Achilles Tendon Tears: Achilles Tendon Injuries and How to Treat Them

Achilles Tendon Tears: Achilles Tendon Injuries and How to Treat Them

Thank you for tuning in to OrthoPedia for a quick discussion on Achilles tendon injuries and how to treat them. We will break this talk into 3 different parts. We will start with some background. Then, we will talk about 2 different problems: midsubstance rupture and insertional Achilles problems.

The human body is incredible. Trained sprinters can exceed 20 mph. The world record long jump is over 29 feet. Athletes at the NFL Combine can often jump nearly 4 feet vertically, and somehow, the world record high jump stands at just over 8 feet. All of the force necessary for these feats is transferred through a unique structure called your Achilles tendon.

The Achilles tendon is responsible for transferring force from your calf muscles right here all the way down to your heel bone. If we take the skin away and look below the surface, we can see that we actually have two different calf muscles. The first one is called the gastrocnemius, and the other is called the soleus. These two muscles grab onto the tendon just like this one; from either side, just like you would hold a piece of paper with both hands. Those two big muscles feed into the Achilles tendon, much like streams going into a river. That central portion where the river is at its widest is called the midsubstance region of the tendon.

What happens when we get down to the heel? To carry the analogy even further, that river fans out into a delta and then grabs onto the heel bone. This is an X-ray of the back of your foot. Looking at it from the side, you can see the ankle joint above and the heel bone down below. The Achilles tendon comes down from the top and grabs onto the back of the heel at a spot the doctors call the Achilles insertion. The Achilles tendon, believe it or not, even has its own waterbed. There is a fluid-filled sack just above the insertion of the achilles tendon that cushions the tendon as it runs across the top portion of the heel bone.

Now that we understand a little bit about the Achilles let us talk more about some of the problems that can occur. We will start with the midsubstance tear this central region, our river is vulnerable to tearing. This happens first when the calf is tightened while the foot is forced up. These are very uncommon injuries. Statisticians tell us this occurs only in about 18 people per 100,000 people every year. This means that in a stadium of 100,000 people, about 18 of them or this group, right there, will rupture their Achilles this year.

If you are one of those lucky ones or unlucky ones that have ruptured their Achilles in the past, you are in good company. Plenty of famous athletes and, believe it or not, actors have torn their Achilles tendon. This tends to happen in men far more commonly than women, approximately about 80% versus 20%. Age-wise, the majority happens between the ages of 20 and 60. The youngest among us are almost always sports-related injuries. The 40 to 60 age range is often weekend warriors. In my personal experience, these patients are often people who are athletes in their younger years, and their brains make a 20-year-old demand on a 40-year-old body.

Achilles ruptures still occur in our later years but these tend to have a medical underpinning. Tendon ruptures are a rare side effect of certain types of antibiotics, especially in those with kidney disease. How do surgeons fix these problems? At the highest level, nonoperative and surgical options are available. In those who have medical comorbidities or who are not doing a whole lot of walking, not doing surgery is an option, but it might heal too long, making your leg feel weaker than the other side. Surgery makes the tendon the correct length and is the most common choice for active patients in the United States.

Here, we have a patient with an Achilles rupture. The traditional surgery requires a long incision, typically about 5 to 6 inches or more. The tendon is exposed, and after the tendon is brought together, the repair is performed with a bunch of sutures and knots. There are some problems with this procedure. The traditional repair leaves us with a big scar and lots of sutures and knots. There is also a risk of infection and poor wound healing as a result of this long incision.

But there is a solution to some of these problems. Arthrex has a technique that they call the Achilles MidSubstance SpeedBridge technique. In this technique, surgeons make a 1-inch incision. The tendon is brought together, and sutures are passed underneath the skin. Anchors are then used to knotlessly attach the sutures to the heel bone. Surgeons use devices just like this in this procedure. The device on top is used to percutaneously pass sutures underneath the skin. The device on the bottom is used to anchor the sutures to the heel bone. The patient gets an even stronger result. Less suture, less knots, and much less scarring.

Finally, let us talk about some problems that can happen where the Achilles actually inserts down into the heel. We are focused on this region here. Problems at the Achilles insertion tend to be chronic rather than a result of trauma. The most common causes are overuse or quickly increasing your activity without giving your body time to adapt. Potential sources of pain are here: the tendon itself, the fluid-filled sack behind the Achilles, or the actual insertion.

This is a normal appearing contour of the back of the heel. In long-standing cases, the body tries unsuccessfully to heal this area, resulting in a growth of bone in and around the tendon. This painful bump is often called a pump bump and can make shoes very uncomfortable. Surgeons can open this area, remove the diseased bone, and securely reattach the Achilles over a broad area using 4 anchors and 2 limbs of FiberTape suture.

We have talked through a lot of background on Achilles anatomy, midsubstance ruptures, and insertional problems. Thank you for tuning in to OrthoPedia.