Achilles Tears Revisited: One Surgeon’s Experience

From elite athletes to weekend warriors, Achilles ruptures can affect all age groups and all types of individuals. The most common Achilles rupture patient in my practice is a 40- to 60-year-old male athlete, most commonly the aforementioned weekend warrior. Often such patients participated in athletics throughout their lives but have slowed down a bit as they aged, possibly put on a bit of weight and the joints become stiffer over the years. The rate of males versus females with Achilles ruptures in my practice is 80 to 20 percent, respectively. In my opinion, this may be partly due to the lack of stretching I see taught to men over women, the type of sports typically played by men versus women as they age, or it may be just a coincidence. Overall, my goal is to return patients to full pre-injury activity following an Achilles rupture and to do so in a timely and rapid manner. In this article, I will present my thoughts, surgical planning and surgery options for Achilles ruptures and how they commonly present to our office and likely most non-emergency facilities.

There are two types of patients who appoint with an Achilles rupture in our practice. The first is one who does not realize the type and extent of their injury. They often make an appointment due to an ankle sprain or something similar and state they have a limp and feel weak with walking. In my experience, this group of patients feel a pop and immediate pain following the Achilles tear, but subsequently the pain resolves, resulting in comfortable walking. The presenting complaint is weakness. The second type of patient is aware of the Achilles tear and come to us for our level of expertise and previous results related to a previous patient. Often this group of patients presents in a very timely manner and proves easier to treat while patients unaware of the Achilles tear think they have a sprain and sometimes present weeks to months later, making for a far more difficult repair.

Key Components Of A Successful Initial Evaluation

Our practice’s initial visits fall into two categories; fresh tear and delayed fresh tear. For a fresh tear, we often note a palpable gap, weakness to plantarflexion and single leg stance with a positive Thompson test. An ultrasound in the office is often sufficient to see the tear and the level of gap needing repair. The second group, delayed fresh tear, often presents weeks to months after initial injury. Some have been to urgent care or the emergency room with a diagnosis of a partial tear. Some have been placed in a boot or splint but many present with no protection.

The palpable gap is missing in such patients as scarring and hematoma fills the gap. In our experience, there is also sometimes difficulty with a Thompson test as there is some minor bridging of the tendon ends with scar and hematoma, which results in a slightly normal test. I find ultrasound is still an adequate diagnostic tool, but there may be a lack of clear visualization of the region of damage and level of gapping. For chronic tears, I suggest magnetic resonance imaging (MRI), while an acute tear can benefit from MRI or ultrasound for diagnostic purposes.

After examination and imaging, the first question is whether surgery is necessary. In my hands, it is rare that a case does better without surgery than with. The main reasons are twofold; recovery time rate of re-tear. I find that recovery time from a non-surgical Achilles repair is far longer as the tendon needs protection, as there is not the benefit of sutures for stability and allowance for faster physical therapy. Furthermore, due to the relative weakness of the Achilles subsequent to non-surgical care, I find that the risk of re-tear is higher. Therefore, I only cast patients who are very sedentary, elderly and inactive and those who refuse surgery. I will discuss in detail the benefits and risks of casting and offer support for both sides, but with serial casting I will not allow weight on the foot for at least 10-to-12 weeks and do allow return to activity for around six months. The rate of re-tear during this period of time is too high, in my observation, and protection is a must.

What You Should Know About A Comprehensive Surgical Toolkit

I believe surgical care of the Achilles tendon is far more complex than most realize. The first and most important aspect of a repair is proper anatomic tensioning of the tendon. The second is scar prevention and the third is adequate strength of repair to allow return to activity and sport. Once one considers these three factors, repair requires far more precision than just placing two ends of tendon together.

For acute tears that are within the first two weeks, I prefer minimally invasive repair. In my experience, this preserves the Achilles peritenon and offers a very robust repair. I have used the Arthrex^® PARS (Percutaneous Achilles Repair System) for my minimally invasive repairs and been very happy. If the tendon is torn on the high side and there is enough tendon for an end-to-end repair, I will pass sutures on both sides and tie them together. With this system I feel I have better tendon motion and less risk of over-tightening. If the tendon tear is on the low end and near the ankle without a sufficient distal stump, I will place sutures in the proximal tear region and then anchor the sutures to the heel with bone anchors. I will, in both cases, add some local sutures at the tear site for micro-repair and better anatomic positioning of the tear site.

It is rare for me to need to open an acute rupture with a large incision. The only time I find this is necessary is if the proximal tendon tear is unreachable through a small incision. In such cases, I will do an open repair with a modified Krackow repair. A second reason for open repair in acute cases is when the Achilles tendon tears off the calcaneus and is very, very distal. In such cases, the tear is truly an avulsion off the calcaneus and there is combination fracture/ tear. In these distal tears, I perform an open calcaneal incision, debride the calcaneus of any spurs, remove any bone in the Achilles tendon and then repair the tendon with an anchor system much like a retrocalcaneal spur removal. My preferred system for repair is the Arthrex SpeedBridge^™ with FiberTape^®. Preservation of the peritenon is important for smooth gliding of the tendon. I will often add a platelet-rich plasma injection for tendon repairs and further add an umbilical cord matrix injection to prevent scar formation in my surgeries. Acute ruptures spend five-to-six weeks in a cast, and then a boot and therapy with partial weight to full weight from week six to week eight. At eight weeks I remove the cast and slow weight bearing with crutches begins. Return to sports is after 12-to-14 weeks and full activity is at around 18-to-20 weeks.

By far, I feel the more difficult cases are those presenting in a delayed manner. In such cases, surgical planning is far more technical and your toolkit of choices needs to be far more full to offer the best options. I have performed some delayed PARS minimally invasive repairs but they are far more difficult, as a region of debridement is necessary and may leave a large gap that requires an open procedure.

In cases of small gaps with high-quality tendon, I will often perform a primary repair with a possible turndown flap and potential augmentation with a tendon replacement system such as Artelon^®. However, I find in most cases, the gap is far larger than a primary repair will address alone and a turndown does not offer anatomic strength. In such cases, I employ a flexor hallucis transfer to the calcaneus as a critical step for anatomic strengthening of the often poor quality torn Achilles.

During delayed tear repairs, I begin with a posterior incision in the region of tear. I open the tendon sheath and check the area of tear. Next I perform careful debridement of the scar and hematoma until good, healthy tendon ends are present. If the gap is less than two cm, an end-to-end repair is possible. In such cases, the plantaris tendon may be present and possibly keeping the tendon ends from separating too far. If the gap is two-to-four cm, a small turndown flap of tendon from the central muscle/tendon junction may fill the gap, taking care to anatomically tension the tendon so there is no weakness. Adding a supplemental tendon augmentation with a free tendon graft or tendon graft substitute should add strength and tension to the repair site. In such cases, the option of a flexor tendon transfer exists.

If the gap is larger than 4 cm, I highly recommend a flexor tendon transfer. The true question is whether a distinct Achilles tendon repair is also necessary with a flexor tendon transfer. I find this not to be necessary, as I tie the proximal and distal Achilles into the flexor transfer to make one, good quality and anatomically tensioned tendon. One may perform a turndown flap if desired, but the length of the gap is difficult to fill and the amount of scarring from the flap often prevents good glide of the tendon, in my experience.

When performing a flexor hallucis transfer, the same posterior incision for the Achilles repair can access the flexor tendon, which is directly deep to the Achilles through the retinacular division. I expose the muscle and tendon and cut the tendon at the medial heel area, taking care to protect the tibial nerve. I place a drill pin out of the Arthrex biotenodesis system directly anterior to the Achilles insertion site and drive it out the plantar heel as a guide to drill partially through the calcaneus, with an over drill to accommodate the tendon. I suture the tip of the flexor tendon and pass it through a hole in the tip of the guide wire. Then I pull the guide wire out the plantar heel with the suture as well. After tensioning the flexor tendon, I place a biotenodesis screw in the proximal calcaneus to lock in the flexor to the heel. I also tie the flexor tendon under tension to the Achilles stump both proximally and distally, and place the muscle of the flexor against the Achilles tendon.

Post-delayed repair, recovery is a bit slower. I find that a flexor transfer is very helpful to speed recovery and have moved more and more to add the flexor tendon to the repair both for strength and for more rapid recovery. I will again keep patients in a non-weight bearing cast for about four-to-six weeks. Subsequently, begin physical therapy and boot protection with partial weight in a plantarflexed position for an additional four weeks or so. Regular shoe gear is possible at 10-to-12 weeks with partial-to-full weight over two weeks. Return to sport is often at four-to-six months depending on the level of surgery and repair needed.

In Conclusion

It is critical to be able to perform all types of Achilles repair if you are going to accept such patients into your practice. Surprises during repairs are non uncommon and having a full toolkit of procedures and treatment options allows for a better repair and a more timely return to full activity. 

Dr. Baravarian is an Assistant Clinical Professor at the UCLA School of Medicine. He is the Director and Fellowship Director at the University Foot and Ankle Institute in Los Angeles (https://www.footankleinstitute.com/podiatrist/dr-bob-baravarian).