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NICOLA MAFFULLI
FIG. 1
Graph showing the stress-strain curve for tendon. Wavy lines indicate the wavy configuration of the tendon at rest, straight unbroken lines
indicate the effect of tensile stresses (at strain levels of less than 4 percent, the tendon can regain its original configuration on removal of the
load), one or two broken lines indicate that the collagen fibers are starting to slide past one another as the intermolecular cross-links fail,
and the set of completely broken lines indicate macroscopic rupture due to the tensile failure of the fibers and the interfibrillar shear
failure. (Modified from: Kannus, P.: Tendon pathology: basic sciences and clinical applications. Sports Exerc. and Injury, 3: 62, 1997. Reprinted
with permission.)
throughout the Achilles tendon and may vary according to age, gender, and loading conditions9.
Biomechanics of the Tendon
Actin and myosin are present in tenocytes76, and the
tendon itself may have an active contraction-relaxation
mechanism, which could regulate the transmission of
force from muscle to bone54. Fukashiro et al.55 measured
a peak force of 2233 newtons within the human Achilles
tendon in vivo. Komi et al.96 used buckle-type forcetransducers attached to the ankles of volunteers to
show that, during walking, force builds up within the
tendon before the heel strikes the ground. The force is
then suddenly released for ten to twenty milliseconds
during early impact. Thereafter, force builds up relatively fast until it reaches a peak at the end of the
push-off phase, in a pattern similar to that observed
during running. More recently, Arndt et al.5 showed that
the Achilles tendon can be subjected to nonuniform
stresses through modifications of individual muscle
contributions. An injury therefore can be produced by
a discrepancy in individual muscle forces caused, for
example, by asynchronous contraction of the various
components of the triceps surae or by uncoordinated
agonist-antagonist muscle contraction due to impaired
transmission of peripheral sensory stimuli125.
At rest, a tendon has a wavy configuration, a result of crimping of the collagen fibrils138. Tensile stresses
cause the loss of this wavy configuration, accounting for
THE JOURNAL OF BONE AND JOINT SURGERY
the toe-region of the stress-strain curve (Fig. 1). As collagen fibers deform, they respond linearly to increasing
tendon loads93. If the strain placed on the tendon remains at less than 4 percent that is, within the limits
of most physiological loads138 the fibers regain their
original configuration on removal of the load. At strain
levels between 4 and 8 percent, the collagen fibers start
to slide past one another as the intermolecular crosslinks fail. At strain levels of greater than 8 percent,
macroscopic rupture occurs because of the tensile failure of the fibers and interfibrillar shear failure138.
The compliance of the tendon is dependent at least
in part on intratendinous waviness29, which may affect
the ability of the gastrocnemius-soleus muscle complex
to generate force at the extremes of joint motion68. Ultimately, it may also influence the forces exerted by
muscle contraction on the tendon and, hence, the propensity of the tendon to rupture.
Epidemiology
Although ruptures of the Achilles tendon are relatively common, the incidence in the general population is
difficult to determine but has probably increased during the past decade104. Leppilahti et al.105 estimated that
the incidence of ruptures of the Achilles tendon in the
city of Oulu, Finland, in 1994, was approximately eighteen per 100,000. Most ruptures of the Achilles tendon
(range, 44 percent [twelve of twenty-seven]144 to 83 percent [ninety-two of 111]31) occur during sports activities.
In the Scandinavian countries, badminton players appear to be at particular risk49; in a large study, fifty-eight
(52 percent) of 111 patients who had a rupture of the
Achilles tendon were playing badminton at the time of
the injury31. A rupture of the Achilles tendon is more
common in males, with a male-to-female ratio ranging
from 1.7:1 to 12:126,146,189, possibly reflecting the greater
prevalence of males than females who are involved in
sports, although there may be other as yet unrecognized
factors. The left Achilles tendon is ruptured more frequently than the right67,172,173, possibly because of a higher
prevalence of individuals who are right-side-dominant
and thus push off with the left lower limb. Typically,
acute ruptures of the Achilles tendon occur in men who
are in the third or fourth decade of life, work in a whitecollar profession, and play a sport occasionally22,67,82.
The prevalence of rupture of the Achilles tendon
has been shown to be greater in patients who have
blood group O, at least among Hungarians80 and in some
Finns99. These findings have not been confirmed in other
studies128 even when the same ethnic groups were involved105. We were not able to prove an association with
blood group in our area of Scotland, which has a high
incidence of rupture of the Achilles tendon152.
Etiology
Spontaneous rupture of the Achilles tendon has
been associated with a multitude of disorders, such
VOL. 81-A, NO. 7, JULY 1999
1021
as inflammatory and autoimmune conditions46, genetically determined collagen abnormalities42, infectious diseases7, and neurological conditions126. However, there is
little agreement with regard to its etiology.
A disease process may predispose the tendon to
spontaneous rupture from minor trauma114. Blood flow
in the tendon decreases with increasing age 66, and the
area of the Achilles tendon that is typically prone to
rupture is relatively avascular compared with the rest of
the tendon100,101,161.
Histological evidence of collagen degeneration was
found in all seventy-four ruptured Achilles tendons described in a study by Arner et al.7. However, nearly
two-thirds of the specimens were obtained more than
two days after the rupture. Davidsson and Salo40 reported marked degenerative changes in two patients
with a rupture of the Achilles tendon who had an operation on the day of the injury. The changes, therefore,
should be regarded as having developed before the
rupture. In a study by Waterston187, performed at our
center, all tendons that were operated on within twentyfour hours after the injury showed marked degenerative
changes and collagen disruption, in accordance with the
findings in another recent study78.
Alternating exercise with inactivity could produce
the degenerative changes seen in tendons97. Sports in
addition to daily activity places additional stress on the
Achilles tendon, leading to the accumulation of trauma,
which, although below the threshold for frank rupture188, could lead to secondary intratendinous degenerative changes53.
Corticosteroids and Rupture of the Tendon
Corticosteroids are administered for a variety of
diseases and have been widely implicated in tendon
ruptures. Injection of hydrocortisone into the calcaneal tendons of rabbits caused necrosis at the site of
injection forty-five minutes after the injection, and the
tendons that had been given an injection of corticosteroids showed a delayed healing response compared with
those that had received an injection of saline solution11. The anti-inflammatory and analgesic properties
of corticosteroids may mask the symptoms of tendon
damage45, inducing individuals to maintain high levels
of activity even when the tendon is damaged. Corticosteroids interfere with healing, and intratendinous injection of corticosteroids results in weakening of the
tendon for as many as fourteen days91. The disruption is
directly related to collagen necrosis, and restoration of
the strength of the tendon is attributable to the formation of an acellular amorphous mass of collagen. For
these reasons, vigorous activity should be avoided for at
least two weeks after injection of corticosteroids in the
vicinity of a tendon91. Unverferth and Olix183 reported a
subcutaneous rupture in five athletes who had been
given injections of corticosteroids in the region of the
Achilles tendon for the treatment of tendinopathy. Re-
1022
NICOLA MAFFULLI
FIG. 2
Photographs showing the appearance of the feet of an eighty-year-old woman who had bilateral rupture of the Achilles tendon; she had
been managed with orally administered corticosteroids for twenty-eight years because of asthma. The ruptures had been undiagnosed for 7.5
months. At the time of referral, the patient walked with plantigrade feet, with no push-off. She refused any management, as she perceived that
she had adapted well to the functional deficit originating from the ruptures of the tendons. A palpable gap in the substance of the Achilles
tendon was evident bilaterally (arrows).
1023
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NICOLA MAFFULLI
1025
1026
NICOLA MAFFULLI
FIG. 3
Photograph showing breakdown of the wound after operative
repair of a rupture of the Achilles tendon. The patient had removed
the cast against medical advice at four weeks after the operation and
had returned to playing volleyball. At his first jump, the skin broke
down.
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NICOLA MAFFULLI
1029
FIG. 4
Photograph showing a repeat rupture in a fifty-four-year-old man who was originally managed nonoperatively. The repeat rupture occurred
when the patient stumbled on a step as he was going to work seven months after the original injury. Note the presence of the plantaris longus
tendon.
aged operatively and 66 percent of those managed nonoperatively were satisfied with the result of treatment.
Cetti et al.31, in a prospective, randomized study, reported on fifty-six patients who were managed operatively and fifty-five who were managed nonoperatively.
The rates of complications and repeat ruptures were
9 and 5 percent, respectively, for the patients managed operatively compared with 16 and 15 percent,
respectively, for the patients who were managed nonoperatively. The differences between the groups, however, were not found to be significant. The authors also
conducted a review of the literature and identified 4597
ruptures of the Achilles tendon. Operative treatment
of the ruptures was associated with lower rates of complications and repeat ruptures than was nonoperative
treatment. Cetti et al. concluded that operative treatment was the method of choice, but nonoperative treatment was an acceptable alternative.
Recently, Lo et al.111 performed a quantitative review of all of the studies on the treatment of rupture of
the Achilles tendon in the English-language literature
published between 1959 and 1997 to determine the optimum treatment of acute ruptures. All of the identified articles were reviewed independently by at least
three of the four authors to decide the eligibility of each
study on the basis of predetermined criteria. Eligible
studies were reviewed independently, and the data were
extracted with use of standardized coding forms. Inconsistencies in data extraction were settled by discussion and majority vote. The main outcomes extracted
were strength, time until the patient returned to work,
VOL. 81-A, NO. 7, JULY 1999
1030
NICOLA MAFFULLI
FIG. 5
Photograph showing a rupture that had been unrecognized for four months in a forty-seven-year-old male farmworker. Note the hypertrophic paratenon and the rounded-off tendon stump.
stumps of the tendon in an end-to-end fashion121. However, more than 20 percent of patients who have a rupture of the Achilles tendon may be diagnosed late122.
In these instances, young and middle-aged patients generally are first seen with a limp and severe impairment
in the performance of day-to-day activities. When, after trimming, the tendon stumps cannot be approximated without undue tension (Fig. 5), the gap can be
bridged with a single central gastrocnemius fascial turndown flap21 or with two such flaps (one medial and one
lateral)110. If it is available, the tendon of the plantaris
longus can be used as a reinforcing membrane112.
When a patient has an extreme rupture, in which the
gap resulting from the rupture of degenerated tissue
does not allow direct suture, the tendons of the tibialis
posterior and peroneus brevis can be split longitudinally
and used as pedicled transplants. The plantaris tendon
is used as reinforcement, and the construct is augmented
by a turndown flap of the superficial aponeurosis of the
gastrocnemius52.
More recently, Wapner et al.185,186 used a transfer of
the flexor hallucis longus muscle and tendon to provide a dynamic repair. The procedure was performed on
seven patients with a mean age of fifty-two years. After a mean of seventeen months (range, three to thirty
months), there were no postoperative infections, loss of
skin, or repeat ruptures. Each patient had a small loss in
the range of motion of the involved ankle and hallux,
but it was of no functional importance. All patients were
satisfied with the functional result, although one needed
a molded foot-ankle orthosis for prolonged walking185.
When the gap between the ends of the tendon is
such that the ends cannot be juxtaposed, the gap can be
bridged by Marlex (monofilament knitted polypropylene) or Dexon (polyglycolic acid) mesh72,140, and tendon
graft can be used to cover the mesh. Postoperatively, the
patients should be managed more conservatively, with
restricted weight-bearing and immobilization in a plaster cast for eight weeks instead of six weeks.
Postoperative Care
Normally, patients are discharged on the day of the
operation or the next day, after an orthopaedic physiotherapist has instructed them regarding the use of
crutches111.125. Patients are allowed to bear weight on the
involved leg as tolerated, but they should be told to keep
the affected leg elevated for as long as possible to prevent postoperative swelling121. Patients are followed on
an outpatient basis at two-week intervals, and the cast
is removed six weeks after the operation119,121,125. If the
cast has been applied with the ankle in the equinus
position, the cast is changed at two and four weeks, with
the ankle placed in gradually increasing dorsiflexion
until a plantigrade position is reached. The cast is removed altogether six weeks after the operation119.
Patients are allowed partial weight-bearing and
gradual stretching and strengthening exercises, increasing the frequency as tolerated, only after removal of
the cast119. Gradually, patients proceed to full weightbearing at eight to ten weeks after the operation.
During the period of immobilization in the cast,
patients are instructed to perform gentle isometric contractions of the gastrocnemius-soleus complex after
weight-bearing has become comfortable119. After removal of the cast, patients mobilize the ankle under the
guidance of the physiotherapist. Two weeks after reTHE JOURNAL OF BONE AND JOINT SURGERY
1031
Overview
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