The treatment of a chronic Achilles tendon rupture will require surgery. If for some reason the patient cannot tolerate surgery, or is medically not fit to undergo an operation, then the treatment can be initiated with the use of a brace. While a brace never restores the full function of the leg, it does permit some increased strength in push off since a spring is attached to the brace that fits inside the shoe.
Surgical treatment should be performed once the diagnosis is made. If the rupture has been present for many months, there is no urgency to the surgery, but one really should not wait too long, since the Achilles tendon continues to pull up into the leg and the gap between the tendon ends gets larger, making the surgery more difficult.
The type of surgery performed depends on the size of the gap between the tendon ends and the extent of separation that is present. If the separation is minimal, then the tendon ends can be stitched together much like what was described for acute Achilles tendon rupture. If the separation is more significant, then other procedures need to be performed. As the gap gets bigger, the options then range from using a strip of the lining of the existing Achilles (called a V-Y advancement), using another tendon as a tendon transfer, or even using an Achilles tendon graft that comes from the tissue bank.
It is always preferable to use the existing Achilles and not a graft. Dr. Mark Myerson has developed a method of bringing the tendon ends together so that a large gap can be bridged together without using a graft or a tendon transfer.
A tendon transfer is only used when there is a massive gap present, or the Achilles has been ripped off its attachment on the heel bone. When it comes to using a different tendon to substitute for the Achilles there are a few tendons that can be used, but the tendon transfer which is preferred uses the second strongest muscle in the leg, the muscle to the big toe (the flexor hallucis longus).
The disadvantage of this operation is that the flexor hallucis muscle is not as strong as the Gastrocnemius that powers the leg. Nonetheless, patients are able to push off fairly comfortably with the tendon transfer and can even participate in some sporting activities. This operation can be performed through a very small incision on the back of the ankle. Some orthopedic surgeons like to make a second cut in the arch of the foot to retrieve the tendon for the transfer, but this is not at all necessary.
Occasionally, the tendon transfer of the flexor hallucis longus is not necessary and a long strip of Achilles tendon is used to slide from top to bottom to restore continuity to the length of the Achilles tendon, (called a V-Y advancement).
Either a graft or a tendon transfer must be performed. The graft can be taken from the back of the leg by sliding down a piece of the tendon (called a V-Y advancement), or using the tendon to the big toe (called the flexor hallucis longus).
Occasionally, a graft is taken from a cadaver (called an allograft Achilles). This has tremendous advantages in that the muscle of the patient is not weakened and is attached to the end of the tendon or directly to the heel bone.
This is a very difficult operation, but will return and restore the most power back to the injured leg. The cadaver Achilles graft is used for very specific types of repairs in certain patients who need more strength in the leg.