Achilles Tendon usman

Achilles Tendon Disorders : 

Achilles Tendon Disorders Dr. M. USMAN SARWAR

HISTORY: 

HISTORY Achilles, the warrior and hero Thetis Achilles' mother made him invulnerable to physical harm by immersing him in river Styx, After prophecy that he will die in battle. However heel remained untouched Won the war of Troy by killing Price Hector Paris killed Achilles by firing poisonous arrow in to his heel.

Anatomy: 

Anatomy Largest, thickest and strongest 1 tendon in the body Origin from gastrocnemius and soleus muscles Insertion on calcaneal tuberosity 1-O’Brien,M;functional anatomy and physiology of tendon.Clin.Sports Med.,11:505-520,1992

Anatomy: 

Anatomy Lacks a true synovial sheath Paratenon has visceral and parietal layers Able to stretch about 1.5-2.0 cm Allowing tendon to glide smoothly

Anatomy: 

Anatomy 95% type-I collagen Small amount of elastin 90 0 spiral configuration

Anatomy: 

Anatomy Blood supply Musculotendinous junction Osseous insertion on calcaneus Surrounding connective tissue midportion 3-4 cm proximal to insertion relatively avascular, prone to various pathological problems like tendinitis and rupture .

Physiology: 

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

Biomechanics: 

Biomechanics Gastrocnemius-soleus-Achilles complex Spans 3 joints Flex knee Plantar flex tibiotalar joint Supinate subtalar joint Force up to 6-8 times body weight through tendon when running

Achilles Tendinitis: 

Achilles Tendinitis Commonly occurs in individuals ,who are active ,subject the tendon to repetitive forces beyond its ability to heal. Recent change in duration,intensity,frequency of activity Variation in running surface or type of shoe

Achilles Tendinitis: 

Achilles Tendinitis Classification Insertional Tendinitis -older, less active/athlete ,obese Noninssertional Tendinitis -In more active athletes.

NonInsertional Achilles Tendinitis : 

NonInsertional Achilles Tendinitis Histopathological classification developed by Puddu et al. 1 Paratenonitis : inflammation of lining of tendon only Tendinosis : inflammation of paratenon and atrophic intratendinous degeneration due to aging,microtrauma,dec . in blood supply More common in hypovascular zone Puddu,G;Ippotlito; A classification of achilles tendon disease. Am.J.Sports Med.,4:145-150,1976

NonInsertional Achilles Tendinitis: 

NonInsertional Achilles Tendinitis

PowerPoint Presentation: 

Paratenonitis with tendinosis

PowerPoint Presentation: 

Chronic Tendinosis -marked weakness -decrease in push off strength -pain and thickening in tendon -increase in passive range of dorsiflexion

Treatment Options: 

Treatment Options Conservative Modification in activity level,shoewear Rest ,ice ,elevation , compression,NSAIDS Heel lift 1.5 cm Stretching exercise Sever /non respondent case Ultrasound and TENS Walking boat for 6 weeks Corticosteroids inj. is contraindicated. Cross training with cycling and swimming is helpful. Saline inj.

Surgical treatment: 

Surgical treatment If the inflammation persists for more than 6 months operative treatment may be indicated.

Surgical treatment: 

Surgical treatment Removal of paratenon Maffulli et al , percuatenous tenotimies (Mafuuli,Testa,Bifulco: results of percutaneous longitudinal tenotomy for achilles tendinopathy in middle and long distance runner.Am.J.Sports Med.,25:835-840,1997)

Chronic Tendinosis: 

Chronic Tendinosis Excision of paratenon and removal of degenerative necrotic tissue If minimal debridement ,multiple 5mm fish mouth incision made in tendon Extensive debridement defect must be augmented with additional tissue FHL Strength + blood supply

After treatment: 

After treatment Non weight bearing 10 days Allowed to walk with walker boot Early range of motion exercise Results of paratendinitis have been better than treatment of Tendinosis,Perhaps b/c of ischemia and degeneration of tendon in tendinosis

Insertional Achilles Tendinitis: 

Insertional Achilles Tendinitis Symptoms quite Sp. At bone tendon junction frequently worse after exercise and become ultimately constant Fairly common in athletes. Differential Diagnosis seronegative spondlyoarthopathies,Gout,Sytemic Steroids,Fluoroquilones,dyslipidemia,sarcoidosis ,Diffuse idiopathic skeletal hyperostosis

Insertional Achilles Tendinitis: 

Insertional Achilles Tendinitis Pain in heel cardinal symptom ,increased with prolong walking,standing,running uphill or on hard surface. Diagnosis clinical Radiograph : ossification in most proximal extent of the insertion or spur off the sup. Portion of calcaneus

Insertional Achilles Tendinitis: 

Insertional Achilles Tendinitis

Insertional Achilles Tendinitis: 

Insertional Achilles Tendinitis Treatment Conservative, Rest,ice,heel lift,NSAIDS,stretching and strengthening exercise. Back open shoe or heel lift of half inch Below knee weight bearing cast or walker boot 6 weeks. Cross training with swimming, bicycyling,aqua should be cont.

Surgical option: 

Surgical option Numerous approaches, medial ,lateral or post splitting incisions Skin should be free of any abonormalities,should have potential of healing , no scar that can cause hypertrophied scar. Common to all , resection of inflamed retrocalcaneal bursa with prominent post lateral bone, debridement of calcific diseased insertion.

Insertional Achilles Tendinitis: 

Insertional Achilles Tendinitis Post edge of bone must be smoothed so that no potential source of irritation. After treatment: Non Wt.bearing till complete wound healing Full wt.bearing 3 rd week while wearing below knee cast or removable walker boot in slight equinus Recovery slow may take 12 months.

Haglund Deformity: 

Haglund Deformity Haglund deformity occurs when the bursal projection is compressed by a poorly fitting heel-counter, leading to subcutaneous irritation and bursitis of the adventitial bursa

Achilles Tendon Rupture: 

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

Achilles Tendon Rupture: Textbook Facts: 

Achilles Tendon Rupture: Textbook Facts Tendinitis/tendinosis in 15% 75% of sports-related ruptures happen in patients between 30-40 years of age. Most ruptures occur in area 4cm proximal to the calcaneal insertion.

Achilles Tendon Rupture: 

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)

Physical Exam: 

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

Achilles Tendon Rupture: 

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

Achilles Tendon Rupture: 

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

Imaging: 

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

Imaging: 

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

Management Goals: 

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

Conservative Management: 

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

Surgical Management: 

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

Surgical Management: 

Surgical Management Bunnell Suture Modified Kessler Many techniques available

Surgical Management : Post– op Care: 

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.

Variations in Post-op Protocols: 

Variations in Post-op Protocols

Functional Bracing: 

Functional Bracing

Post- Op Care: 

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

Surgical Management: Post-op Care: 

Surgical Management: Post-op Care J Trauma. 2003 Jun;54(6):1171-80; discussion 1180-1. Kangas J et al. Early functional treatment versus early immobilization in tension of the musculotendinous unit after Achilles rupture repair: a prospective, randomized, clinical study. 50 pts had repair of Achilles rupture Casted in neutral x 6 weeks. WBAT at 3 weeks Immediate active ROM from PF to neutral. WBAT at 3 wk Better calf strength only for first 3 months. One re-rupture Two re-ruptures One deep infection Same satisfaction 25 25

Conservative vs Surgical: 

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. 2001 Aug;83(5):863-8 112 patients Surgery + Early functional rehab in brace Casted x 8 wks 21 % re-rupture 1.7% re-rupture 5% infection 2% Sural nerve inj. No difference in functional outcome

Summary of Pooled Outcome Measures: 

Summary of Pooled Outcome Measures

Risk of Re-Rupture: 

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

Thank You !: 

Thank You !