Skip to main content
SpringerLink
Log in

Marked pathological changes proximal and distal to the site of rupture in acute Achilles tendon ruptures

  • Ankle
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

A laboratory study was performed to evaluate the histopathological features of the macroscopically intact portion of the Achilles tendon in patients undergoing surgery for an acute rupture of the Achilles tendon. Tendon samples were harvested from 29 individuals (21 men, 8 women; mean age: 46 ± 12) who underwent repair of an Achilles tendon tear tear, and from 11 male patients who died of cardiovascular events (mean age: 61). Three pieces of tendon were harvested: at the rupture site, 4 cm proximal to the site of rupture, 1 cm proximal to the insertion of the Achilles tendon on the calcaneum. Slides were assessed using a semiquantitative grading scale assessing fiber structure and arrangement, rounding of the nuclei, regional variations in cellularity, increased vascularity, decreased collagen stainability, and hyalinization. Intra-observer reliability of the subscore readings was calculated. The pathological features were significantly more pronounced in the samples taken from the site of rupture than in the samples taken proximally and distal to it (0.008 < P < 0.01). There were no significant differences in the mean pathologic sum-scores in the samples taken proximally and distal to the site of rupture. Unruptured Achilles tendons, even at an advanced age, and ruptured Achilles tendons are clearly part of two distinct populations, with the latter demonstrating histopathological evidence of failed healing response even in areas macroscopically normal.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Ames PR, Longo UG, Denaro V, Maffulli N (2008) Achilles tendon problems: not just an orthopaedic issue. Disabil Rehabil 30:1646–1650

    Article  PubMed  Google Scholar 

  2. Arner O, Lindholm A (1959) Subcutaneous rupture of the Achilles tendon; a study of 92 cases. Acta Chir Scand Suppl 116:1–51

    PubMed  CAS  Google Scholar 

  3. RA AstromM (1995) Chronic Achilles tendinopathy. A survey of surgical and histopathologic findings. Clin Orthop Relat Res 316:151–164

    Google Scholar 

  4. Cetti R, Junge J, Vyberg M (2003) Spontaneous rupture of the Achilles tendon is preceded by widespread and bilateral tendon damage and ipsilateral inflammation: a clinical and histopathologic study of 60 patients. Acta Orthop Scand 74:78–84

    Article  PubMed  Google Scholar 

  5. Chhajed PN, Plit ML, Hopkins PM, Malouf MA, Glanville AR (2002) Achilles tendon disease in lung transplant recipients: association with ciprofloxacin. Eur Respir J 19:469–471

    Article  PubMed  CAS  Google Scholar 

  6. JL Cook, Bonar SF, Khan KM (2004) Abnormal tenocyte morphology is more prevalent than collagen disruption in asymptomatic athletes’ patellar tendons. J Orthop Res 22:334–338

    Article  Google Scholar 

  7. Denaro V, Ruzzini L, Longo UG, Franceschi F, De Paola B, Cittadini A, Maffulli N, Sgambato A (2009) Effect of dihydrotestosterone on cultured human tenocytes from intact supraspinatus tendon. Knee Surg Sports Traumatol Arthrosc. [Epub ahead of print]. doi: 10.1007/s00167-009-0953-3

  8. Ebinesan AD, Sarai BS, Walley GD, Maffulli N (2008) Conservative, open or percutaneous repair for acute rupture of the Achilles tendon. Disabil Rehabil 1–5

  9. Forriol F, Longo UG, Concejo C, Ripalda P, Maffulli N, Denaro V (2009) Platelet-rich plasma, rhOP-1 (rhBMP-7) and frozen rib allograft for the reconstruction of bony mandibular defects in sheep. A pilot experimental study. Injury 40(Suppl 3):S44–S49

    Article  PubMed  Google Scholar 

  10. Jozsa L, Kannus P (1997) Histopathological findings in spontaneous tendon ruptures. Scand J Med Sci Sports 7:113–118

    Article  PubMed  CAS  Google Scholar 

  11. Kannus P, Jozsa L (1991) Histopathological changes preceding spontaneous rupture of a tendon. A controlled study of 891 patients. J Bone Joint Surg Am 73:1507–1525

    PubMed  CAS  Google Scholar 

  12. Kannus P, Natri A (1997) Etiology and pathophysiology of tendon ruptures in sports. Scand J Med Sci Sports 7:107–112

    Article  PubMed  CAS  Google Scholar 

  13. Karousou E, Ronga M, Vigetti D, Passi A, Maffulli N (2008) Collagens, proteoglycans, MMP-2, MMP-9 and TIMPs in human achilles tendon rupture. Clin Orthop Relat Res 466:1577–1582

    Article  PubMed  Google Scholar 

  14. Khan KM, Cook JL, Maffulli N, Kannus P (2000) Where is the pain coming from in tendinopathy? It may be biochemical, not only structural, in origin. Br J Sports Med 34:81–83

    Article  PubMed  CAS  Google Scholar 

  15. Khan KM, Maffulli N (1998) Tendinopathy: an Achilles’ heel for athletes and clinicians. Clin J Sport Med 8:151–154

    Article  PubMed  CAS  Google Scholar 

  16. Khan RJ, Fick D, Keogh A, Crawford J, Brammar T, Parker M (2005) Treatment of acute achilles tendon ruptures. A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am 87:2202–2210

    Google Scholar 

  17. Khurana R, Torzillo PJ, Horsley M, Mahoney J (2002) Spontaneous bilateral rupture of the Achilles tendon in a patient with chronic obstructive pulmonary disease. Respirology 7:161–163

    Article  PubMed  Google Scholar 

  18. Lee WT, Collins JF (1992) Ciprofloxacin associated bilateral achilles tendon rupture. Aust N Z J Med 22:500

    PubMed  CAS  Google Scholar 

  19. Lippi G, Longo UG, Maffulli N (2010) Genetics and sports. Br Med Bull; 93:27–47

    Article  PubMed  Google Scholar 

  20. Longo UG, Fazio V, Poeta ML, Rabitti C, Franceschi F, Maffulli N, Denaro V (2010) Bilateral consecutive rupture of the quadriceps tendon in a man with BstUI polymorphism of the COL5A1 gene. Knee Surg Sports Traumatol Arthrosc; 18:514–518

    Article  PubMed  Google Scholar 

  21. Longo UG, Franceschi F, Ruzzini L, Rabitti C, Maffulli N, Denaro V (2009) Foreign-body giant-cell reaction at the donor site after autologous osteochondral transplant for cartilaginous lesion. A case report. J Bone Joint Surg Am 91:945–949

    Article  Google Scholar 

  22. Longo UG, Franceschi F, Ruzzini L, Rabitti C, Morini S, Maffulli N, Denaro V (2009) Characteristics at Haematoxylin and Eosin staining of ruptures of the long head of the biceps tendon. Br J Sports Med; 43:603–607

    Article  PubMed  CAS  Google Scholar 

  23. Longo UG, Franceschi F, Ruzzini L, Rabitti C, Morini S, Maffulli N, Denaro V (2008) Histopathology of the supraspinatus tendon in rotator cuff tears. Am J Sports Med 36:533–538

    Article  PubMed  Google Scholar 

  24. Longo UG, Franceschi F, Ruzzini L, Rabitti C, Morini S, Maffulli N, Forriol F, Denaro V (2007) Light microscopic histology of supraspinatus tendon ruptures. Knee Surg Sports Traumatol Arthrosc 15:1390–1394

    Article  PubMed  Google Scholar 

  25. Longo UG, Franceschi F, Ruzzini L, Spiezia F, Maffulli N, Denaro V (2009) Higher fasting plasma glucose levels within the normoglycaemic range and rotator cuff tears. Br J Sports Med 43:284–287

    Article  PubMed  CAS  Google Scholar 

  26. Longo UG, Franceschi F, Spiezia F, Forriol F, Maffulli N, Denaro V (2009) Triglycerides and total serum cholesterol in rotator cuff tears: do they matter? Br J Sports Med. [Epub ahead of print]. doi:10.1136/bjsm.2008.056440

  27. Longo UG, Oliva F, Denaro V, Maffulli N (2008) Oxygen species and overuse tendinopathy in athletes. Disabil Rehabil 30:1563–1571

    Article  PubMed  Google Scholar 

  28. Longo UG, Rittweger J, Garau G, Radonic B, Gutwasser C, Gilliver SF, Kusy K, Zielinski J, Felsenberg D, Maffulli N (2009) No influence of age, gender, weight, height, and impact profile in achilles tendinopathy in masters track and field athletes. Am J Sports Med 37:1400–1405

    Article  PubMed  Google Scholar 

  29. Longo UG, Ronga M, Maffulli N (2009) Achilles tendinopathy. Sports Med Arthrosc 17:112–126

    Article  PubMed  Google Scholar 

  30. Longo UG, Ronga M, Maffulli N (2009) Acute ruptures of the achilles tendon. Sports Med Arthrosc 17:127–138

    Article  PubMed  Google Scholar 

  31. Maffulli N, Ajis A (2008) Management of chronic ruptures of the Achilles tendon. J Bone Joint Surg Am 90:1348–1360

    Article  PubMed  Google Scholar 

  32. Maffulli N, Ajis A, Longo UG, Denaro V (2007) Chronic rupture of tendo Achillis. Foot Ankle Clin 12:583–596

    Article  PubMed  Google Scholar 

  33. Maffulli N, Barrass V, Ewen SW (2000) Light microscopic histology of achilles tendon ruptures. A comparison with unruptured tendons. Am J Sports Med 28:857–863

    CAS  Google Scholar 

  34. Maffulli N, Ewen SW, Waterston SW, Reaper J, Barrass V (2000) Tenocytes from ruptured and tendinopathic achilles tendons produce greater quantities of type III collagen than tenocytes from normal achilles tendons. An in vitro model of human tendon healing. Am J Sports Med 28:499–505

    CAS  Google Scholar 

  35. Maffulli N, Longo UG (2008) Conservative management for tendinopathy: is there enough scientific evidence? Rheumatology (Oxford) 47:390–391

    Article  CAS  Google Scholar 

  36. Maffulli N, Longo UG (2008) How do eccentric exercises work in tendinopathy? Rheumatology (Oxford) 47:1444–1445

    Article  CAS  Google Scholar 

  37. Maffulli N, Longo UG, Denaro V (2009) Complications after surgery or nonoperative treatment for acute achilles tendon rupture. Clin J Sport Med 19:441–442

    Article  PubMed  Google Scholar 

  38. Maffulli N, Longo UG, Franceschi F, Rabitti C, Denaro V (2008) Movin and Bonar scores assess the same characteristics of tendon histology. Clin Orthop Relat Res 466:1605–1611

    Article  PubMed  Google Scholar 

  39. Maffulli N, Longo UG, Maffulli GD, Khanna A, Denaro V (2010) Achilles tendon ruptures in diabetic patients. Arch Orthop Trauma Surg. [Epub ahead of print]. doi: 10.1007/s00402-010-1097-0

  40. Maffulli N, Longo UG, Oliva F, Ronga M, Denaro V (2009) Minimally invasive surgery of the achilles tendon. Orthop Clin North Am 40:491–498

    Article  PubMed  Google Scholar 

  41. Maffulli N, Longo UG, Ronga M, Khanna A, Denaro V (2010) Favorable outcome of percutaneous repair of Achilles tendon ruptures in the elderly. Clin Orthop Relat Res; 468:1039–1046

    Article  PubMed  Google Scholar 

  42. Maffulli N, Testa V, Capasso G, Bifulco G, Binfield PM (1997) Results of percutaneous longitudinal tenotomy for Achilles tendinopathy in middle- and long-distance runners. Am J Sports Med 25:835–840

    Article  PubMed  CAS  Google Scholar 

  43. Maffulli N, Testa V, Capasso G, Ewen SW, Sullo A, Benazzo F, King JB (2004) Similar histopathological picture in males with Achilles and patellar tendinopathy. Med Sci Sports Exerc 36:1470–1475

    Article  PubMed  Google Scholar 

  44. Maffulli N, Wong J (2003) Rupture of the Achilles and patellar tendons. Clin Sports Med 22:761–776

    Article  PubMed  Google Scholar 

  45. Matthews TJ, Hand GC, Rees JL, Athanasou NA, Carr AJ (2006) Pathology of the torn rotator cuff tendon. Reduction in potential for repair as tear size increases. J Bone Joint Surg Br 88:489–495

    CAS  Google Scholar 

  46. McClelland D, Maffulli N (2002) Percutaneous repair of ruptured Achilles tendon. J R Coll Surg Edinb 47:613–618

    PubMed  CAS  Google Scholar 

  47. GA MovinT, Reinholt FP, Rolf C (1997) Tendon pathology in long-standing achillodynia. Biopsy findings in 40 patients. Acta Orthop Scand 68:170–175

    Article  Google Scholar 

  48. Murrell GA (2007) Oxygen free radicals and tendon healing. J Shoulder Elbow Surg 16:S208–S214

    Article  PubMed  Google Scholar 

  49. Murrell GA (2007) Using nitric oxide to treat tendinopathy. Br J Sports Med 41:227–231

    Article  PubMed  Google Scholar 

  50. Newnham DM, Douglas JG, Legge JS, Friend JA (1991) Achilles tendon rupture: an underrated complication of corticosteroid treatment. Thorax 46:853–854

    Article  PubMed  CAS  Google Scholar 

  51. Nyyssonen T, Luthje P (2000) Achilles tendon ruptures in South-East Finland between 1986–1996, with special reference to epidemiology, complications of surgery and hospital costs. Ann Chir Gynaecol 89:53–57

    PubMed  CAS  Google Scholar 

  52. Royer RJ, Pierfitte C, Netter P (1994) Features of tendon disorders with fluoroquinolones. Therapie 49:75–76

    PubMed  CAS  Google Scholar 

  53. Scherb MB, Han SH, Courneya JP, Guyton GP, Schon LC (2009) Effect of bupivacaine on cultured tenocytes. Orthopedics 32:26

    Article  PubMed  Google Scholar 

  54. Shrier I, Matheson GO, Kohl HW 3rd (1996) Achilles tendonitis: are corticosteroid injections useful or harmful? Clin J Sport Med 6:245–250

    Article  PubMed  CAS  Google Scholar 

  55. Tallon C, Maffulli N, Ewen SW (2001) Ruptured Achilles tendons are significantly more degenerated than tendinopathic tendons. Med Sci Sports Exerc 33:1983–1990

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, UK

    Nicola Maffulli, Gayle D. Maffulli & Anil Khanna

  2. Department of Orthopaedic and Trauma Surgery, Campus Biomedico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy

    Umile Giuseppe Longo & Vincenzo Denaro

  3. Department of Surgical Pathology, Campus Biomedico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy

    Carla Rabitti

Authors
  1. Nicola Maffulli
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Umile Giuseppe Longo
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Gayle D. Maffulli
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Carla Rabitti
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Anil Khanna
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Vincenzo Denaro
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Nicola Maffulli.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Maffulli, N., Longo, U.G., Maffulli, G.D. et al. Marked pathological changes proximal and distal to the site of rupture in acute Achilles tendon ruptures. Knee Surg Sports Traumatol Arthrosc 19, 680–687 (2011). https://doi.org/10.1007/s00167-010-1193-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-010-1193-2

Keywords

Search

Navigation