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Achilles Tendinosis and Rupture
KEY FACTS
Achilles Tendinosis
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Achilles tendinosis can be noninsertional or insertional, although it is the same pathology, i.e., degenerative tendinopathy.
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Insertional tendinopathy can be associated with a Haglund deformity, insertional ossification, or both.
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A heel lift and physical therapy are the mainstays of treatment and are often effective, although it tends to be more effective in noninsertional tendinopathy.
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Operative treatment consists of tendon debridement and repair with patients having insertional tendinopathy often requiring resection of any insertional ossification as well as the Haglund deformity. Surgery is often successful in eliminating the patient's symptoms.
Achilles Tendon Rupture
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Achilles tendon rupture is on the same spectrum as Achilles tendinosis in that a rupture occurs when a tendinotic tendon is subjected to an eccentric contracture of sufficient force to rupture the tendon.
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It often occurs with sporting activity; physical exam is often sufficient diagnostically.
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The goal of treatment is restoration of appropriate tension, which can be accomplished with either nonoperative or operative means.
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There is much debate as to the optimal treatment of Achilles tendon ruptures with the discussion generally framed by the increased risk of wound complications with surgical treatment on the one end and the increased risk of rerupture with nonoperative treatment on the other.
Notice the thickening of the tendon in a noninsertional position in this patient with noninsertional Achilles tendinopathy. This thickening is often readily apparent clinically and often tender to palpation.
Simply having the patient lay prone with the knees flexed to 90° will often allow for the diagnosis of Achilles tendon rupture, as the resting tension of the injured tendon will show relatively more dorsiflexion.
An Achilles tendon laceration is more difficult to get right than Achilles tendon ruptures, as the zone of injury is less diffuse. Special attention should be paid to matching the tension of the contralateral side.
The proximal stump is very retracted
, and the distal stump is very degenerative
. The tendon is often diffusely degenerative in those patients who rupture their tendons.
, and the distal stump is very degenerative . The tendon is often diffusely degenerative in those patients who rupture their tendons.
Clinical Anatomy
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The Achilles tendon is formed from the confluence of the gastrocnemius and soleus tendons distally. The gastrocnemius originates from the posterior femoral condyles, while the soleus has its origin from the posterior tibia and fibula.
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The Achilles tendon is notable for its "twisted" structure with longitudinal rotation from proximal to distal.
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Right Achilles tendons rotate counterclockwise; left Achilles tendons rotate clockwise.
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The Achilles inserts in a specific way onto the calcaneus.
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Soleus and lateral gastrocnemius insert more proximally; medial gastrocnemius inserts more distally.
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The sural nerve typically runs with the lesser saphenous vein from proximal posterior to more anterior and lateral.
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Blood supply to the tendon is from the posterior tibial artery proximally and distally and the peroneal artery in its midsection.
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Pathology
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