Achilles tendon for presentation

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CME- on Tendo Achillis Injury

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Achilles tendon for presentation

  1. 1.  Largest tendon in the body Origin from gastrocnemius and soleus muscles Insertion on calcanealtuberosity
  2. 2. Lacks a true synovial sheath- Paratenon has visceral and parietal layers Allows for 1.5cm of tendon glide
  3. 3. Paratenon  Anterior – richly vascularized  The remainder – multiple thin membranes
  4. 4. Blood supply1) Musculotendinous junction2) Osseous insertion on calcaneus3) Multiple mesotenal vessels on anterior surface of paratenon (in adipose) – Transverse vincula  Fewest @ 2 to 6 cm proximal to osseous insertion
  5. 5.  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
  6. 6.  Gastrocnemius-soleus-Achilles complex  Spans 3 joints  Flex knee  Plantar flex tibiotalar joint  Supinatesubtalar joint Up to 10 times body weight through tendon when running
  7. 7. 1. Close injury/rupture2. Open injury/rupture • Acute injury • Neglected injury
  8. 8. 1. Accidental cut injury (bath room injury, road traffic injury)2. Social/political Violence
  9. 9. 1. Diagnosis andassessment of extendof injury.2. Primary care3. Operative treatment
  10. 10.  Pathophysiology  Repetitive microtrauma in a relatively hypovascular area.  Reparative process unable to keep up  May be on the background of a degenerative tendon
  11. 11.  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.
  12. 12. 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)
  13. 13. 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
  14. 14.  Partial Localized tenderness +/- nodularity Complete Defect Cannot heel raise Positive Thompson test
  15. 15.  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
  16. 16. This lateral x-ray of thecalcaneus shows anavulsion fracture at theinsertion of the Achillestendon, with markedseparation of fragments..
  17. 17.  Inexpensive, fast, reproducable, dynamic examination possible Operator dependent Best to measure thickness and gap Good screening test for complete rupture
  18. 18.  Expensive, not dynamic Better at detecting partial ruptures and staging degenerative changes, (monitor healing)
  19. 19.  Restore musculotendinous length and tension. Optimize gastro-soleous strength and function Avoid ankle stiffness
  20. 20. CAM Walker or cast with 2 wks plantarflexion q 2 wks 4 weeksStart physio for ROM Allow progressive weight-exercises bearing in removable cast When WBAT and 2- 4 weeks foot is plantigradeStart a strengthening Remove cast and walk with shoeprogram lift. Start with 2cm x 1 month, then 1cm x1 month then D/C
  21. 21.  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
  22. 22.  Acute case : usually end to end repair is enough Neglected case: Advancement plasy (V-Y) or reconstruction by other tendons
  23. 23.  Assess strength of repair, tension and ROM intra-op. Apply long leg cast with ankle in the least amount of planterflexion(gravityequinus) & knee 60 degree flexion with window at operated site. Stitch removal after 2 wks. Short leg cast after 3 wks with partial equinus correction
  24. 24.  2 weekly plaster change with gradual equinus correction (4-6 episode ). Walking with heel raised shoe & regular physiotherapy. Reverse ankle stop brace up to 6 months.
  25. 25. Acute rupture of tendon Achilles. A prospective randomised study ofcomparison between surgical and non-surgical treatment. Moller M, et al. J Bone Joint Surg Br. 2001 Aug;83(5):863-8 112 patientsCasted x 8 wks Surgery + Early functional rehab in brace21 % re-rupture 1.7% re-rupture 5% infection No difference in functional outcome 2% Sural nerve inj.
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