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Achilles Tendon

Anatomy

The Achilles tendon (calcaneal tendon) is the largest and strongest tendon in the body. It is formed by the fusion of the tendons of the soleus and the two heads of the gastrocnemius - together called the triceps surae - which are powerful muscles involved in plantar flexion.
  • The tendon is round at its proximal part and becomes flat distally.
  • Its fibers rotate 90 degrees from proximal to distal, so the medial part becomes posterior and the lateral part becomes anterior. This torsion mechanically enhances the tendon's resistance to stress.
  • It inserts onto the posterior surface of the calcaneus, below the posterosuperior angle.
  • It does not have a synovial sheath but is surrounded by a paratenon (connective tissue envelope).
  • The retrocalcaneal bursa lies between the tendon and the posterosuperior angle of the calcaneus.
  • Its midportion is most vulnerable to pathology due to relatively poor vascularization.

Pathology

The tendon is prone to: tendinitis, paratenonitis, tendinosis, rupture, and retrocalcaneal bursitis.
Rupture - Complete rupture is common; 20% of acute injuries are missed. It typically occurs from sudden forced calf contraction during sports like badminton or squash. The patient feels as if they were "kicked in the heel."
  • On exam: a palpable gap may be present.
  • The Simmonds-Thompson test confirms diagnosis: with the patient prone, squeezing the calf normally causes passive plantarflexion; absence of this movement indicates rupture. Active plantar flexion may still be possible (via long toe flexors), so this should not be relied upon.

Treatment of Rupture

  • Options include surgical repair or functional (conservative) management.
  • There is an increasing trend toward functional management over direct surgical repair.
(Sources: Imaging Anatomy: Bones, Joints, Vessels and Nerves; Bailey and Love's Short Practice of Surgery, 28th Ed.)
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