“Though art not immortal “screamed Pares
And Achilles collapsed with detached cord of heel”
Tendo Achilles is the tendon of Gastronemius and soleus. It is the thickest and strongest tendon in the body, about 15 cm long and 4 cm thick.Achilles tendon appears to spiral toward its insertion on calcaneum. The blood supply for the Achilles tendon is derived from the posterior tibial artery and its contributions. The watershed zone is an area 2-6 cm proximal to the calcaneum, in which the blood supply is less abundant and becomes even lesser with age.
The most common mechanisms of injury is sudden forced plantar flexion or unexpected dorsiflexion of the foot. Less commonly, it may due to direct trauma.
Patient present with complaints of a sudden snap associated with severe pain. The patient may be able to ambulate with a limp, but unable to run, climb stairs.
Signs
There is pain and swelling. A palpable gap in the Achilles tendon is appreciated. Active plantar flexion is not possible.
Clinical tests
Hyperdorsiflexion sign: There is excessive dorsiflexion of the affected ankle.
Thompson test: On squeezing the calf, there is suggestive absence of plantar flexion of the foot.
O’Brien needle test: A needle is inserted 10 cm proximal to insertion of the Achilles tendon. With passive dorsiflexion of the foot, the needle will not rotate.
Conservative management
Conservative line can be given for partial or near complete tear in sedentary individual. Surgical treatment is advocated for athletic individuals.
Initially above knee cast (in equinus) is applied for 4 weeks.
At the 4 weeks, Orthotic is prescribed.Plantar flexion is gradually reduced.
At 6 weeks, the patient is allowed to bear weight.
At 8 weeks, patients were weaned from the brace and then began physical therapy for stretching and strengthening. The average time for immobilization is 9 weeks.
Percutaneous surgery: Ma and Griffith repair
Percutaneous sutures are used to approximate .Through stab wounds, sutures are passed through the distal and proximal ends, which are approximated and tied above skin.
Open surgical repair
Open reconstruction is undertaken using a medial longitudinal approach. The ends are then approximated and sutured with a heavy non absorbable suture using a modified Kessler, Krackow, or Bunnell technique.
If the repair is insecure, reinforcement is required with a pull-out wire or tendon graft. Nearly same protocol is used regards immobilisation.
Outcome
Usually recovery from the injury takes around 4 months. During the recovery phase the athlete is trained for ROM and strengthening exercises.
Before a athlete reaches field, he is re acclimatised with endurance and sports related skill.