Avulsion for once

Not a Rupture

The Explanation

Most everyone on this site suffers from a very similar injury, the dreaded “Achilles Rupture”.¬† Its one of those injuries that makes itself felt most often amongst people who are attempting to do something to make themselves feel vital again, recover form and grace they lost while they tried to raise their children or their career.

Sometimes though its a little less understandable as with Barb Howe a professional cyclist who ruptured unladen, or with Ezmalicious who had her tendon lacerated.

I didn’t suffer anything like this.

The Injury

I had what is called an Avulsion Fracture of the Achilles tendon. The difference is that while a rupture is a violent partial or complete severing of the Achilles tendon an Avulsion Fracture happens when the tendon dismounts from the bone, often taking pieces of the bone with it.

The standard tests are used in diagnosis, basically gathering the description of the incident, performing a Thompson’s test and then some form of imaging. Its during the imaging stage that an Avulsion Fracture is diagnosed with the Achilles because the presentation of the Avulsion and the Rupture are so similar.

In my case I was misdiagnosed. I hesitate to think that it was because the ultrasound residents weren’t familiar enough to suspect something other than a rupture and more because my injury continued to mislead their diagnostic procedures.

When a tendon avulses (is that a term?) it typically does so because some trauma has weakened the bone to which it is attached and the tendon pulls bone fragments with it. These fragments would of course show up readily in x-ray or ultrasound. In my case the tendon, as my surgeon described it, peeled right off the bone. If you imagine that a typical Avulsion is like removing a price sticker from an expensive gift, mine was like peeling warm wax from glass. The only way the injury could have been diagnosed correctly was by using MRI and the confidence of the diagnosis was so high they didn’t feel it was necessary.

This image compares a normal and a rupture Achilles tendon

This image compares a normal and a rupture Achilles tendon

The Avulsion Fracture as it normally presents. Notice the white tail where you would normally expect a rupture point. This is a bone fragment pulled from the Calcaneous.

The Avulsion Fracture as it normally presents. Notice the white tail where you would normally expect a rupture point. This is a bone fragment pulled from the Calcaneous.

The Treatment

Everyone here is familiar with the two basic treatments available for the Achilles Rupture, surgical treatment where the Achilles is patched together or non-surgical where the patient is placed in a boot or cast with their foot in extreme plantarflexion.

The treatment for an Avulsion Fracture is surgical, the tendon cannot re-attach itself and so the tendon must be forced to assume its original position. This also requires traction in order to counteract the tension placed on the tendon by the muscle. Previously the procedure used included the use of large headed surgical screws but more often the procedure originally developed for dealing with a Haglund’s Deformity is used.

In this case my surgeon ran a whip stitch from the bottom of the tendon up to the bottom of the muscle to act as a platform for the sutures that he would put in place. He then drilled two holes through my calcaneous (heel bone) and out through the bottom of my foot adding two counter sink holes on the outside into which he sunk two suture pins. Then he ran very heavy sutures through the tendon, down through my calcaneous and out through the heel. While keeping my foot in extreme plantar flexion and heavy pressure on the tendon they set the tendon into traction by using a surgical button on the outside of the bottom of my heel. When that was set in place he whip stitched through the tendon and the suture pins, snugging everything in place.

The idea of the surgery is that the tendon will be forced into contact with the bone after appropriate debridement, the tendon is then meant to resume its connection with the heel. There are two other options to this, one is the PBT Transfer where the Achilles is attached to the Peroneus Brevis Tendon or the FHL Tendon Transfer where the tendon used to flex the big toe is detached, fed backwards through the foot and up a channel cut in the calcaneous and the FHL tendon and muscles are stitched to the tendon. (The big toe is then attached to the tendons governing the next toe over.)

This is the original and typical method used to remount the tendon to the bone - they simply put large screws into your heel through the tendon. Not fun.

This is the original and typical method used to remount the tendon to the bone - they simply put large screws into your heel through the tendon. Not fun.

This is the right way - hopefully. The two bright spots are the suture pins and the bottom of the heel shows the button.

This is the right way - hopefully. The two bright spots are the suture pins and the bottom of the heel shows the button.

The Success

As far as I’ve gone with this its successful. I’ve not noticed anything to indicate that the tendon is dismounting again and I’ve still got my full range of motion. Now all I need is to get moving on rebuilding my strength. I may stay away from doing too many jumping exercises but that’s just sensible I think.

The Pun

Yes, the name I adopted for this site is indeed a pun. Remember, the doctor’s assumed they knew what my injury was (denied) and my tendon is meant to assume on the calcaneous (denied).

music used to inspire this post - siouxsie and the banshees ‘the millennium collection’, love and rockets ‘mirror people’, national velvet - ‘courage’

5 Comments

5 responses so far ↓

  • annieh // Oct 5th 2009 at 6:37 am

    What an incredible blog, quite fascinating although I am not sure about those large screws. Fortunately I had finished my lunch before reading it.

  • sam66 // Oct 5th 2009 at 7:56 am

    I agree with Annie - glad I’d already eaten before I saw the screws.
    Sounds much worse than the average ATR surgery.

  • ultidad // Oct 5th 2009 at 7:39 pm

    Awesome visual aids. And yes, “avulses” is the right term.

  • tripletail // Oct 20th 2009 at 4:49 pm

    wow I thought i was looking at my own x-ray, right down to the washer on 1 of the screws… I think my first doctor has missed my achilles rupture and just fixed the broken off peice of my calcanium i uess i’ll let my second opinion doctor fix whats broken….uuuurrrggghhhh

  • Postcards from the Emergency Department « The EMBER Project // Nov 28th 2012 at 12:14 pm

    [...] EMBER: Here is a nice blogpost from someone who went through the experience.  Sometimes a well told patient story is better than any textbook. Share [...]

You must log in to post a comment.