5 Anatomy Blood supply Musculotendinous junction Osseous insertion on calcaneusMultiple mesotenal vessels on anterior surface of paratenon (in adipose)Transverse vincula2 to 6 cm proximal to osseous insertion
6 Physiology Remarkable response to stress Exercise induces tendon diameter increaseInactivity or immobilization causes rapid atrophyAge-related decreases in cell density, collagen fibril diameter and densityOlder athletes have higher injury susceptibility
7 Biomechanics Gastrocnemius-soleus-Achilles complex Spans 3 jointsFlex kneePlantar flex tibiotalar jointSupinate subtalar jointUp to 10 times body weight through tendon when running
8 Achilles Tendon Rupture PathophysiologyRepetitive microtrauma in a relatively hypovascular area.Reparative process unable to keep upMay 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 HistoryFeels like being kicked in the legCase reports of fluoroquinolone use, steroid injectionsMechanismEccentric 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 ROMCompare tendon width to other sideNote tenderness, crepitation, warmth, swelling, nodularity, palpable defects
14 Achilles Tendon Rupture Diagnostic Pitfalls23% missed by Primary Physician (Inglis & Sculco)Tendon defect can be masked by hematomaPlantar-flexion power of extrinsic foot flexors retainedThompson test can produce a false-negative if accessory ankle flexors also squeezed
15 ImagingUltrasoundInexpensive, fast, reproducable, dynamic examination possibleOperator dependentBest to measure thickness and gapGood 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 functionAvoid ankle stiffness
18 Conservative Management CAM Walker or cast with plantarflexion q 2 wksCast in Plantarflexion2 wks4 weeksAllow progressive weight-bearing in removable castStart physio for ROM exercisesWhen WBAT and foot is plantigrade2- 4 weeksStart a strengthening programRemove 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 nerveDebride and approximate tendon endsUse 2-4 stranded locked suture techniqueMay augment with absorbable sutureClose 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.
24 Post- Op Care Cast applied in OR Remove sutures, apply a walking cast with heel liftCast applied in OR2 wksTouch WB2 weeksAllow progressive weight-bearing in removable castStart physio for ROM exercises. No active plantarflexionWhen WBAT and foot is plantigrade2- 4 weeksStart a strengthening programRemove 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): ; discussion50 pts had repair of Achilles rupture2525Casted in neutral x 6 weeks. WBAT at 3 weeksImmediate active ROM from PF to neutral. WBAT at 3 wkTwo re-rupturesOne deep infectionSame satisfactionBetter 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):863-8112 patientsCasted x 8 wksSurgery +Early functional rehab in brace21 % re-rupture1.7% re-rupture5% infection2% Sural nerve inj.No difference in functional outcome