What is the management for a laceration over the Achilles tendon?

Management of Lacerations Over the Achilles Tendon

For lacerations over the Achilles tendon, immediate surgical evaluation and repair is recommended for any injury that penetrates the paratenon or involves the tendon substance, as these injuries require prompt surgical intervention to prevent complications and optimize functional outcomes. 1

Initial Assessment and Diagnosis

• Immediate evaluation of the depth and extent of the laceration:

  • Assess for tendon involvement through careful wound inspection
  • Evaluate ankle plantar flexion strength
  • Check for a palpable gap in the tendon
  • Perform Thompson/Simonds squeeze test (compression of calf muscle should produce plantar flexion if tendon is intact)

• Diagnostic imaging if tendon involvement is suspected:

  • Ultrasound: 92% accuracy for differentiating full vs. partial tears 1
  • MRI: 95% sensitivity/specificity for tendon pathology (if diagnosis remains unclear) 1

Treatment Algorithm

1. Superficial Lacerations (Skin Only)

• Thorough wound irrigation and debridement
• Standard wound closure techniques
• Tetanus prophylaxis if indicated
• Consider prophylactic antibiotics for contaminated wounds

2. Partial Tendon Lacerations

• Surgical repair is indicated to prevent progression to complete rupture 1, 2
• Unrecognized partial lacerations can lead to delayed complete rupture, as demonstrated in case reports 2
• Primary repair within 24 hours shows excellent outcomes 3

3. Complete Tendon Lacerations

• Immediate surgical repair is the standard of care 1, 3
• Surgical approach:
  • Thorough irrigation and debridement
  • Primary end-to-end tendon repair
  • Immobilization with ankle in slight plantar flexion (10-20°) 1

Post-Repair Management

• Initial immobilization:

  • Below-knee cast or splint with ankle in plantar flexion for approximately 4 weeks 1, 3
  • Initially non-weight bearing with crutches

• Progressive rehabilitation:

  • Early protected weight-bearing may be considered depending on repair stability 1
  • Gradual transition to weight-bearing after 4 weeks
  • Progressive range of motion exercises
  • Tensile loading exercises to stimulate collagen production
  • Eccentric strengthening exercises

Special Considerations and Pitfalls

• Beware of missed injuries: Partial tendon lacerations may be initially overlooked but can lead to complete rupture with minimal trauma later 2
• Wound complications: Open injuries have higher infection risk; thorough irrigation and debridement are critical 3
• Avoid extending the wound during surgical exploration as this can cause additional devascularization 4
• Psychological impact: These injuries can significantly affect patients' quality of life and ability to participate in activities; appropriate counseling is important 5

Expected Outcomes

• With proper surgical management and rehabilitation, 70-90% of athletes successfully return to pre-injury activity levels 6
• Full recovery and return to activities typically takes 5-8 months 2
• Approximately 20% of cases may require reoperation, particularly if initial management was inadequate 6

Follow-up Schedule

• Inpatient monitoring for 1-7 days for IV antibiotics and wound care 3
• Outpatient follow-up at 1-2 weeks post-repair
• Subsequent visits at 4,8, and 12 weeks to monitor healing and guide rehabilitation 3
• Regular assessment of pain and function to guide return to activities