Conservative functional therapy of closed rupture of the Achilles tendon. Treatment approach and analysis of results

In a prospective study in the period from May 1989 to April 1994, 161 patients at the Unfallchirurgische Klinik in Braunschweig were treated for rupture of the Achilles tendon using a conservative functional method. A follow-up examination was carried out on 132 patients (81%) after an average of 12.6 months. Conservative therapy was indicated if dynamic ultrasonography showed sufficient adaptation of the rupture. Continuous retention of the adapted tendon fragments was guaranteed by means of special footwear that raises the back of the foot (Variostabil). The average age of the patients was 39.5 years. In 97 cases (73.5%) the injury was caused by sports. In 68 ruptures the dehiscence was compensated in plantar flexion. In 48 cases the dehiscence was 1-5 mm, and in 16 cases it was between 6 and 10 mm. The average period of hospitalization was 4.8 days (1/19). The period of inability to work was an average of 4 weeks (27.4 days (0/98)). The rupture healed on an average of 9.5 weeks (5.9/23). Complications included seven cases of re-rupture (5.3%), and, in the course of treatment, four patients (3%) suffered profound leg vein thrombosis that in one case developed into postthrombotic syndrome. In two cases there was tendovaginitis of the Achilles tendon. Early functional conservative therapy using the VARIO-STABIL shoe is a suitable method for treating a newly ruptured Achilles tendon. When there is a precise indication, the method is equally as good as operative therapy and because of the low complication rate, it is even preferable.     

Tendon transfer for equinovarus deformed foot caused by cerebrovascular disease

Surgical correction was performed on 125 patients who had equinovarus deformity caused by a cerebrovascular accident and who needed an ankle foot orthosis for walking. The operative procedures involved anterior transfer of the long toe flexors (flexor hallux longus and flexor digitorum longus; long toe flexor group) or lateral transfer of the anterior tibial tendon (anterior tibial tendon group), combined with lengthening of the Achilles tendon. On evaluation more than 2 years after surgery, 83 of 110 patients of the long toe flexor group and eight of 15 patients of the anterior tibial tendon group were able to walk without a brace. Five patients of the anterior tibial tendon group who had shown strong contraction of the anterior tibial muscle during the swing phase before surgery, needed a brace because of a drop foot after surgery. Thus, lateral transfer of the anterior tibial tendon was abandoned in 1984. Recurrence of varus deformity was seen in approximately 15% of the patients in both groups. Anterior transfer of the long toe flexors, using them as dorsiflexor tendons or for tenodesis, seemed to produce better results.     

Outcome and prognostic factors of achilles rupture repair using a new scoring method

A new clinical scoring system, including subjective assessment of symptoms and evaluation of ankle range of motion and isokinetic measurement of ankle plantar flexion and dorsiflexion strengths, is presented in 101 patients (86 men, 15 women) who had repair of a closed Achilles tendon rupture. Twenty-one patients were competitive athletes and 70 were recreational athletes. Eighty-one percent of the ruptures were related to sports, and 32% occurred while playing volleyball. Twenty-six patients had previous Achilles tendon symptoms. At followup, an average of 3.1 years after repair, the overall result scores were excellent in 34 cases, good in 46, fair in 17, and poor in four. Only age was a predictor of overall results. The isokinetic strength scores were excellent or good in 72 cases, fair in 18, and poor in 11. Presence of systemic diseases, activity level, previous Achilles tendon symptoms, and later return to physical exercise were predictors of strength results. Gender, body weight, height, period between rupture and operation, surgeon, rupture site, operative method, complications, and thickness, width, and area of the Achilles tendon at followup were not related significantly to the outcome.     

Surgical repair of Achilles tendon rupture. Comparison of surgical with conservative treatment

Achilles tendon suture combined with a triceps surae tendon tip-over graft was performed in 314 patients with acute rupture of the Achilles tendon between 1980 and 1991. Analysis of these cases showed a low tissue complication rate compared with that reported in the literature. An average of 8.1 years after repair, 223 patients were examined using Holz's scale of clinical assessment after Achilles tendon repair. The results were 'good' in 87.4%, 'fair' in 11.2% and 'poor' in 1.4%. The re-rupture rate was very low (0.4%). These results are better than the re-rupture rate after surgical repair with solely end-to-end suture or after conservative immobilizing or conservative functional treatment. In conclusion, these data show that the fascial reinforcement is a valuable complement to the tendon suture.     

Comparison of ultrasonography and magnetic resonance in the postoperative monitoring of complete subcutaneous rupture of the Achilles tendon]

The diagnostic accuracy of US and MRI in the subcutaneous rupture of the Achilles tendon has already been assessed. We used both techniques to study the Achilles tendon during the postoperative repair process after surgery according to Bosworth. The results were compared and discussed in relation to clinical recovery. Ten patients with complete subcutaneous rupture of the Achilles tendon were followed-up with physical examination and submitted to US and MR studies 40, 60 and 90 days postoperatively. Eighty patients recovered in the expected time, while 2 took longer. At 90 days, the US findings in 7 patients and the MR findings in 8 patients who recovered in the expected time could be considered normal. US poorly distinguished the tendon from the reinforcement flap because of gross tendon echostructure. The tendon and the reinforcement flap were not distinguishable at MRI because they were uniformly hypointense. Clinical recovery appeared as a hyperechoic structure and a gross fibrillar pattern at US and as a hypointense structure with some small hyperintense areas at MRI. US and MRI were in disagreement in one patient with a postoperative algodystrophic syndrome, where US showed some alterations which were considered false positives because of clinical recovery and negative MR findings. US and MR patterns were considered abnormal in the 2 patients with delayed recovery. US showed persistent hyperechoic areas within the tendon, while the MR signal was of intermediate intensity in the tendon and reinforcement flap. To conclude, we believe that US is an appropriate technique for the postoperative follow-up of complex subcutaneous ruptures of the Achilles tendon. Additional MRI should be performed in all the cases where US findings are in disagreement with clinics.     

Balloon extraction of esophageal foreign bodies in children

A study to determine the sensitivity, specificity, and positive and negative predictive values of several clinical diagnostic tests of subcutaneous Achilles tendon rupture was performed during a 13-year period. There were 174 patients with clinical diagnosis of unilateral complete subcutaneous Achilles tendon tear and 28 patients with unilateral suspected but no actual Achilles tendon tear. The following tests were used: palpation, calf squeeze, Matles, Copeland, and O'Brien. Palpation of the gap was the least sensitive clinical test with the patient awake (0.73), increasing to 0.81 when the test was performed under anesthesia; the Copeland and O'Brien tests showed a sensitivity of 0.8. Both the calf squeeze and Matles tests were significantly more sensitive than the other tests (0.96 and 0.88, respectively; 0.022 < P < 0.05). All tests showed a high positive predictive value, with no statistically significant difference between the various tests. In the 28 patients with no evidence of a subcutaneous Achilles tendon tear on imaging, the tests showed a high capability to detect that the Achilles tendon was intact (gap palpation specificity, 0.89; calf squeeze test specificity, 0.93; Matles test specificity, 0.85). Whichever tests were performed, at least two of them were positive for a subcutaneous tear of the Achilles tendon in all patients in this study.     

Bilateral Achilles tendon rupture: a report on two cases

Two cases of traumatic bilateral Achilles tendon rupture are reported. One of the patients was a healthy middle-aged man, who had been an active national-level gymnast 20 years earlier. He had not suffered any complaints of Achilles tendons before. The ruptures occurred when, after a sauna, he showed his guests a vault forwards, which he had been able to perform easily. This time the landing took place on the toes, causing a high peak stretch to the calf muscles and Achilles tendons. The total rupture of both Achilles tendons was treated surgically, with an excellent result 2 days after the trauma. End-to-end suturation and a fascial flap plasty were made on both sides. No macroscopic degeneration could be detected on the rupture sites. He was allowed to walk freely 6 weeks after the surgery. The second case was a 54-year-old woman, who had suffered from Achilles tendinitis and peritendinitis for 2 years. Both tendons had been surgically treated, and severe adhesions and local degenerative changes had been found. The tendon rupture occurred when she injured her left ankle while getting out of the car. Two days later she fell at home, because of the weakness of the left side, and consequently the right Achilles tendon was injured. She was treated conservatively for 10 days, before the surgery was performed. Both tendons were ruptured and an extensive degeneration of the area was observed. The right side suffered from a rerupture, which was again treated surgically. After surgery the recovery was slow, but the final result 3 years later was moderate. Neither of the patients had any systemic diseases.     

Increasing incidence of Achilles tendon rupture

During the period 1987-91, 153 cases of total Achilles tendon rupture were diagnosed in the city of Malmo (population 230,000). Almost two thirds were caused by sporting activities, notably badminton. Ruptures caused by nonsports injuries were found in older subjects. Compared to the age-specific incidence in 1950-73, a marked increase in both sports and nonsports injuries was found and patients in the latter group were older than in the former period. Patients with Achilles tendon ruptures can be classified into two subgroups with partly different etiologies: young or middle-aged athletes and older non-athletic persons. The increase in the former group is mostly explained by increased participation in recreational sports; the cause of increase in the latter group is unknown.     

Propofol bolus facilitates reduction of luxed temporomandibular joints

All patients with badminton-related acute Achilles tendon ruptures registered during 1990 to 1994 at the University Hospital of Ume? were retrospectively followed up using a questionnaire. Thirty-one patients (mean age, 36.0 years), 27 men and 4 women, were included. Thirty patients (97%) described themselves as recreational players or beginners. The majority of the injuries (29 of 31, 94%) happened at the middle or end of the planned game. Previous local symptoms had been noticed by five patients (16%). Long-term results showed that patients treated with surgery had a significantly shorter sick leave absence than patients treated without surgery (50 versus 75 days). There was no obvious selection favoring any treatment modality. None of the surgically treated patients had reruptures, but two reruptures occurred in the nonsurgically treated group. There seemed to be fewer remaining symptoms and a higher sports activity level after the injury in the surgically treated group. Our results indicate that local muscle fatigue may interfere with strength and coordination. Preventive measures such as specific treatment of minor injuries and adequate training of strength, endurance, and coordination are important. Our findings also indicate that surgical treatment and careful postoperative rehabilitation is of great importance among badminton players of any age or sports level with Achilles tendon rupture.     

Anterior tibialis tendon ruptures: an outcome analysis of operative versus nonoperative treatment

Ruptures of the anterior tibialis tendon are a rare clinical entity. Case reports in the literature reveal a total of 28 cases. Unfortunately, because of the limited discourse in the orthopaedic literature, there are few guidelines regarding the treatment for these injuries. This study analyzes the treatment of 16 anterior tibialis tendon ruptures. Eight patients in this group had operative treatment of their ruptures, and eight patients had nonsurgical treatment of their ruptures. The average follow-up for the operative and nonoperative patients were 6.68 years and 3.86 years, respectively. The Foot and Ankle Outcome questionnaire provided by the American Academy of Orthopaedic Surgeons and an outcome-based foot score described by Kitaoka et al. were used as the methods of analysis. Our outcome results show no statistically significant difference between operative and nonoperative treatment in anterior tibialis tendon ruptures. The lack of statistical difference between operative and nonoperative groups may be a reflection of the age bimodality present in this study. Elderly low demand patients were treated nonsurgically and young active patients were treated operatively. Therefore, despite a lack of statistical difference present in the outcome of both groups, we still maintain the need to repair/reconstruct anterior tibialis tendon ruptures in young active patients with high functional demands. The deficits present in the nonoperative group, we believe, would not be well tolerated in a young high functional demand patient. Nonsurgical management is an appropriate alternative in low demand elderly patients.     

Locations of crossover breakpoints within the CMT 1 A-REP repeat in patients with hereditary neuropathy with liability to pressure palsy--detection by recombinant chromosome-specific polymerase chain reaction

The "short Achilles tendon" syndrome, characterised by limited dorsiflexion of the tibiotarsal joint, is not well-known but could be a disposing factor for trophic disorders and plantar ulcer related to hypersupport in the diabetic subject. We report two cases of multicomplicated diabetic patients treated during several months for plantar ulcer superinfected with underlying osteoarthrits, whose course became rapidly favourable after tenotomy of the Achilles tendon. This simple surgical act can be performed in ambulatory conditions under local anaesthesia. Functional disability is negligible. The benefit of this treatment as part of the curative or preventive therapeutic arsenal for care of the diabetic foot remains to be evaluated.     

The treatment of prolactinomas during pregnancy and the lactation period

Thanks to its good long-term results, surgery is the method of choice to treat subcutaneous ruptures of the Achilles tendon. Reconstructed tendons present typical morphological and functional US patterns which depend partly on the kind of surgical reconstruction and partly on the time passed since surgery. The authors report the results of the clinical and US follow-up of a series of 62 surgical patients treated in 7 years for the subcutaneous rupture of the Achilles tendon. The patients were 55 men and 7 women, whose mean age was 36 years (range: 25-65 years). The left-hand side was affected in 38 patients and the right-hand side in 24 patients. All patients were operated on using an end-to-end suture and reinforcement plastic surgery pulling down a gastrocnemius tendon flap. To homogenize the results, all the US exams were performed by the same operator, in the presence of the orthopedic specialist and under the same conditions: both the involved and the contralateral Achilles tendons were studied, longitudinal and transverse scans were performed with the foot in max. plantar and dorsal flexion and, whenever possible, dynamic scans were also performed making the sural triceps contract against resistance. The following parameters were studied clinically: pain (which was absent in 39 patients, occasional in 11, after stress in 9 and on walking in 3 patients), skin scar trophism (which was eutrophic in 53.23% of patients, keloid in 27.42% and hypertrophic in 19.35% of patients), ankle joint excursion (plantar flexion was impaired in 32.3% and dorsal flexion in 36% of patients), walking on tiptoe (in all, 22.6% of patients complained of difficulties walking on tiptoe) and, finally, work activity resumption (which all patients achieved). US depicted the surgical tendons as much bigger than the contralateral ones (3-4 times on the average), which increase in volume lasted throughout the follow-up. In 75% of patients the echo structure of the surgical tendons was inhomogeneous, with scattered hypoechoic and hyperechoic areas. In the extant 25% of patients, nearly all of them followed-up for over 6 years, US depicted a clear-cut hyperechoic area whose size and echo structure were similar to the healthy tendons'. Our results strongly suggest that tenorrhaphy and flap plastic surgery be used to repair subcutaneous ruptures of the Achilles tendon. US proved to be the most reliable and feasible method also in the follow-up. The US images of the patients submitted to surgery more than 6 years earlier revealed fibrillate reorganization patterns and tendon restructuring. These processes involve both ends of the sutured tendon and not the reinforcement flap, which further confirms the exclusively mechanical, and not biological, function of the latter.     

Determination of pharmacological half-life of propranolol in man]

After conservative respectively operative treatment of two exactly comparable patients who suffered from rupture of the long head of the biceps tendon of the arm, the myoelectric activity of both muscle heads was investigated on the injured arm and compared to the uninjured side. There was a significant diminution of activity in the ruptured long head as well as a reactive hyperactivity in the short head after conservative treatment in contrast to the operative treated patient, where these alterations in muscle activity were less marked. The operative treatment therefore shows a better functional result when compared with the conservatively treated rupture.     

Some biomechanical aspects of the foot and ankle in athletes with and without shin splints

Thirteen adult male athletes (long-distance runners and orienteerers without foot problems) and 35 male athletes with shin splints were compared with respect to: 1) the position of the lower leg and the heel while standing, 2) the passive range of mobility in the subtalar joint, and 3) the angular displacement between the calcaneus and the midline of the lower leg (Achilles tendon angle) while running with bare feet on a treadmill. In standing, the two groups differed statistically significantly in the Achilles tendon angle, which values were greater in the shin splint group. With respect to passive mobility, the athletes with shin splints had significantly greater (P less than 0.05-0.01) angular displacement values in inversion, eversion, and in their sum than the control group. While running, the Achilles tendon angle of the shin splint group was significantly greater (P less than 0.01) at the heel strike. Further, the shin splints group had a significantly greater (P less than 0.01) angular displacement between the heel strike and the maximal everted position. The results suggest structural and functional differences in the feet and ankles between healthy athletes and those with shin splints.     

Case report: can sacroiliac joint dysfunction cause chronic Achilles tendinitis?

This case study discusses the possible relationship between chronic Achilles tendinitis and sacroiliac joint dysfunction. The patient presented is an active pole jumper, competing at both the national and international levels. He suffered from chronic Achilles tendinitis during the 1994-95 season, and conservative treatment applied locally was not successful. The athlete discarded the possibility of operative debridement of the tendon. Instead, an evaluation of the kinetic chain of the lower extremity and pelvic-lumbar area was performed, and the athlete was diagnosed with sacroiliac joint dysfunction and Achilles tendinitis. Evaluation findings, treatment program, and treatment outcome are also presented. The literature regarding sacroiliac joint mechanics and biomechanics of the foot-knee-hip and pelvic area is discussed and used to support the author's thesis that sacroiliac joint dysfunction, in this case a backward rotation of the right ilium, may have changed the kinematic chain of the lower extremity and caused a tendinitis in the Achilles tendon of the affected leg. Sacroiliac joint function and dysfunction, the reliability of sacroiliac joint mobility tests, and the validity of treatment programs are still considered controversial, and more research is needed to understand these mechanisms.     

1998 William J. Stickel Gold Award. The effects of extrinsic muscle forces on the forefoot-to-rearfoot loading relationship in vitro. Tibia and Achilles tendon

The effects of muscular activity on the distribution of forces under the foot, as well as within the foot, are of great importance for determining the mechanisms of foot pathologies. Limited data exist concerning muscle forces during the gait cycle and the effects of muscle forces conveyed to the ground-reactive forces of the foot. The authors developed a cadaveric loading system to determine the effects of force applied to the Achilles tendon on the forefoot-to-rearfoot loading relationship in eight cadaveric specimens. The study indicated that, during axial loading of the tibia, force was inherently transferred from the rearfoot to the forefoot. However, the observed forefoot-to-rearfoot loading relationship did not match the predicted loading relationship from a rigid-body diagram, as would be observed in a class I lever. The results indicated that, as the force was increased on the Achilles tendon, the change in loads on the forefoot and rearfoot was not linear. Specimens with calcaneal inclination angles greater than 20 degrees demonstrated a more linear increase as compared with those with inclination angles less than 20 degrees.     

Anterior tibial tendon rupture

Twelve patients with rupture of the anterior tibial tendon are presented. Nine patients were aware of an acute event prior to their symptom onset and three were not aware of any acute event. Complete rupture of the tendon was noted in 10 patients and incomplete rupture was seen in two patients. Treatment was individualized based on age, etiology, preinjury function, patient health, and personal considerations. Five patients were treated without surgery. Three preferred no orthotic devices, and two believed their function was improved with an ankle-foot orthosis. Seven patients were treated operatively using a variety of individualized reconstructive techniques. All operatively treated patients demonstrated increased function and strength. Based on our findings, operative reconstruction is recommended in appropriate patients.     

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.     

Diseases of the Achilles tendon in dogs and cats

Dogs and cats rarely have problems with the Achilles tendon and if so, it usually results from a direct trauma. Prime area for injuries is the insertion on the tuber calcanei or directly proximal. One defers between complete and partial ruptures, acute and chronic injuries as well as displacement of the tendon of the superficial digital flexor muscle. In 38 cases (33 dogs and five cats) the clinical examination, radiology, ultrasonography and therapy are shown. Usually the clinical examination is sufficient for a diagnosis (hyperflexion of the hock and weight-bearing on the plantar surface of the metatarsus). The radiology primarily shows up abnormalities on the calcaneus, mineralisations of the tendon and allows the assessment of implants. Ultrasonography is the diagnostic imaging of choice for judgement of tendon diseases as well as the progress of their healing. Tendon suture is advisable if the rupture is open, fresh and/or complete and in cases of luxation of the superficial digital flexor muscle. Immobilisation of the tarsus in hyperextension seems to be of utmost importance no matter if an operative or conservative therapy is chosen.