Untreated Achilles tendinosis leads to a reduction in the mechanical strength of the tendon and an increased risk of disruption of its continuity. Achilles tendon rupture usually occurs in middle-aged men who start sports and increase their training volume too quickly. The Achilles tendon can also be damaged in people who lead a sedentary lifestyle and occasionally engage in physical activity. Achilles tendon rupture occurs when a sudden and strong load occurs - it often happens when running uphill or when jumping onto uneven ground with a forced dorsiflexion of the foot.
At the time of the rupture, patients report an audible click and a sensation of sharp pain in the back of the calf. You may palpate a gap between the tendon stumps, usually 2-6 cm above the calcaneus bone. The torn Achilles makes it impossible to climb on the fingers of the injured limb. A positive Thomson test is also observed - when compressing the tummy of the triceps muscle, the foot remains stationary (with the continuity of the Achilles tendon, the foot plantar flexes).
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Treatment of a torn Achilles tendon
The goal of treatment is to restore the anatomical course and length of the tendon. A ruptured Achilles tendon is most often treated surgically, as the close stitching of the tendon ultimately results in a higher tendon strength than the spontaneous healing of similar stumps. Conservative treatment (application of a plaster cast in the horse's position of the foot) is used only in elderly patients with a high risk of complications related to the healing of soft tissues (diabetes, leg ulcers). Surgical treatment enables faster return to normal activity and sports, therefore in the vast majority of cases it is the treatment of choice.
Surgical suturing of the torn Achilles tendon should be performed as early as possible. There are three types of surgical techniques: open, minimally invasive and percutaneous.
Open surgery for a torn Achilles tendon
The surgeon makes a longitudinal incision in the skin medial to the Achilles tendon to bypass the calf nerve. It then opens the tendon for direct access to the Achilles tendon. The tendon is sutured with non-absorbable sutures with possible interlacing of the plantar muscle to strengthen the tissue of the obtained connection. If the Achilles tendon is detached from its attachment on the calcaneus, the bone is first cleaned of fibrous tissue, and then two or three holes are drilled through which the Achilles anchored sutures are led. After the wound is closed, the foot is placed in a slight plantar flexion and a pressure dressing is applied. The open method allows the direct assessment of the tendon stumps and its precise stitching under visual control. This gives you the best chance of getting the maximum to reach tendon strength.
Percutaneous surgery for a torn Achilles tendon
The percutaneous technique is characterized by a much better cosmetic effect and a lower risk of Achilles tendon infection. On the other hand, a visual assessment of the tendon suturing is not possible. The surgeon performs a suture several times through the skin and the tendon, making minimal incisions (up to 3mm).
Minimally invasive access to the ruptured Achilles tendon
The minimally invasive procedure requires only a small transverse incision at the level of the tendon rupture. During the procedure, a special fork-shaped device with four teeth is used. Through the skin incision, the middle two teeth are inserted into the tendon area. The sutures are threaded through the holes in all the teeth and through the tendon, resulting in the sutures being drawn outward from both tendon stumps. The ends of the tendon are brought closer together and the fork is removed.
Reconstruction of the aged Achilles tendon injury
Omission of an Achilles tendon rupture (e.g. in torsion injuries of the ankle joint or fractures of the ankles) leads to contraction of the abdominal muscles and the separation of the tendon stumps. Suturing delay beyond 6 weeks after rupture prevents primary reconstruction from being performed and alternative techniques are required. To obtain the correct length of the tendon, the surgeon lengthens it using the "V-Y" technique above the tendon rupture. To do this, he cuts the V-shaped tendon, then moves the ends apart and sutures the tendon so that the edges of the wound take the shape of the letter "Y". A technique where the cut line resembles the letter "Z" is also often performed. If there is a need to fill larger cavities, the surgeon can sew a closely lying flexor tendon to the Achilles tendon.
Rehabilitation after repair of the Achilles tendon
After the Achilles tendon suturing procedure, the patient moves on crutches without loading the operated leg, but with a moderate step by touching the ground with his fingers. From the second week on, it is possible to gradually load the leg with a Walker type brace with a 2 cm heel inserted.
The main tasks of rehabilitation include obtaining a flexible and durable postoperative scar and restoring the range of dorsiflexion of the foot to 10 degrees (or equal to the opposite limb) with the knee joint straightened. This goal is achieved gradually - by week 8 you should be able to reach zero position, and by week 12 you should be able to reach full range of motion in the ankle joint. Until the 6th week, mainly manual therapy of the soft tissues of the posterior group of the lower leg and thigh is performed, passive and active exercises of the ankle joint without aggressively exceeding the tissue resistance, strengthening the muscles of the hip girdle and training to stabilize the torso. From 7-8 weeks, you can start the first gentle stretching of the Achilles tendon - provided that a full-fledged scar is formed at the suturing site. You can start walking in shoes with slightly higher heels about 8 weeks after the procedure. At 8-12 weeks, the muscular system requires appropriate re-education in terms of stimulation of appropriate muscles by the central nervous system in order to restore the physiological pattern of gait with normal foot shunting. PNF exercises are performed to stimulate particular phases of gait and exercises to improve deep feeling (proprioception).
The first climbs and jogging are possible approximately 4 months after the procedure. It takes about 6 months to recover. The rehabilitation process is completed when the free undertaking of the chosen activity does not cause symptoms of overloading the tendon and the triceps muscle of the calf.
Important information
| Duration of the procedure (depending on the method) | 45 - 60 minutes |
| Tests required for surgery |
basic - preparation for surgery tab |
| Anesthesia | standard subarachnoid, periosteal block |
| Hospital stay | until 4 - 6 after surgery |
| A period of significant dysfunction | 2 weeks |
| A period of limited dysfunction | 2 - 6 weeks after surgery |
| Removal of stitches - first visit | 12-16 days after surgery |
| Change of dressings | every 3 - 4 days |
| Contraindications to the procedure | old damage, infection |
Frequently asked questions about the Achilles tendon suturing procedure:
Achilles tendon suturing should be performed as soon as possible - no later than 6 weeks after the injury. The longer the procedure is delayed, the greater the risk of shortening and atrophy of the calf triceps muscle. An early procedure allows the Achilles tendon to be fully restored using classical methods, without the need to extend the tendon or harvest grafts.
