management

1. ACHILLES TENDONITIS
AND RUPTURE
SUSHANT S SONARKAR

2. a) Attaches the plantaris/ gastrocnemius and
soleus muscles to the calcaneus.
b) Thickest and strongest tendon in the body.
c) Achilles muscle reflex tests the integrity
of the S1 spinal root.
d) About 15cm (6 inches) long.
ANATOMY

3. BIOMECHANICS
e) The tendon can receive a load stress
3.9 times body weight during walking
and 7.7 times body weight during running.
f) The tendon is surrounded by a connective tissue
sheath (paratenon) rather than a true synovial
sheath.
The midsection is void of vascularity (risk rupture and
surgical complications at its midsection).

4. BLOOD SUPPLY
- SUPPLIED BY TWO ARTERIES - THE POSTERIOR TIBIAL ARTERY
- THE PERONEAL ARTERIES
- 3 VASCULAR TERRITORIES - THE MIDSECTION SUPPLIED BY
THE PERONEAL ARTERY
- PROMIXAL AND DISTAL SECTION
SUPPLIED BY THE POSTERIOR
TIBIAL ARTERY

5.  PATIENT POPULATION
 1. YOUNGER ATHLETE
 2. MORE ELDERLY COMMUNITY AMBULATION
 THERE ARE 3 MECHANISMS OF ACTION :
1. FALL DURING PLANTAR FLEXION
 2. ANKLE HYPER EXTENSION
 3. FEET FIXED ON THE GROUND WITH SUDDEN MUSCULAR
CONTRACTION
 (MOST COMMON RUPTURES ARE SEEN IN PATIENTS WITH H/O FALL, IN WATERSHED
AREA OF RELATIVE HYPOVASCULARITY APPROX 2-6CM, PROXIMIAL TO THE INSERTION OF
TENDON ON POSTERIOR CALCANEOUS)
PATHOLOGY

6. WILL NOT INCLUDE PATHOLOGIES :-
a) Retrocalcanel Bursitis
b) Haglund’s Deformity
c) Impingement Syndrome
d) ‘Pump Bump’
e) Ankle O/A
f ) DVT

7. A) Overuse - Too Long/ Too Fast/ Too Steep/ Too Explosive
B) Misalignment - Gait (Excessive Pronation)
C) Improper Footwear - Saddle Too Low/ Extra
Dorsiflexion
D) Cortisone- Indirectly weakens Achilles
E) Accidents - Laceration/ Crush
F) Genetics - Individuals With The Single Nuclear
Polymorphism
G) Systemic Conditions - Gout/ RA/ SLE/ Cushing’s Syndrome
EPIDEMIOLOGY AND CAUSES

8. A) ACHILLES TENDONITIS
- Gradual onset pain/stiffness
- improves with heat and exercise ‘able to run off
symptoms’
- May with strenuous activity get worse or
experience calf pain
- Tenderness of the tendon on palpation
- Swelling
- Pain on active movement of the ankle joint
PATIENTS PRESENTATION

9. b) ACHILLES RUPTURE
- Rupture can occur at any age but most common
30 - 50 year old
- Acute onset of pain in tendon
- Swelling
- Sudden ‘sharp pain’
- Snap ‘heard’
- Inability to stand on tiptoe
- Altered gait ‘inability to push off’

10. - Observe gait
- Look for swelling/bruising
- May have a palpable GAP
- Active plantar flexion is weak or absent
- ‘Thompson’s test’ ‘calf squeeze test’
- Fusiform swelling with pain to palpation
-Rule out: Gout/RA/SLE/cushings’ syndrome/DVT/
ruptured/ bakers’s cyst/ OA ankle.
- Through examination of ankle/knee/calf
EXAMINATION

11. INVESTIGATIONS
-ULTRASOUND
-MRI
-X-RAYS (FOR CALCANEAL FRACTURE INVOLVEMENT)

12. ACHILLES TENDONITIS
Insufficient evidence from randomised controlled
trials to determine which method of treatment is the
most appropriate.
MANAGEMENT

13. a) Abstain from aggravating activities
b) Use NSAID (inflammation v degenerate)
c) Physiotherapy + relative rest (alternative exercise)
- ‘Stretching/strengthening’
Hip/back muscles tight
Calf muscles tight
Strengthening anterior tibialis
- Massage
- Eccentric exercises
- Orthotics (gait) / review footwear

14. D) Physical therapy - US/electric stimulation/laser
photo stimulation
E) Other treatments
- Heparin
- Steriod injections
- Glycosamino glycan sulfate
- GTN patches
- Electronic wave shock treatment
- Extra corporeal shockwave therapy
- Blood letting/blood injections
- Needling
- Casting

15. f) Surgery
(Patients frequent questions)
- ? after six months
- ? plantaris wrap around
- ? foot in equinus in plaster 6 weeks,
then plaster positions and duration.
- ? degenerative vs. inflammatory

16. MANAGEMENT
SURGICAL VS CONSERVATIVE
1. Best surgical approach
(linear midline incision over prone position)
Open end to end repair with either krackow , bunnell or kessler
technique
2. Best non-surgical approach
(Plaster or fibre glass immobilization for 04weeks, followed by
exchange casting to neutral position )

17. Surgical treatment of Acute Achilles
Rupture significantly reduces the risk
of re-rupture compared with non-
surgical treatment,
but produces significantly higher
risks of other complications such as
infection, adhesions and disturbed
skin sensibility/ breakdown.

18. PROGNOSIS
ACHILLES TENDONITIS
a) No consensus on best treatment
b) Recovery can take weeks or months
c) Surgery is possible

19. PROGNOSIS
ACHILLES RUPTURE
a) No consensus on best treatment
b) Surgical treatment has decreased risk of re-rupture
c) May take 1 year to fully recover
d) May be left with slight loss of function
e) Usually good prognosis however

20.  NAME - HAV C K HAZARA
 AGE - 42 M
 UNIT - 1809 PIONEER UNIT ( INDIAN ARMY)
 SERVICE NO - 8035383-H
 DIAGNOSIS - CALCANEAL TUBEROSITY AVULSION
FRACTURE WITH RUPTURED ACHILLES TENDON RIGHT
ANKLE
 MODE OF INJURY – ANKLE TWISTING INJURY WHILE
PLAYING VOLLEYBALL
 PT IS ALCOHOLIC AND SMOKER
CASE PRESENTATION

21.  CHIEF COMPLAINTS - INABILITY TO STAND AND WALK
ON HIS OWN.
 SEVERE PAIN IN RT ANKLE AND FOOT
 CLINICAL EXAMINATION FINDINGS -
 DISCONTINUATION CAN BE FELT ON PALPATION
 SWELLING +, TENDERNESS +
 EXTERNAL DEFORMITY+
 THOMPSONS TEST +
 ROM –PAINFULL
 NO DNVD
CLINICAL FINDINGS

22. PRE OPERATIVE INVESTIGATIONS

23.  CLASSIFICATION ACCORDING TO THE FRACTURE PATTERN:
 BY LEE & BEAVIS ET AL
 1. SIMPLE EXTRA ARTICULAR AVULSION
 2. BEAK FRACTURE
 3. INFRA BURSAL AVULSIONFROM MIDDLE THIRD OF
POSTERIOR TUBEROSITY OF CALCANEOUS.
 4. SMALL TRIANGULAR FRAGMENT IS SEPARETED FROM
UPPER BORDER OF TUBEROSITY.
CALCANEAL TUBEROSITY AVULSION FRACTURE

24.  Avulsion fracture of calcaneal tuberosity are usually caused by
sudden muscular contractions of Achilles tendon when heel is
flat on ground .
 REASONS:
 1) BROAD BASED INSERTION
 2) BRAIDED AND COILED ANATOMICAL PATTERN WITH
90DEGREE ROTATED COLLAGEN FIBRES.
 3) VARIABLE AND SUDDEN DISTRIBUTION OF FORCE ON EACH
AVULSION

25.  THE AVULSION PATTERNS OF THE CALCANEAL TUBEROSITY
FRACTURES ARE THE RESULT OF SEVERAL FACTORS
 1. BONE DENSITY LEVEL
 2. MECHANISM OF INJURY AND FIBRE OF ACHILLES
TENDON THAT TRANSMITS THE FORCE
 3. TYPE 3 & 4 FRACTURE ARE DEMARKATED ON MRI AND
PLANNED FOR SURGICAL FIXATION ACCORDINGLY.

26. 3D CT RECONSTRUCTION

27. MRI STUDY

28. INTRA OP IMAGES

29. SURGEON : GP CAPT SANJEEV KAPOOR
SQN LDR SUSHANT SONARKAR

32. POST OP XRAY
(pop cast applied in gravity equinus)

33. • 1. By 04 weeks the mechanical strength of the repair increases
as there is consolidated and remodeling of the maturing
granulation tissue under tension and collagen synthesis
changes.
 2. Various other factors influence the rate and strength of
tendon healing like tension across repair which speeds
realignment of collagen fibers.
 3. Goal of treatment is to shorten immobilization and
indirectly produces a better functional end result.
POST SURGERY THINGS TO REMEMBER

34. THANK U, HAVE A GREAT DAY AHEAD
July 2013