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