Mohammed Salim and Rajiv Limaye discuss the rupture of the largest, strongest and thickest tendon in the human body
Introduction
The Tendo-Achilles (TA) is the largest, strongest and thickest tendon in the human body [1]. Risk factors predisposing to its rupture include being middle aged and male, sports (weekend warriors [1]), obesity, steroid injections and antibiotics (fluroquinolones). The rupture commonly occurs 2–6cm proximal to the TA insertion at the musculotendinous junction, which is a relatively hypovascular area [2].
Historically, TA ruptures were considered a rare injury, but more recently their incidence has increased to the extent that it has become the most common tendon rupture of the lower extremity [3]. 10–25 per cent of acute ruptures are undiagnosed [4,5], eventually leading to the neglected TA rupture. The possible reasons for the development of this entity can be attributed to misdiagnosis/delay in diagnosis, inappropriate treatment, delay in treatment or delayed presentation of the patient [6].
There is no consensus on the exact time for an acute rupture to turn into a chronic/neglected rupture, but generally an interval of four to six weeks from injury to treatment is the accepted time period [3,7,8].
Clinical presentation and evaluation
This injury is commonly seen in middle-aged men who present with complaints of difficulty or inability to climb stairs/slopes, weakness and difficulty in walking normally. Pain is usually not the chief complaint. These patients may find difficulty in resuming sports at the same capacity as before the injury. Often, history of the initial injury can be obtained.
On examination of the affected side an obvious gap may be palpable, calf atrophy, increased range of dorsiflexion, weakness in plantar flexion and a positive Thompson’s test may be demonstrable. The patient will be unable to perform a single limb heel raise on the affected side.
Radiologically, the diagnosis can be confirmed by an ultrasound or MRI evaluation. Although the Ultrasound examination is better in acute ruptures, the MRI plays a better role in finding the details of the tear and associated injuries. MRI has the advantage of confirming the injury and assessing the distance between the tendon ends, which in turn can help in surgical planning [3,5,7].
Literature review
The treatment of the neglected TA rupture has been a challenge for most orthopaedic surgeons [9-11]. There is plenty of literature discussing the treatment for an acute TA injury, but there is a paucity of data on the treatment for a neglected TA rupture. Various options have been suggested but there is no clear “gold standard” procedure [3,7]. Some of the options available include conservative management, direct end-to-end repair, V-Y advancem