Articles written by professionals from The Wellington Hospital for Healthcare Professionals.
How to spot a late presenting Achilles tendon and the treatment that follows
The history of an Achilles rupture is classically described as a feeling of a direct impact to the Achilles area with sometimes a very audible ‘crack’ or ‘snap’, heard by the patient. There is an immediate inability to continue with activity and well localised pain. In the vast majority of cases, posterior ankle bruising and swelling occurs rapidly
with most patients seeking immediate treatment.
However, there are a number of patients who either present late following a complete rupture, or in whom the diagnosis is initially missed. The reasons for this vary, but it is important to be aware that beyond two weeks after a complete rupture, there is usually very little pain anymore. The patient at this stage is likely to complain of weakness of gait, possibly a feeling of instability and may also limp, and not recount a helpful and classical history. It is at this stage that the opportunity for relatively early intervention is missed (or missed again) and where an open mind needs to be kept about diagnosis.
Examination starts with an observation of barefoot gait. The patient will invariably walk with a shortened stride and be voluntarily limiting the range of movement. A visual inspection of the posterior ankle is important, as the Achilles is likely to be poorly defined. Getting the patient up onto both tiptoes at the same time is possible, even with a ruptured Achilles (most patients will simply transfer weight to the uninjured side). A single heel rise on the injured side, however, will not be possible.
The most sensitive and specific test for the Achilles rupture is squeezing the injured calf with the patient prone, and the ankle hanging off the end of the examination couch . If there is no plantar flexion on compressing the calf, then this is likely to indicate the presence of a significant injury to the Achilles tendon complex. The tests can sometimes be difficult to perform, due to significant swelling or pain, but an equivocal result should also be recorded in the notes and warrants urgent imaging of the Achilles tendon.
The advent of commonly available, good quality ultrasound (and radiologists skilled in the technique) has revolutionised the management of Achilles tendon injuries. The investigation is highly sensitive for detecting ruptures, takes only minutes and, logistically, is often far easier to organise than an MRI scan. An additional and important advantage is that the dynamic nature of the investigation (allowing the radiologist to move the ankle and Achilles actively during the investigation) enables clear advice on a key point with the ruptured Achilles. This is namely whether the ends are easily opposable with the ankle placed into an appropriate plantar-flexion.
For clinicians treating a late presenting rupture, there is good evidence that a direct repair of the Achilles can be carried out up to six, (or possibly 12) weeks after the rupture, with little adverse effect on the outcome. The only thing that delays of this magnitude mean is that the opportunity for conservative treatment is lost.
The operation to repair the Achilles tendon is relatively small in itself, with occasional complications of wound infection, wound breakdown, scar adhesion or scar sensitivity. Beyond this timeframe, the tendon ends can become more difficult to mobilise and the tendon tissue less prone to heal, even if surgically re-approximated.
A very good salvage procedure for these later presentations (even up to several years post rupture) is to transfer the flexor hallucis longus tendon (which lies immediately adjacent to the Achilles) and weave it between the tendon ends; producing a composite tendon. The functional outcome of such tendon transfer procedures is also likely to be excellent, more dependent on patient age and pre-injury function than anything else. The period of time immobilised post procedure is also the same as for a primary Achilles repair.
Mr Mark Herron, Orthopaedic, Foot and Ankle, Achilles tendon, late presenting, MRI, ultrasound,
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