Achilles Tendon

Achilles Tendon Rupture



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

- gout

- hyperthyroidism

- tendinitis

- cavus foot

- varus 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




Palpable gap


Achilles Tendon Rupture 1Achilles Tendon Rupture 1


Weak PF

- unable to perform single heel raise 


Positive Thompson Test

- patient prone

- squeezing calf doesn't produce plantarflexion of ankle


Thompson Sign Normal PreThompson Sign Normal Post


Chronic tear

- gap fills with scar tissue

- gap not palpable

- excessive DF compared with other side


TA rupture increased DF




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

- measurement of gap in chronic cases / information 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


Kellam meta-analysis 



- 1% rupture in operative

- 85% return to pre-injury activity level

- 95% satisfied with treatment


Non Operative

- 18% rupture

- 70% return to pre-injury activity level

- 65% satisfied with treatment


Moller et al JBJS Br 2001

- 112 patients randomised non-operative & operative

- non-operative 20% rerupture & 3% complication rate (all minor)

- operative 2% rerupture & 25% complication rate (all minor)


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





- 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 minimall loss of plantarflexion strength


No risk of infection / wound breakdown





- 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 with No 2 Ethibond

- 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


Chronic TA rupture




< 3cm 

- turndown


3 - 5 cm 

- VY lengthening


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


Achilles Tendonitis



Inflammation of achilles tendon at or near insertion into calcaneus




1.  Runners / Tennis players / Dancers


2.  Sero -ve arthropathies / gout / RA


3.  Overweight middle aged diabetics




Tendonitis / Tendonosis / Rupture




Triceps surae

- medial and lateral gastrocnemius

- soleus

- surrounded by paratenon which allows gliding and supplies nutrition


Inserts middle 1/3 calcaneal tuberosity

- 2 x 2 cm area

- 90o rotation distally


Retrocalcaneal bursa (x2)

- proper is between tendon and calcaneum

- superficial is between tendon and skin




1.  Non-insertional form 


Younger / fitter / more active patients

- overuse and over training


Occurs in area of hypo-vascularity & fibre rotation

- 3-5 cm from insertion

- due to repetitive loading associated with jumping

- Angiofibrotic Dysplasia


Risk Factors


A.  Pronated foot 

- mid-foot pronation is coupled with IR force on tibia 

- opposite to the normal ER in knee extension

- forces are concentrated at the hypovascular area of TA producing high tensile stresses


B.  Heel cord tightness


C.  Changes in activity level 


2.  Insertional form 


Occurs at site of insertion

- more common in the overweight / middle aged / unfit / diabetics

- have combination of tendonitis / retrocalcaneal bursitis / spur


Risk factors


A. Poor women's shoe-wear


B. Bony protuberance of Os Calcis 

- Haglund's Deformity / Pump bump

- prominence of posterosuperior & lateral calcaneus

- causes impingement & mechanical abrasion of T achilles at insertion


Pump Bump Clinical Photo


C. Retrocalcaneal Bursitis

- retrocalcaneal bursa lies between tendon & posterior surface of calcaneum

- normal lubricating structure

- may become inflamed


Ankle Retrocalcaneal Bursa


DDx insertional

- seronegative enteropathy

- gout

- corticosteroids

- oral fluoroquinolones

- hyperlipidaemia






- inflammation limited to paratenon



- tendon thickened

- focal areas of degeneration

- increased type 3 collagen

- may be partial tear


Clinical Features


Non Insertional



- pain 2-6 cm proximal to insertion

- usually worse in morning & post exercise

- may present with tendon rupture



- localised tenderness

- tendon may be palpably thickened

- pain with DF and PF

- DF may be limited





- pain at bone-tendon interface

- worse after exercise



- localised tenderness & thickening

- bony lump

- DF may be limited




Some younger patients may present only with pump bump / Haglund's

- no tendonitis

- just problems with foot wear




Haglund's Deformity

- may be calcification of bone-tendon interface with spur in insertional tendonitis

- can define with Pavlow lines / Fowler's angle


Achilles Insertional Tendonitis XrayTendoachilles insertional calcification



- lateral weight bearing x-ray

- draw parallel pitch lines

- defines Haglund's deformity to be removed (above second line)


Achilles Haglund's and Pavlov lines


Fowler's angle  


Normal < 70°

Abnormal > 80°




Thickening of the tendon with some intra-substance degeneration


Tendoachilles Noninsertional Tendonitis Sagittal MRITendoachilles Noninsertional Tendonitis Axial MRI


Non-Insertional Management




Re-assurance / education / physio / orthotics


Phase 1:

- rest


- stretching programme - T Ach + plantar fasciitis

- soft heel cup with medial arch support

- night resting splints to stretch T Achilles

- HCLA contraindicated


Phase 2:

- eccentric exercises






- failure non operative > 12 months




Para-tenon resected

- tendon debrided

- tears in tendon repaired


Percutaneous vertical tenotomies

- may stimulate revascularisation


> 50% tendon degenerative

- may need augmentation





Rompe Am J Sports Med 2009

- RCT of eccentric v eccentric + ECSW

- improved results with combined treatment


Cochrane Review 2011

- weak evidence for NSAIDS

- no evidence for topical laser or peritendinous NSAID
- weak evidence for Actovegin


Kearney 2012 Foot Ankle Int

- systematic review

- some evidence for eccentric loading and ECSW

- minimal evidence for surgery / case series only


Insertional Management




As for non-insertional





- if fails to settle in one year

- high risk

- these patients have poor tendon and skin


Open / Arthroscopic Technique


Lateral approach

- preserve sural nerve


Retrocalcaneal bursa excised


Osteotome resection Haglund's if present


Resection of bone spur if present


Tendon debrided 

- remove inflammed paratenon

- vertical tenotomies

- if tendon severely compromised, transfer required