is most accessible / directly medial to T achilles




VY advancement


Turndown / Bosworth technique


Harvest central third fascia

- from musculotendinus junction as far proximal as possible

- leave attached distally, detach proximally

- closure fascia above

- tubularise fascia with 2.0 ethibond

- drill hole through calcaneal tuberosity

- pass through calcaneum

- suture to itself


Can reinforce with plantaris / FHL / FDL / PB


Turndown and FHL Harvest


FDL / FHL transfer


Medial foot incision

- harvest tendon

- suture distal FDL stump to FHL


Medial calf incision

- pull tendon through

- through drill hole in calcaneum

- pass tendon through and suture to itself


FHL Transfer 2FHL Transfer 3


Peroneus brevis transfer


Lateral incision

- divide tendon


Standard Posteromedial calf incision

- pass through calcaneal drill hole


Augment with plantaris if needed


Free Gracilis tendon transfer