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Achilles Tendon Disorders

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Presentation on theme: "Achilles Tendon Disorders"— Presentation transcript:

1 Achilles Tendon Disorders
Daniel Penello Foot & Ankle Rounds

2 Anatomy Largest tendon in the body
Origin from gastrocnemius and soleus muscles Insertion on calcaneal tuberosity

3 Anatomy Lacks a true synovial sheath
Paratenon has visceral and parietal layers Allows for 1.5cm of tendon glide

4 Anatomy Paratenon Anterior – richly vascularized
The remainder – multiple thin membranes

5 Anatomy Blood supply Musculotendinous junction
Osseous insertion on calcaneus Multiple mesotenal vessels on anterior surface of paratenon (in adipose) Transverse vincula 2 to 6 cm proximal to osseous insertion

6 Physiology Remarkable response to stress
Exercise induces tendon diameter increase Inactivity or immobilization causes rapid atrophy Age-related decreases in cell density, collagen fibril diameter and density Older athletes have higher injury susceptibility

7 Biomechanics Gastrocnemius-soleus-Achilles complex
Spans 3 joints Flex knee Plantar flex tibiotalar joint Supinate subtalar joint Up to 10 times body weight through tendon when running

8 Achilles Tendon Rupture
Pathophysiology Repetitive microtrauma in a relatively hypovascular area. Reparative process unable to keep up May be on the background of a degenerative tendon

9 Achilles Tendon Rupture: Textbook Facts
Antecedent tendinitis/tendinosis in 15% 75% of sports-related ruptures happen in patients between years of age. Most ruptures occur in watershed area 4cm proximal to the calcaneal insertion.


11 Achilles Tendon Rupture
History Feels like being kicked in the leg Case reports of fluoroquinolone use, steroid injections Mechanism Eccentric loading (running backwards in tennis) Sudden unexpected dorsiflexion of ankle (Direct blow or laceration)

12 Physical Exam Prone patient with feet over edge of bed
Palpation of entire length of muscle-tendon unit during active and passive ROM Compare tendon width to other side Note tenderness, crepitation, warmth, swelling, nodularity, palpable defects

13 Achilles Tendon Rupture
Physical Partial Localized tenderness +/- nodularity Complete Defect Cannot heel raise Positive Thompson test

14 Achilles Tendon Rupture
Diagnostic Pitfalls 23% missed by Primary Physician (Inglis & Sculco) Tendon defect can be masked by hematoma Plantar-flexion power of extrinsic foot flexors retained Thompson test can produce a false-negative if accessory ankle flexors also squeezed

15 Imaging Ultrasound Inexpensive, fast, reproducable, dynamic examination possible Operator dependent Best to measure thickness and gap Good screening test for complete rupture

16 Imaging MRI Expensive, not dynamic
Better at detecting partial ruptures and staging degenerative changes, (monitor healing)

17 Management Goals Restore musculotendinous length and tension.
Optimize gastro-soleous strength and function Avoid ankle stiffness

18 Conservative Management
CAM Walker or cast with plantarflexion q 2 wks Cast in Plantarflexion 2 wks 4 weeks Allow progressive weight-bearing in removable cast Start physio for ROM exercises When WBAT and foot is plantigrade 2- 4 weeks Start a strengthening program Remove cast and walk with shoe lift. Start with 2cm x 1 month, then 1cm x1 month then D/C

19 Surgical Management Preserve anterior paratenon blood supply
Beware of sural nerve Debride and approximate tendon ends Use 2-4 stranded locked suture technique May augment with absorbable suture Close paratenon separately

20 Surgical Management Bunnell Suture Modified Kessler
Many techniques available

21 Surgical Management : Post– op Care
Assess strength of repair, tension and ROM intra-op. Apply cast with ankle in the least amount of plantarflexion that can be safely attained. Patient returns to fracture clinic 2 weeks post-op.

22 Variations in Post-op Protocols

23 Functional Bracing

24 Post- Op Care Cast applied in OR
Remove sutures, apply a walking cast with heel lift Cast applied in OR 2 wks Touch WB 2 weeks Allow progressive weight-bearing in removable cast Start physio for ROM exercises. No active plantarflexion When WBAT and foot is plantigrade 2- 4 weeks Start a strengthening program Remove cast and walk with a 1cm shoe lift x 1 month then D/C.

25 Surgical Management: Post-op Care
Early functional treatment versus early immobilization in tension of the musculotendinous unit after Achilles rupture repair: a prospective, randomized, clinical study. Kangas J et al. J Trauma Jun;54(6): ; discussion 50 pts had repair of Achilles rupture 25 25 Casted in neutral x 6 weeks. WBAT at 3 weeks Immediate active ROM from PF to neutral. WBAT at 3 wk Two re-ruptures One deep infection Same satisfaction Better calf strength only for first 3 months. One re-rupture

26 Conservative vs Surgical
Acute rupture of tendon Achillis. A prospective randomised study of comparison between surgical and non-surgical treatment. Moller M, et al. J Bone Joint Surg Br Aug;83(5):863-8 112 patients Casted x 8 wks Surgery + Early functional rehab in brace 21 % re-rupture 1.7% re-rupture 5% infection 2% Sural nerve inj. No difference in functional outcome


28 Summary of Pooled Outcome Measures

29 Risk of Re-Rupture Surgery = 68% risk reduction for re-rupture

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