Episode 2
Achilles Tendon Rupture
Listen to Episode:
Objectives:
After listening to this episode, we hope that you can:
- Describe the typical clinical presentation and mechanism of an acute Achilles tendon rupture.
- Identify key physical exam findings and diagnostic tests used to evaluate Achilles tendon injuries.
- Understand the role of imaging modalities, including ultrasound and MRI, in confirming or further assessing a suspected rupture.
- Compare and contrast nonoperative and operative management strategies, including indications, techniques, and associated risks.
- Outline the phases of rehabilitation and expected timeline for recovery following both surgical and non-surgical treatment of Achilles tendon rupture.
Show Notes
Episode 2: Achilles Tendon Rupture
Management of Achilles tendon ruptures extends beyond initial diagnosis and requires a thoughtful understanding of both operative and non-operative treatment strategies. Decisions regarding repair technique, rehabilitation protocols, and timing are influenced by patient factors, tendon quality, chronicity of injury, and functional demands.
In the section below, we will go further into operative primary repair options for Achilles tendon rupture, including open repair, minimally invasive techniques, and suture-anchor–based constructs, as well as surgical strategies for chronic ruptures. We will also outline principles of modern non-operative management, with emphasis on accelerated functional rehabilitation protocols.
Operative Primary Repair Options
#1 – Open End-to-End Repair
Best for:
- Acute ruptures with large gaps
- Delayed presentations
- Poor tendon quality
Advantages:
- Direct visualization
- Precise tensioning
- Allows augmentation if needed
- hypovascular
Disadvantages:
- Higher wound complication risk
- Posterior ankle skin is thin and hypovascular
Anatomy Pearl:
Posterior midline incisions carry higher wound risk than minimally invasive approaches
2. Percutaneous/Minimally Invasive Repair (PARS)
The PARS technique uses small percutaneous incisions with suture-passing guides.
Advantages:
- Lower wound complication rate
- Smaller incision
Faster soft-tissue recovery
Disadvantages:
- Higher risk of sural nerve injury
- Limited visualization
Anatomy Pearl:
The sural nerve runs posterolateral to the Achilles and is most at risk during percutaneous lateral suture passes.
3. Knotless 4-Anchor Achilles Repair
This technique uses suture anchors placed into the calcaneus and creates a double-row fixation construct.
Commonly used for:
- Insertional ruptures
- Augmented acute repairs
Why surgeons like it
- Strong biomechanical construct
- Restores native tendon footprint
- May allow earlier progression in rehab
Chronic Achilles Ruptures (>4 Weeks): Why Primary Repair Fails
After several weeks, 1) tendon ends retract, 2) scar tissue forms, and 3) the muscle-tendon unit shortens.
Surgical Options:
V–Y Advancement
- Lengthens proximal tendon
- Useful for moderate gaps
Tendon Transfers
- Flexor hallucis longus (FHL) — gold standard as strong plantar flexor, fires during push-off, and leaves minimal functional deficit of great toe.
- Peroneus brevis — alternative
Non-Operative Management
