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ORIGINAL RESEARCH
ASE REPOR
C

The Achilles Tendon Vascular Flow is Achilles’ True

Weakness

Michael Hust MD ; Caroline Fife MD ; Oscar R. Rosales MD 3
1
2
1 University of Texas-McGovern School of Medicine, Houston
2 St. Luke’s Hospital, Woodlands, Texas
3 Memorial Hermann Heart and Vascular Institute; University of Texas-McGovern School of Medicine, Houston

Abstract: The Achilles tendon is the strongest and thickest tendon in the human body. Its vascular supply is shared by
the posterior tibialis and peroneal arteries. This case report illustrates how frozen biopsies of a benign lesion located on
the tendinous segment of the Achilles tendon led to a deep non-healing ulceration with exposure of the mid tendon. This
case report intends to review the Achilles tendon different sources of blood flow to its three portions: proximal musculo-
tendinous junction; middle tendinous segment; and the distal osteotendinous junction to the calcaneum. The mid-portion
of the tendon is the one least vascularized and more prone to non-healing arterial ulcerations.

VASCULAR DISEASE MANAGEMENT 2020;17(6):E117-E120.
Key words: Peripheral arterial disease, Achille’s tendon, vascular ulceration

Case Report Discussion
We present an 82-year-old woman with a history of hyperten- The Achilles tendon is the thickest and strongest tendon in the
sion who presented as a referral to our center for a non-healing human body. It is composed of the adjoining terminal ends of the
ulcer of the left Achilles area. Two months prior to the onset of gastrocnemius, soleus, and the plantaris muscles. The tendon is
1
the wound, the patient underwent two separate dermatological unique in its anatomical arterial flow, drawing from distinct vas-
frozen biopsies proximal to the lesion and of the lesion itself. cular beds for its vascular supply. The proximal musculotendinous
Initial evaluations found the patient to have chronic venous stasis junction and the distal osteotendinous junction of the tendon draw
and treatment with compression stockings and dressings were their arterial blood supply from branches of the posterior tibialis
attempted without resolution. She underwent further treatment artery, whereas the middle tendinous portion of the Achilles is
of the lesion with antibiotics; however, with no improvement. supplied by the fibular/peroneal artery. The mid-portion of the
The patient was referred to our center after the wound pro- tendon has been reported to have relatively poor vascularization
2,3
gressed to exposure of the tendinous segment of the Achilles (Figure 4). The distal branches of the peroneal artery, which
tendon (Figure 1). Ulcer etiology was hypothesized to be due provide blood flow to the mid tendon, are of smaller diameter
to the disruption of the arterial bed to the tendon by the der- than the posterior tibialis artery trunk which supplies the arterial
matologic frozen biopsies. Arterial Doppler ultrasound depicted flow to the proximal and distal portions of the tendon.
normal triphasic flow in the femoropopliteal artery and in all Wound healing is the interplay between vascular supply and
three tibial vessels. To further evaluate arterial flow to the ulcer, delivery of building blocks for hemostasis, inflammation, pro-
we advised an arteriogram of the left lower extremity with run- liferation, and wound remodeling/repair. This interplay is
4,5
off to the foot. Digital subtraction arteriogram of the left lower especially delicate if the wound has multiple vascular beds sup-
extremity was remarkable for practical absence of vascularity to pling vital factors for healing. Uniquely, in our case report, the
the ulceration site despite patent popliteal, posterior tibialis, pe- patient’s dermatological freezing served as the noxious insult for
roneal, and anterior tibialis arteries (Figure 2). local microvascular injury. Peroneal artery microvascular network
The patient has undergone intensive wound therapy including injury led to severe hypoxemia of the tendinous portion of the
OxyBand (OxyBand™ Technologies) dressing and various levels Achilles and the development of a deep ulceration which healed
of immobilization of the Achilles tendon and of left ankle range after several months of intensive wound care.
of motion for several months. This strategy has led to substantial
success in wound healing (Figure 3).

Vascular Disease Management Volume 17, No. 6, June 2020 E117
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