Degeneration and rupture of the Achilles tendon

Achilles tendon ruptures. A new method of repair, early range of motion, and functional rehabilitation

We prospectively treated 29 athletes who had Achilles tendon ruptures according to a functional rehabilitation protocol. The 25 male and 4 female patients had a mean age of 35 years (range, 19 to 56). The repair was performed with a Krackow suture of No. 2 nonabsorbable polyfilament. Patients began range-of-motion exercises 72 hours after surgery, used a posterior splint for 2 weeks, and then began ambulation in a hinged orthosis. Six weeks after surgery, use of the orthosis was discontinued, full weightbearing was allowed, and progressive resistance exercises were initiated. Isokinetic strength and endurance testing were performed at 3, 6, and 12 months after surgery. There were no reruptures. Two patients developed superficial wound infections that responded to debridement or local wound care. One patient suffered a pulmonary embolism. At 3 months' followup, isokinetic testing showed the mean functional deficits were 36% and 35% of the opposite leg at 60 and 120 deg/sec, respectively. By 6 months, the mean deficits were 2.9% and 2.3% at 60 and 120 deg/sec, respectively. All patients returned to preinjury activity levels at a mean of 4 months (range, 3 to 7) after repair. By 12 months, there were no significant differences in ankle motion, isokinetic strength, or endurance as compared with the uninvolved side.

Surgical management of Achilles tendon overuse injuries. A long-term follow-up study

We studied 79 cases of surgically treated Achilles tendon overuse injuries in 66 patients. Fifty-three (80%) of these patients were competitive or serious recreational runners operated on between 1978 and 1991. There were 49 men and 17 women with a mean age of 33 years (range, 17 to 59). The cases were divided into surgical subgroups based on their site of primary symptoms and abnormalities: paratenonitis (23), tendinosis (partial rupture or degeneration) (15), retrocalcaneal bursitis (24), insertional tendinitis (7), and combined abnormalities (10). Followup included a comprehensive patient questionnaire and office examination. There were 79% satisfactory (51% excellent, 28% good) and 21% unsatisfactory (17% fair, 4% poor) results. The percentages of satisfactory results in the paratenonitis group (87%) were best and those in the tendinosis group were the worst (67%). Satisfactory results were obtained in 75% of the patients with retrocalcaneal bursitis and 86% with insertional tendinitis. Seven of the 45 cases with longer than 5-year followup with initially satisfactory results deteriorated with time and required reoperation (16%). Of these, 4 were in the tendinosis group, 2 had retrocalcaneal bursitis, and 1 had paratenonitis. One of the 34 patients followed less than 5 years required reoperation.

Subcutaneous suturing of the ruptured Achilles tendon under local anaesthesia

Debate concerning the appropriate treatment of ruptures of the Achilles tendon still continues. Conservative treatment can be associated with a high incidence of re-rupture and with relative weakness and lengthening of the triceps surae but with low costs. Surgical treatment contributes to a much lower incidence of re-rupture but can be associated with significant complications as well as with time loss and high costs of hospitalization. Subcutaneous reconstruction combines the advantages of surgical and non-surgical management. Operating with local anaesthesia reduces hospitalization time and operative costs; there are also almost no contraindications for the operation. The functional results in 36 patients operated on in this way are encouraging.

Tendo Achillis pain: steroids and outcome

A retrospective study is presented of 83 athletes with tendo Achillis pain (TAP) treated conservatively over a 12-year period from 1976 to 1988. Local steroid injections did not contribute to an earlier return to sport, though many individuals were improved symptomatically. Local steroids were not found to have a deleterious effect on outcome. Steroids were used most frequently in the chronic cases that presented late and had been treated previously: this group had most recurrences and surgical intervention. One case of Achilles rupture (3%) occurred in the group treated with steroids. Early presentation for treatment led to an earlier return to sport and avoidance of recurrences. Recurrences were most frequent in athletes with bilateral Achilles tendinopathy. The tendo Achillis lesion may range from peritendinitis through a mixed lesion of the tendon and paratenon, to complete rupture. The management depends upon accurate diagnosis, its chronicity and the age and aspirations of the patient. Steroids are safe to use and further prospective trials should note presentation time and disease staging accurately.

Chronic achilles paratenonitis with tendinosis: an experimental model in the rabbit

An experimental model for inducing chronic Achilles paratenonitis with tendinosis in the rabbit is presented. Thirteen rabbits were exercised in a kicking machine producing passive flexions and extensions of the ankle joint. Active contractions of the triceps surae muscles were induced by electric stimulation via surface electrodes. The animals were exercised for 5 to 6 weeks, with a rate of 150 flexions and extensions per minute for 2 h, three times a week. Light microscopic examination showed degenerative changes of the tendon, and increased number of capillaries, infiltrates of inflammatory cells, edema, and fibrosis in the paratenon. We conclude that chronic Achilles paratenonitis with tendinosis can be experimentally induced in a standardized manner in rabbits.

Percutaneous and open surgical repairs of Achilles tendon ruptures. A comparative study

A comparative study between percutaneous repair and open surgical repair of acute spontaneous Achilles tendon ruptures in young athletic patients is presented. Twenty-seven patients with acute Achilles ruptures were evaluated objectively and with subjective questionnaires. Fifteen of the patients were treated by reconstruction with a gastrocsoleus fascial graft (followup, 4.6 years) and 12 treated by percutaneous repair (followup, 1.8 years). Subjectively, both groups were very satisfied with the results of their treatment. Cybex II dynamometer measuring strength, power, and endurance revealed no statistical significant differences between groups, even in light of the shorter followup of the percutaneous group. The percutaneous repairs demonstrated significantly more symmetry in injured/uninjured tendon size than did the open surgical repairs. Two reruptures occurred in the percutaneous group. No other complications were noted. After evaluation of both subjective and objective data we recommend percutaneous repair in the recreational athlete and in patients concerned with cosmesis. Open repair is recommended for all high-caliber athletes who cannot afford any chance of rerupture.

The role of recreational sport activity in Achilles tendon rupture. A clinical, pathoanatomical, and sociological study of 292 cases

During the last few decades, the incidence of tendon ruptures has increased in civilized countries. Our material comprises 749 patients who had 832 tendon ruptures treated surgically between 1972 and 1985. There were no competitive athletes among the patients studied. There were 292 single ruptures of the Achilles tendon, 274 of the proximal biceps brachii, 113 of the extensor pollicis longus, and 70 of other tendons. Forty-eight patients had multiple ruptures and 35 patients had reruptures. Achilles tendon ruptures often occurred in recreational sports activities (59%), in contrast to other tendon ruptures (2%; P less than 0.001). The mean age for patients who had Achilles tendon rupture was 35.2 years and for patients with other ruptures, 50.7 years (P less than 0.001). There was a connection between the high incidence of blood group O and tendon ruptures (P less than 0.001). In cases of multiple ruptures and reruptures, the frequency of blood group O was 71%. Sixty-two point three percent of the patients with Achilles tendon rupture were professionals or white collar workers, which is markedly more than in the Hungarian population (12.7%; P less than 0.001). Two hundred and six Achilles tendon ruptures were studied histologically, and all cases displayed pathological alterations. The results indicate that complete rupture of the Achilles tendon is usually a sequel to a sedentary life-style and participation in sports activities.

Surgical management of Achilles tendinitis

Inflammation of the Achilles tendon and its contiguous structures is one of the most common overuse problems seen in runners. There are actually several etiologies. Involvement of the tendon itself is secondary to areas of mucinoid or fibrotic degeneration, or may be a result of a partial rupture. The sheath (or mesotenon) may also become chronically inflammed. Retrocalcaneal bursitis seems to be a separate entity with hypertrophy and fibrosis of the bursa usually occurring in conjunction with a prominent posterior superior angle of the os calcis. The vast majority of patients can be successfully treated nonoperatively; however, there is a group of patients who are refractory to nonoperative management who would like to continue running, particularly if they are competitive. A retrospective review of 45 surgical cases in 37 patients was performed. All but two of these patients were competitive long-distance runners. There were 24 cases of Achilles tendinitis and/or tenosynovitis, 14 cases with retrocalcaneal bursitis, and 7 with a combination of both. Mean followup was 3 years (range, 1 1/2 to 8 years). Overall there were 87% satisfactory results. Ninety-two percent of the patients with involvement with the tendon and/or sheath had a satisfactory outcome as compared with 71% of patients with retrocalcaneal bursitis. Passive dorsiflexion in the 29 unilateral cases improved from a mean of 17 degrees preoperatively to a mean of 25 degrees postoperatively. We feel that surgery offers a solution for highly motivated runners with chronic posterior heel pain who would like to continue running when conservative measures have failed.

Surgical repair of Achilles tendon ruptures

We evaluated the surgical results of 42 consecutive patients with spontaneous rupture of the Achilles tendon treated from 1973 to 1984 to determine the causes of rupture and to evaluate our treatment methods. Patients were divided into early and late repair groups and their charts reviewed to determine common clinical features. A new method of repair with early functional range of motion exercises before casting was used and compared to other techniques in common use. Thirty-one patients were contacted for long-term followup (average, 4.7 years). Twenty-three of these patients returned for intensive reevaluation and Cybex testing. We found a high incidence of gout (14.3%) and previous steroid injections (7.1%) in our patients. Good results were obtained from the four surgical methods used. There were no reruptures and only 7% of the patients experienced minor wound problems. Patients treated with early functional range of motion exercises averaged 12.5 degrees more dorsiflexion at the time of cast removal and did not require adjunctive protective devices. Long-term results, however, revealed equilibration of range of motion and near normal function in all repair techniques with 88% of all patients returning to preinjury activity levels.

Achilles tendon lesions in sport

Achilles tendon pain is a common cause of disability in sportsmen. The majority of cases are due to overuse injury often exacerbated or precipitated by specific and recognisable factors. A variety of pathologies is demonstrable in Achilles tendon pain which accounts for the considerable variation in the described natural history of the disease. The study of patients with Achilles tendon pain is almost impossible unless an accurate diagnosis is made first. The specific factors of the various conditions demonstrated as causes of Achilles tendon pain are set out and the value of different laboratory and other investigations indicated in the particular pathological conditions. Conservative management of Achilles tendon pain may be unrewarding except in acute crepitating peritendinitis. Various forms of conservative treatment are discussed and the literature reviewed. The role of surgery in management of chronic resistent Achilles tendon pain is discussed in detail with particular reference to the indications and the surgical procedures available. The postoperative management of patients following Achilles tendon surgery is discussed and the outcome indicated.

A review of ruptures of the Achilles tendon

Rupture of the Achilles tendon is a relatively infrequent injury that is often missed by the initial treating physician. The diagnosis can be established on the basis of the physical examination with weakness of plantarflexion, a palpable gap in the tendon, and a positive squeeze test. Special diagnostic studies are rarely necessary. In the majority of cases, the etiologic basis for the rupture appears to be a combination of intratendon degeneration and mechanical stress. Conservative treatment of an acute rupture by immobilization with a cast provides satisfactory results. For the younger, more athletic patient, surgical repair should be considered.

Partial calcaneal ostectomy for retrocalcaneal bursitis

Heel pain in runners is very common. Retrocalcaneal bursitis may be disabling to the competitive runner. When conservative treatment fails, surgery (partial calcaneal ostectomy) may be indicated. Ten patients underwent partial calcaneal ostectomies at our clinic and returned to their desired level of activity within 6 months. When the surgeon adheres to the surgical principles outlined in this article, the results are uniformly good.

Bilateral rupture of the Achilles tendon in patients on steroid therapy

Three patients are presented who sustained bilateral rupture of the Achilles tendon while on systemic steroid therapy for chest disease; a fourth patient with polymyalgia rheumatica on steroids is also presented. This is further evidence that tendon rupture can be a direct complication of steroid treatment. The English-language literature on bilateral Achilles tendon rupture is reviewed.

Achilles Tendon Injuries and Disabling Conditions

In brief Athletes whose Achilles tendon function is impaired need proper treatment so that they may successfully resume their athletic careers. This review details causes, symptoms, and treatment of a variety of disabling tendocalcaneus conditions, most of which are inflammatory in nature. Recommended treatment usually includes rest, medication, heel lifts, and stretching and strengthening programs. Surgery may also be required.

Achilles tendonitis in runners: a report of five cases

Achilles tendonitis is a significant disability in the runner and may often cause runners to lose an entire season of competition. The exact pathophysiology of the problem is uncertain. However, it is the belief of the authors that Achilles tendonitis in the runner often represents a microscopic tear in the tendon which, if not adequately treated, may lead to a macroscopic tear. We recommend surgical treatment in those patients with chronic symptoms who have not responded to conservative measures.