Neglected Achilles Ruptures

Neglected achilles ruptures can have serious long term consequences with long term disability due to muscle weakness, chronic pain and swelling in the affected limb. Achilles ruptures are a clinical diagnosis supplemented with MRIs. There needs to be a high index of suspicion to reach an accurate diagnosis. 

Most patients who suffer from such injuries go to the Emergency Room immediately after the injury occurs. Clinically the patient is able to walk but with weakness during push off and plantar flexion.  This weakness is an indication of a rupture. Oftentimes this is missed clinically as there are other muscles in the leg which can perform push off albeit with weakness. Emergency Rooms also are burdened with serious life threatening conditions specially during the ongoing COVID-19 Pandemic. Confirmation of diagnosis also requires MRI which takes at least 45 minutes to perform and is often not done when patients present to the ER due to staffing and scheduling issues. 

Here is a case that presented to a local ER after suffering from a work injury that resulted in a laceration of the posterior leg. In the ER patient’s skin laceration was sutured and the patient was discharged without non weight bearing instructions. Patient then followed up with his PCP in 2 weeks and sutures were taken out. Patient returned to work and continued to have pain, swelling and weakness. 

Eventually the patient was seen in our clinic where it was immediately evident that he has no plantarflexion strength. MRI was ordered which confirmed the diagnosis. The biggest challenge with delayed and neglected care is that the proximal part of the achilles tendon retracts leaving a big gap to fill. This patient had a gap of approximaly 7 cm.

Surgical intervention was recommended for this patient. He underwent a V-Y advancement flap to reduce the 7 cm gap. Once the gap between the two ruptured ends was reduced, a direct repair of the tendon was performed. Prior to the direct repair, flexor hallucis longus (FHL) tendon was transferred to the heel to augment and support the repair. This is oftentimes required when the injury is significant as it was in this case. Platelet rich plasma was also injected along the repaired tendon to enhance healing. Patient was placed in a cast and immobilized for 6 weeks followed by formal PT and he was returned to work at week 10.