Jay Lieberman DPM, FACFAS, Director of Podiatric Medical Education, Northwest Medical Center Guest Case Study: Rupture of the Achilles Tendon in a Patient with and Anterior Cavus Deformity An 18-year-old male sustained an injury to his left Achilles tendon while participating in a track meet.  He was sprinting to the finish line when he felt a sharp “pop” in his left heel.  Unfortunately, he was not able to finish the race.  After you watch the video, ask yourself, "Did the runner fall and rupture the tendon or rupture his tendon and then fall? The patient was seen at the Emergency Department.  X-rays were within normal limits.  He was placed in a posterior splint.  This occurred approximately twenty-four hours prior to presentation in the office.

PAST MEDICAL HISTORY: Essentially unremarkable.

MEDICATIONS: None other than a three-day prescription for associated pain.

ALLERGIES: NKA, NKDA

SOCIAL HISTORY: He is not a smoker, nor does he consume alcohol. He does not drink coffee or tea. The patient is a student.

PAST FOOT/ANKLE HISTORY: None

FAMILY HISTORY: None

REVIEW OF SYSTEMS: He has had his tonsils removed.

NEUROVASCULAR EXAMINATION: The patient's neurovascular status is intact. Pedal pulses are graded +2/+4 bilateral. Proprioceptive sensoriums are intact. The skin is supple and well hydrated. The nails are normal.

Click on these images for a full-screen view

LOWER EXTREMITY EXAMINATION:  Clinically one notes an anterior cavus deformity bilateral.  The patient has retrocalcaneal prominences.  There is an apparent limitation of ankle dorsiflexion bilaterally. 

A large effusion is present along the posterior aspect of the left heel. 

ASSESSMENT:  Probable rupture, complete, of the Achilles tendon.

PLAN:  Stat MRI evaluation. 

Complete rupture of the Achilles tendon reported

Alternatives including expectations and possible complications associated with primary repair of the Achilles tendon were discussed with the parents.  The vulnerability to injury with this type of foot was explained to the parents. 

Postoperatively, the patient will need to wear an orthotic device with small heel lift, particularly if he is to return to track and field events.

Click on these images for a full-screen view
The paratenon was intact but engorged with Hematoma.	Only the Plantaris tendon remained intact.

A Krackow stitch was used to repair the tendon.	The paratenon was re-approximated.

At six weeks he wore a low profile cast walker with 8° wedging. Physical therapy followed.

Ankle equinus is a sagittal plane deformity in which there is less than 10° of dorsiflexion available at the ankle joint.  The lack of dorsiflexion can be due to osseous or soft tissue pathology.  Gastrocnemius or gastroc-soleal equinus are soft tissue causes, which must be differentiated.  The evaluation of the ankle dorsiflexion with the knee flexed and extended allows for this distinction. 

The anterior cavus foot presents clinically in the sagittal plane as a hyperdeclinated forefoot.  During clinical examination of these patients, a restriction of ankle dorsiflexion may be falsely inferred.  The plantar flexed forefoot to rear foot relationship in closed chain kinetics results in an early heel raise.  Because heel raise occurs earlier in the gait cycle, it gives the erroneous impression that ankle dorsiflexion is restricted. 
The term “pseudoequinus” has been coined to describe this condition.  In these patients, sagittal plane compensation results in postural imbalance, which causes increased strain on the Achilles tendon, calf, and posterior knee.  Achilles tendon ruptures often occur in the region that is 2-6cm from the insertion where the blood supply is poorest.  Systemic administration or local injection of corticosteroids, use of fluoroquinolone antibiotics, prolonged degeneration, direct blow, laceration, and violent muscular contraction against a loaded tendon are known causes of rupture.  In young athletes, the latter is usually the reason.  The track athlete, more specifically, short distance runners, are consistently in the propulsive region of the stance phase as they forcefully contract the triceps surae.  The individual with a pseudoequinus is at risk due to the constant strain on the Achilles tendon.

Orthotics play a key role in the healing of an achilles tendon rupture

In addition to rehab, orthotics also play a crucial part in healing post-operative Achilles tendon injuries. Our patient wants to return to competitive track and field events.  So with this in mind, I consulted Ed Glaser, DPM of Sole Supports (based out of Lyles, TN) , an innovator in biomechanics and orthotic control.  Unlike other custom orthotics labs, Sole Supports requires training the care provider in their specialized casting technique and theoretical model, prior to the placing their first order. They thoroughly inspect each cast that comes to the lab prior to production.

We managed to lure Dr. Glaser to South Florida to examine the patient and give us an in-service. Dr. Glaser’s generosity allowed this aspiring athlete to have the benefit of his expertise and also a state-of-the-art orthotic laboratory and research facility. Dr. Glaser, (see below) explains that, "to achieve full contact in the arch with enough rigidity to change the posture of the foot in a weight-bearing position, you must be sure that the corrected position of the patient's foot is captured perfectly." I urge all residents and their attendings to become certified in Dr. Glaser’s approach to full contact orthotic casting by attending the Bottom Block Seminar and Workshop.

Sole Support's Dr. Glaser casts the achilles tendon patient for his new orthotics.

To learn more about Sole Supports and Dr. Glaser's techniques, a multi-media lecture series is available online at https://www.solesupports.com/dvd.htm. There's also a three-part PRESENT Lecture series, whereby Dr. Glaser carefully outlines and explains his theories on orthotic design and utilization: