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Achilles Tendon Disorders: Daniel Penello Foot & Ankle Rounds

The document discusses the anatomy, physiology, biomechanics, and typical presentation of Achilles tendon disorders. It describes the Achilles tendon anatomy including its origin, insertion, blood supply, and paratenon. Common Achilles tendon injuries like ruptures are then reviewed in terms of typical presentation, diagnostic testing, and management considerations for both conservative and surgical treatment approaches. Post-operative protocols are also compared between early immobilization versus early functional rehabilitation strategies.

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Wulan Neen
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37 views29 pages

Achilles Tendon Disorders: Daniel Penello Foot & Ankle Rounds

The document discusses the anatomy, physiology, biomechanics, and typical presentation of Achilles tendon disorders. It describes the Achilles tendon anatomy including its origin, insertion, blood supply, and paratenon. Common Achilles tendon injuries like ruptures are then reviewed in terms of typical presentation, diagnostic testing, and management considerations for both conservative and surgical treatment approaches. Post-operative protocols are also compared between early immobilization versus early functional rehabilitation strategies.

Uploaded by

Wulan Neen
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPT, PDF, TXT or read online on Scribd
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Achilles Tendon Disorders

Daniel Penello
Foot & Ankle Rounds
Anatomy
 Largest tendon in
the body
 Origin from
gastrocnemius and
soleus muscles
 Insertion on
calcaneal
tuberosity
Anatomy

 Lacks a true synovial sheath


 Paratenon has visceral and parietal layers
 Allows for 1.5cm of tendon glide
Anatomy

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

 Blood supply
1) Musculotendinous junction
2) Osseous insertion on calcaneus
3) Multiple mesotenal vessels on anterior
surface of paratenon (in adipose)
– Transverse vincula
 Fewest @ 2 to 6 cm proximal to osseous insertion
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

 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
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
 Antecedent tendinitis/tendinosis in 15%

 75% of sports-related ruptures happen in


patients between 30-40 years of age.

 Most ruptures occur in watershed area


4cm proximal to the calcaneal insertion.
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
 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

 Physical
 Partial
 Localized tenderness +/- nodularity
 Complete
 Defect
 Cannot heel raise

 Positive Thompson test


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

 Ultrasound
 Inexpensive, fast,
reproducable, dynamic
examination possible
 Operator dependent

 Best to measure thickness


and gap
 Good screening test for
complete rupture
Imaging

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

 Restore musculotendinous length and


tension.

 Optimize gastro-soleous strength and


function

 Avoid ankle stiffness


Conservative Management
Cast in Plantarflexion CAM Walker or cast with
2 wks plantarflexion q 2
wks
4 weeks

Start physio for ROM Allow progressive weight-


exercises bearing in removable cast

When WBAT and 2- 4 weeks


foot is plantigrade

Start a strengthening Remove cast and walk with


program shoe lift. Start with 2cm x 1
month, then 1cm x1 month
then D/C
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
 Bunnell Suture

 Modified Kessler

 Many techniques
available
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
Functional Bracing
Post- Op Care
Cast applied in OR Remove sutures, apply a
2 wks walking cast with heel lift

Touch WB 2 weeks

Start physio for ROM Allow progressive weight-


exercises. No active bearing in removable cast
plantarflexion
When WBAT and 2- 4 weeks
foot is plantigrade

Start a strengthening Remove cast and walk with a


program 1cm shoe lift x 1 month then
D/C.
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. 2003 Jun;54(6):1171-80; discussion 1180-1.

50 pts had repair


25 of Achilles rupture 25

Casted in neutral x 6 Immediate active ROM from


weeks. WBAT at 3 weeks PF to neutral. WBAT at 3 wk

Two re-ruptures Better calf strength only


for first 3 months.
One deep infection
One re-rupture
Same satisfaction
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

Casted x 8 wks Surgery +


Early functional rehab in
brace

21 % re-rupture 1.7% re-rupture


5% infection
No difference in
functional outcome 2% Sural nerve inj.
`
Summary of Pooled Outcome Measures
Risk of Re-Rupture
 Surgery =
68% risk
reduction for
re-rupture

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