how a. t. rupture and how to manage

3. • Largest tendon in the
body
• Origin from
gastrocnemius and
soleus muscles
• Insertion on calcaneal
tuberosity

4. • ORIGIN OF GASTROCNEMIUS----
FROM LATERAL AND MEDIAL CONDYLE
OF FEMUR
ORIGIN OF SOLEUS----- FROM UPPER
HALF OF TIBIA,FIBULA AND
INTEROSSIOUS MEMBRANE

5. • GASTROCNEMEUS FIBRES LYING
LATERALLY
• AND SOLEUS FIBRES MEDIAL SIDE
• INSERTION—CALCANEAL
TUBEROCITY

6. Lacks a true
synovial sheath-
• Paratenon has
visceral and
parietal layers
• Allows for 1.5cm of
tendon glide

7. • COLLAGEN FIBRILS
•
• PRIMARY FIBRIL BUNDLE
•
• SECENDARY FIBRIL BUNDLE
• ENDOTENDENINEUM

8. EPITENDENIUM(EPITENONE)
PARATENDENIUM(PARATENONE)

9. • Composite material consisting of collagen fibril
embedded in matrix of proteoglycans
• ----------TYPE 1 COLLAGEN- 95%
• ----------TYPE III AND TYPE IV COLLAGEN5%
• Tenocytes are arranged in parallel rows in between
bundles

10. Paratenon
• Anterior – richly
vascularized
• The remainder – multiple
thin membranes

11. • MESOTENONE-- VASCULAR AREA OF
PARA TENONE

12. 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

13. AVASCULARISED AREA OF TENDON
2 TO 6 cm proximal to its insertion
most common site
for rupture

14. • 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

15. • 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

16. 1. Close injury/rupture
2. Open injury/rupture
• Acute
•Chronic
• Neglected injury

17. 1. Accidental cut injury
(bath room injury, road
traffic injury)
2. Social/political Violence

18. 1. Diagnosis and assessment
of extend
of injury.
2. Primary care
3. Operative treatment

19. • Pathophysiology
• Repetitive microtrauma
in a relatively
hypovascular area.
• Reparative process
unable to keep up
• May be on the
background of a
degenerative tendon

20. • 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
2cm to 6cm proximal to the calcaneal
insertion.

21. • Achilles tendenosis
may be—
(1) insertional
(2) noninsertional

22. • INSERTIONAL;
• MAY be with one or more conditions
• (1) Haglund DEFORMITY
• --a large exostosis may be
present off the posterosuperior surface of
calcaneal tuberosity.(=PUMP BUMP)
• (2) RETEROCALCANEAL
BURSITIS.
• INFLAMATION N
DEGENERATION OF TENDON
•

23. • CHRONICALLY OSTEOPHYTES
FORMATION in substance of tendon
• severity
• ENLARGED THICKENING AND
BOGGINESS OF TENDON

24. • C/F
• PAIN AFTER A PERIOD OF REST
(IN Morning)
tenderness more centralized over
insertion of tendon
O/E
SEVERE CONTRACTURE of
gastrocnemius complex especially with knee
extention

25. • X ray
• calcified spur present over
posterosup. Surface of calcanium
• increased thickness of tendon area

26. CALCANIUM SPUR IN
HAGLUND DEFORMITY

28. • CONSEVATIVE MANAGEMENT
• ANTI INFLAMMATORY DRUGS
• COMPRESSIVE STRETCHING
EXERCISE FOR CALF MUSCLE
• SURGERY
• debridement of tendon with bursitis.
• (50% of tendon could be
resected safely) with
preventing tear
•

30. 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)

31. TEXT BOOK FACTS
• Middle aged atheletes
• ( *30 to 40 yrs of age)
• One of the Most common tendon rupture
• Have nearly 200 fold increasd risk of
contralateral tendon rupture
• Most ruptures occur in watershed area
2cm to 6cm proximal to the calcaneal
insertion.
• Antecedent tendinitis/tendinosis in 15%
• 75% of sports-related ruptures happen
in patients between 30-40 years of age.

33. •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

34. • Partial
• Localized tenderness
+/- nodularity
• Complete
• Defect
• Cannot heel raise
• Positive Thompson test

38. • MATLES TEST—
• PT. WITH supine position and
extended leg. Pt asked to fold his knee
joint actively.
• result– there is planter flexion occur
first before flexion of knee normally.
• ******but this is not happen with
rupture tendon..

39. • O’ brien’s niddle test---
• 25 gauge niddle is inserted at right
angle through skin of calf muscles just
medial to midline at point 10cm proximal to
• superior border of calcaneus.
• Normally motion of the hub of niddle in a
direction opposite that of the tendon during
passive dorsiflexion and planter flexion of
the foot confirm the intact tendon.

41. • MISSED DIAGNOSIS
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

42. • SOMETIMES PSTEROSUP. PART OF
CALCANIUM AVULSED WITH TENDON
• TREATMENT----
• EITHER FIX THE BONY FRAGMENT
• IF LARGE IN SIZE AND WITH
INTACT TENDON INSERTION
• OR REMOVE THE BONY PART N
FIX THE TENDON WITH CALCANEUS

43. This lateral x-ray
of the calcaneus
shows an
avulsion fracture
at the insertion of
the Achilles
tendon, with
marked
separation of
fragments.
.

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

45. • Expensive, not dynamic
• Better at detecting partial
ruptures and staging
degenerative changes,
(monitor healing)

46. • Restore musculotendinous length and
tension.
• Optimize gastro-soleous strength and
function
• Avoid ankle stiffness

47. CAM Walker or cast with
plantarflexion q 2 wks2 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

48. • 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

50. • Acute case : usually end
to end repair is enough
• Neglected case:
Advancement plasy (V-Y)
or reconstruction by
other tendons

54. • Assess strength of repair, tension and
ROM intra-op.
• Apply long leg cast with ankle in the least
amount of planterflexion(gravity equinus)
& knee 60 degree flexion with window at
operated site.
• Stitch removal after 2 wks.
• Short leg cast after 3 wks with partial
equinus correction

55. • 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.

56. 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 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