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 Largest   tendon in the  body Origin from  gastrocnemius and  soleus muscles Insertion on  calcanealtuberosity
Lacks a true synovial    sheath- Paratenon has visceral  and parietal layers Allows for 1.5cm of  tendon glide
Paratenon   Anterior – richly vascularized   The remainder – multiple thin    membranes
Blood supply1)   Musculotendinous junction2)   Osseous insertion on calcaneus3)   Multiple mesotenal vessels on     anteri...
   Remarkable response to stress     Exercise induces tendon diameter      increase     Inactivity or immobilization ca...
   Gastrocnemius-soleus-Achilles    complex       Spans 3 joints         Flex knee         Plantar flex tibiotalar joi...
1.   Close injury/rupture2.   Open injury/rupture     • Acute injury     • Neglected injury
1.   Accidental cut injury     (bath room injury, road     traffic injury)2.   Social/political     Violence
1. Diagnosis andassessment of extendof injury.2. Primary care3. Operative treatment
      Pathophysiology     Repetitive microtrauma      in a relatively      hypovascular area.     Reparative process   ...
 Antecedent tendinitis/tendinosis in 15% 75% of sports-related ruptures happen  in patients between 30-40 years of  age....
History Feels like being kicked in the leg Case reports of fluoroquinolone use,  steroid injections Mechanism    Eccen...
Prone   patient with feet over edge of bedPalpation of entire length of muscle- tendon unit during active and passive RO...
 Partial  Localized tenderness +/-   nodularity Complete  Defect  Cannot heel raise  Positive Thompson test
 Diagnostic Pitfalls 23% missed by Primary Physician  (Inglis&Sculco)     Tendon defect can be masked by hematoma     ...
This lateral x-ray of thecalcaneus shows anavulsion fracture at theinsertion of the Achillestendon, with markedseparation ...
 Inexpensive, fast, reproducable,  dynamic examination possible Operator dependent Best to measure thickness and gap G...
   Expensive, not dynamic   Better at detecting partial    ruptures and staging    degenerative changes,    (monitor hea...
 Restore  musculotendinous length  and tension. Optimize gastro-soleous  strength and function Avoid ankle stiffness
CAM Walker or cast with                        2 wks      plantarflexion q 2 wks                                          ...
 Preserve anterior paratenon blood  supply Beware of sural nerve Debride and approximate tendon ends Use 2-4 stranded ...
 Acute  case : usually end  to end repair is enough Neglected case:  Advancement plasy (V-Y)  or reconstruction by  othe...
 Assess strength of repair, tension and  ROM intra-op. Apply long leg cast with ankle in the least  amount of planterfle...
 2 weekly plaster change with  gradual equinus correction (4-6  episode ). Walking with heel raised shoe &  regular phys...
Acute rupture of tendon Achilles. A prospective randomised           study ofcomparison between surgical and non-surgical ...
Achilles tendon for presentation
Achilles tendon for presentation
Achilles tendon for presentation
Achilles tendon for presentation
Achilles tendon for presentation
Achilles tendon for presentation
Achilles tendon for presentation
Achilles tendon for presentation
Achilles tendon for presentation
Achilles tendon for presentation
Achilles tendon for presentation
Achilles tendon for presentation
Achilles tendon for presentation
Achilles tendon for presentation
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Achilles tendon for presentation

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CME- on Tendo Achillis Injury

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Transcript of "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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