1、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,Para
2、tenon Anterior richly vascularized The remainder multiple thin membranes,Anatomy,Blood supply Musculotendinous junction Osseous insertion on calcaneus Multiple mesotenal vessels on anterior surface of paratenon (in adipose) Transverse vincula Fewest 2 to 6 cm proximal to osseous insertion,Physiology
3、,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 S
4、pans 3 joints Flex knee Plantar flex tibiotalar joint Supinate subtalar jointUp to 10 times body weight through tendon when running,Achilles Tendon Rupture,PathophysiologyRepetitive microtrauma in a relatively hypovascular area. Reparative process unable to keep up May be on the background of a dege
5、nerative 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
6、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 bedPalpation of entire length of muscle-tendon un
7、it during active and passive ROMCompare tendon width to other sideNote 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
8、,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, reproducab
9、le, 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
10、and tension.Optimize gastro-soleous strength and function Avoid ankle stiffness,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 1
11、cm 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,Preserve anterior paratenon blood supply Beware of sural nerve Debride and approximate tendon ends Use 2-4 stranded locked suture technique May a
12、ugment with absorbable suture Close paratenon separately,Surgical Management,Bunnell SutureModified KesslerMany 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
13、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 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
14、 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,J Trauma. 2003 Jun;54(6):1171-80; discussion 1180-1.,Kangas J et al.,Early functional treatment vers
15、us 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
16、 for first 3 months. One re-rupture,Two re-ruptures One deep infection Same satisfaction,25,25,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,Risk of Re-Rupture,Surgery = 68% risk reduction for re-rupture,
