1
1
Rupture of the tendo Achillis: an affect of the large tendon of the heel.
It oftimes is rent or torn by a small occasion without any sign of injury or solution of continuity on the outside as by a little jump, the slipping aside of the foot, the too nimble getting on horseback, or the slipping of the foot out of the stirrup in mounting into the saddle.
When this chance happens, it will give a crack like a coachman’s whip: above the head where the tendon is broken the depressed cavity may be felt with your fi nger; there is great pain in the part and the party is unable to go. This mischance may be amended by long lying and resting in bed and repelling medicines applied to the part . . . neither must we promise to ourselves or to the patient certain or absolute health. But on the contrary at the beginning of the disease we must foretell that it will never be so cured, and that some relics may remain. . . .
From his description it does not appear to have been a rare event, but the treatment was ineffec- tive. He also wrote,4
For the wounds of that large tendon which is composed in the leg by the concourse of three muscles, and goes to the heel, I have observed that when it has been cut by a Sword, that the wounds have been long and hard to cure, and besides, when at the last they have been healed, as soon as the patient got out of his bed and endeavoured to go, they have grown ill and broke open again. . . .
It has remained a diffi cult wound to treat.
In 1724, Jean Louis Petit (1674–1750), the fore- most surgeon in Paris during the fi rst half of the eighteenth century, reported three cases, one of which was bilateral.5
The story of the tendo Achillis is bound up with both ancient Greek mythology and palaeoanthro- pology.1 The tendo Achillis does not occur in the great apes (Fig. 1.1), our immediate ancestors, and is a hallmark of bipedal man. Its presence may be related to the greater relative length of the tarsal bones in man. The name is derived from the Iliad by the Greek poet, Homer, written between 750 and 650 B.C.
Achilles was a magnifi cent warrior and, accord- ing to myth, made invulnerable in infancy by his mother Thetis, who plunged him into the river Styx, one of the fi ve rivers of the netherworld.
Since he was held by one heel, this part was not bathed in the waters, and so was the one part of him that was unprotected. It was here that Achil- les was mortally wounded by a poisoned arrow launched from the bow of Paris during the Trojan war (Fig. 1.2), which was waged by a confedera- tion of Greeks against the people of Troy to recover Helen, whom Paris had abducted from her lawful husband Menelaus, King of Sparta.
The confusion between Achilles’ heel and Achilles’ tendon, as pointed out by Kirkup2 prob- ably dates from 1693, when the Flemish anatomist Phillippe Verheyen (1648–1710) (Fig. 1.3), Regius Professor of Anatomy and later of Surgery at the University of Louvain, Belgium, fi rst recorded the term tendo Achillis in place of the ancient tendo magnus of Hippocrates, and the chorda Hippocra- tis of later authors.
Ambrose Pare (1510–1590), the famous French war surgeon, described the fi rst closed rupture of the tendo Achillis:3
The History of the Tendo Achillis and Its Rupture
Leslie Klenerman
2 L. Klenerman
Gast.L
Gast.M
FIGURE 1.1. The insertion of the gastrocnemius and soleus into the calcaneum in a gorilla. Note the absence of a tendo Achillis. (By kind permission of Dr Rachel Payne of The Structure and Motion Laboratory, The Royal Veterinary College, Hawkshead Lane, Hatfield, Hertfordshire, UK.)
FIGURE 1.2. The wounded Achilles by the French sculptor Jean- Baptiste Carpeaux, 1850. (By kind permission of Conway Library, Courtauld Institute of Art, London, UK.)
John Hunter (1728–1793) described “Broken Tendo-Achilles” as “case number 355” in his notebooks:
On Thursday morning at four o’clock the 20th of Febru- ary 1766, I broke my Tendo-Achilles. I was jumping and lighting upon my toes without allowing my heels to come to the ground, by which means I supported the
whole weight of my Body, joined with the velocity of it in falling, upon the Gastro-cnemii and Soloei muscles:
these two joined was too much for the tendon, which gave way at once, by which my heel came to the Ground.
The snap (or report) made by breaking of the Tendon was heard all over the room. I stood still without being able to make another spring; and the sensation it gave me was as if something had struck the calf of my leg, and that the noise was the body that had struck me, falling on the fl oor and I looked down to see what it was, but saw nothing. I walked to a Chair, but could not throw myself forwards on the toes on that foot: the Calf of the leg was extremely painful, and was in the state of a Cramp. I endeavoured to take off the Cramp by bending the foot, but found that the motion had no effect upon the muscles of the Calf of the leg, and upon further examination I found that the Tendo-Achilles was broken.
I bound it up at fi rst with the foot extended, and the knee a little bent; with the ends of the Tendon about
1. The History of the Tendo Achillis and Its Rupture 3
In about a fortnight after this last accident, the parts became again more easy, and the swelling abated. I now began to walk again; for this purpose I got an old shoe raised in the heel about an inch, with a strap behind the buckle to a laced bandage round the Calf; but this was principally when I went to bed that I wore it, which was to avoid the consequence that might arise from any involuntary motions in those muscles in my sleep.
Hunter’s request that his injured tendo Achillis be preserved after his death was not complied with, but it was confi rmed at autopsy that there was ossifi cation at the site of rupture. This acci- dent led him, in 1767, to perform an experiment in which he divided the tendo Achillis of several dogs using a couching needle (the type of needle used for lens dislocation in the treatment of cata- racts), to simulate a ruptured tendon. The dogs were killed at different periods to show progress of union.6
During the following centuries, the injury was recorded by a number of authors, although usually in single instances. The fi rst major series was published by Quenu and Stoianovitch in 1929.7 They compared the operative results with those obtained by conservative treatment in two groups, each of 29 cases. This showed the superiority of tendon suture, and was the start of a long con- troversy that still persists today. Harry Platt, who later became president of the Royal College of Surgeons of England and lived to 100 years of age, recorded 11 cases in 1931.8 For fresh ruptures he advocated a stout transfi xion suture of kangaroo tendon inserted well above the line of suture to provide contact between the ends of the tendon.
Additional security was provided by a number of catgut sutures of lesser caliber. Surgeons from the Massachusetts General Hospital wrote up a series of 31 cases treated during the period 1900 to 1954, and found that 25% of patients sought treatment from 2 to 14 months after injury.9 Arner and Lindholm5 noted that the total number of cases up to 1958 was between 300 and 400. The numbers described are small in contrast to modern series due to greater awareness of the injury and more careful examination, particularly the use of Sim- monds’ squeeze test for diagnosis,10 in addition to more frequent occurrence.
One of the earliest descriptions of surgical tenotomy appears in the treatise, “On Surgery,”
by the Greek surgeon Antyllus (second century FIGURE 1.3. Professor Philippe Verheyen. (By kind permission of
the Wellcome Library, London, UK.)
half an inch distant (asunder). This bandage remained for fi ve days, when I got Monro’s bandage. In shifting the bandage I had the opportunity of examining the parts but they were a good deal swelled, so that I could not now tell whether the ends of the tendon were closed together or not. I examined the parts every day, and when the swelling of the infl ammation abated, which was in less than a fortnight, the parts were so smooth that I could not fi nd any inequality: the only swelling that remained was of the oedematous kind, which only swelled at night and was down in the morning. . . .
It continued much the same for about three weeks after the accident, when my Foot slipt upon a Wet fl oor, which made me pitch on the toe of that foot; which gave me great pain at the time, and which continued for a considerable time. Whether the parts were torn asunder or not I could not tell; the infl ammation from this acci- dent was more than the former; was now in a good deal of pain upon the least motion of the parts; and the swelling was more considerable than before.
4 L. Klenerman
A.D.), who performed the procedure subcutane- ously for the treatment of ankylosis of the ankle.1 Frederick Louis Stromeyer (1804–1876), in Hanover, using very fi ne knives, was the fi rst surgeon in more modern times to use sub cutaneous tenotomy for the treatment of clubfoot.11
Both traumatic and overuse injuries of the tendo Achillis have now become relatively com- mon, and it is not infrequent to fi nd surgeons who have operated on several hundreds of such patients in their professional career—and all of this from a mythological Greek warrior!
References
1. Diab M. Lexicon of Orthopaedic Etymology. Singa- pore: Harwood Academic Publishers, 1999.
2. Kirkup J. Chapter 1: Mythology and history. In:
Helal B, Wilson D, eds., The Foot. Edinburgh:
Churchill Livingstone, 1999, p. 2.
3. Pare A. Workes. (Translated by T. Johnstone.) London: 1665, p. 285.
4. The Workes of that Famous Chirurgion Ambrose Parey. (Translated out of Latin and compared with the French by T.H. Johnson.) London: Richard Cotes, 1649.
5. Arner O, Lindholm A. Subcutaneous rupture of the Achilles’ tendon. Acta Chir Scand 1959, Supple- mentum 239, Chapter 1: Brief history, p. 48.
6. Allen E, Turk JL, Murley R, eds. The Case Books of John Hunter FRS. London: Royal Society of Medi- cine Services Limited, 1993.
7. Stoïanovich QJ. Les ruptures du tendon Achille.
Rev de Chirurg 1929; 67:647–678.
8. Platt H. Observations on some tendon ruptures.
Br Med J 1931; 1:611–615.
9. Lawrence GH, Cave EF, O’Connor H. Injury to the Achilles’ tendon. Am J Surg 1955; 89:795–802.
10. Simmonds FA. The diagnosis of the ruptured Achil- les tendon. The Practitioner 1957; 179:56–58.
11. L. Klenerman, ed. The Evolution of Orthopaedic Surgery. Royal Society of Medicine Press, London:
2002, p. 3.
