Diagnostics and pre-hospital care
Clinical diagnosis is based on the assessment of motor function: if the patient is unable to perform spontaneous plantar flexion of the foot, this directly indicates a complete rupture of the tendon itself or the triceps surae muscle. In cases where the clinical presentation is blurred or doubtful, instrumental methods such as ultrasound examination (ultrasound) or magnetic resonance imaging (MRI) should be used.
At the pre-hospital stage, it is extremely important to properly immobilize the injured limb. Ladder splints are used for transport immobilization.
- Splint application boundaries: from the tips of the toes to the upper or middle third of the thigh (along the anterior surface).
- Limb position: the ankle joint is placed in maximum plantar flexion (equinus), and the knee joint is slightly flexed. This is necessary to relieve tension from the damaged tissues.
Management of open and partial injuries
Treatment strategy strictly depends on the nature of the injury.
Open injuries Require exclusively surgical treatment. During primary surgical debridement (PSD), the tendon ends are sutured end-to-end. For this purpose, Küneao's suture is used, which surgeons routinely supplement with mattress and interrupted sutures for reliability. If the wound is complicated (severe contamination or tissue crushing), immediate suturing is contraindicated. Tendon repair is postponed until the infection is completely resolved and the skin wounds have healed.
Partial closed injuries In this case, conservative therapy is indicated:
- A plaster cast is applied from the middle of the thigh to the toes.
- The limb is given a specific position: slight flexion of the knee and equinus position of the foot. This position ensures maximum relaxation of the gastrocnemius muscle.
- After 3 weeks, the knee joint is freed from immobilization, and the foot is very carefully moved to the neutral anatomical position.
- By the end of the 6th week, the plaster cast is completely removed.
Surgical treatment of complete ruptures
In complete ruptures, conservative management is ineffective, and surgery is indicated. The choice of technique depends on the time elapsed since the injury.
If the patient presents in the early period, surgeons perform a closed repair using S.P. Girshin's technique.
If the injury is chronic (2 weeks or more have passed), the tendon ends undergo secondary scar changes. It is no longer possible to suture them using a closed technique, so doctors resort to plastic surgery. The most common technique is Achilles tendon reconstruction using V.A. Chernavsky's method.
Stages of Chernavsky's reconstruction:
- The scar-changed ends of the tendon are excised.
- A tongue-shaped flap is carved from the aponeurosis of the gastrocnemius muscle (it maintains its anatomical connection with the proximal end).
- This flap is sutured into the distal end of the damaged tendon.
After surgery, a plaster cast is applied (from the middle of the thigh to the toes; subsequently, the immobilization borders may be changed from the upper third of the lower leg to the toes). The limb is fixed in the equinus position with the knee flexed to an angle of 150°. After 3 weeks, the foot is returned to the normal position. The total immobilization period after reconstruction is 6 to 8 weeks.
Rehabilitation
Rehabilitative measures begin even during the immobilization period and continue after the cast is removed.
- In the cast: the patient is prescribed therapeutic exercise (physical therapy) and physical therapy modalities (PTM).
- After cast removal: gradual, graded mobilization of the ankle joint is performed. Special attention is paid to training and strengthening the triceps surae muscle (m. triceps surae), as it provides the primary function of the repaired complex.
Briefly: answers to topical questions
What clinical tests and symptoms are used for the physical diagnosis of a complete Achilles tendon rupture?
For the physical diagnosis of a complete Achilles tendon rupture, the motor functions of the foot are assessed. The main clinical sign:
- Absence of spontaneous plantar flexion of the foot — a sign of a complete injury of the Achilles tendon or triceps surae muscle.
In doubtful cases, ultrasound or MRI is indicated.
Class and exam questions
How to clinically distinguish a complete Achilles tendon rupture?
The primary sign is the patient's inability to perform active plantar flexion of the foot.
In what position should the leg be immobilized during first aid?
The limb is fixed with a ladder splint with slight flexion of the knee joint and maximum plantar flexion of the foot.
Why is it impossible to simply suture the tendon ends in chronic ruptures?
After 2 weeks or more, secondary scar changes in tissues develop, so closed suturing is impossible, and Achilles tendon reconstruction is required.
Why is the foot fixed in equinus (plantar) flexion?
This position allows for maximum relaxation of the gastrocnemius muscle and relieves tension from the ruptured ends of the tendon.
What else to study on this topic
- Technique of Küneao's suture
- Features of closed repair using S.P. Girshin's technique
- Biomechanics of the tongue-shaped flap in Chernavsky's reconstruction
- PTM and physical therapy protocols after plaster cast removal
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