Achilles Tendon Anatomy. Achilles Tendon Anatomy. Acute Achilles Rupture. Acute Achilles Rupture 8/19/14. Primary plantarflexor

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Amos Butler
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Non-insertional Achilles Tendonopathy Insertional Achilles Tendonopathy Outline Pathophysiology Conservative Therapy Operative

1 Disclosure Conditions of the Achilles Tendon Brian Clowers, M.D. I have no financial relationships that would influence the content of this presentation Oklahoma Sports and Orthopedic Institute September 27, 2014 Achilles Tendon Anatomy Achilles Rupture Non-insertional Achilles Tendonopathy Insertional Achilles Tendonopathy Outline Pathophysiology Conservative Therapy Operative Therapy Achilles Tendon Anatomy Largest tendon in the body Can see loads upwards of 6-7 times normal body weight No true tendon sheath Paratenon layer 1

Achilles Tendon Anatomy Primary plantarflexor of the hindfoot

Vascular supply proximal and distal with avascular zone

plantarflexion maneuver against a fixed object, or rapid

2 Achilles Tendon Anatomy Primary plantarflexor of the hindfoot Secondary invertor of the hindfoot Achilles Tendon Anatomy Vascular supply proximal and distal with avascular zone centrally Biomechanics Usually result of a forced plantarflexion maneuver against a fixed object, or rapid forceful dorsiflexion of the ankle Can also be a direct blunt or sharp injury to the tendon 2

3 Pathophysiology Rupture usually occurs in the zone between the two vascular supplies 2-6 cm proximal to insertion Possibly related to pre-existing degenerative change in the tendon Pre-disposing factors Fluoroquinolone therapy Systemic corticosteroid use Steroid injections locally Systemic inflammatory conditions Clinical Presentation Swelling Ecchymosis Pain Weakness Difficulty walking Somebody hit me with a baseball bat Physical Exam Palpable defect Decreased plantarflexion strength Thompson s testing Resting tension 3

4 Diagnostics Diagnosis can often be made clinically Plain radiographs Ultrasound MRI Non-operative treatment Non-weightbearing in boot with a neutral wedge for 2-4 weeks Advance weightbearing in boot for 2-4 weeks and initiate functional rehabilitation protocol Transition to regular shoe wear with a neutral wedge at 8-10 weeks Return to higher impact activities at 4-6 months Non-operative treatment Advantanges Avoid surgical risks Disadvantages Higher re-rupture rate Potential for lower long term functional ability Operative repair Repair technique depends on location of tear Open suture repair Percutaneous suture repair Suture anchor repair 4

5 s Adjunctive Procedures V-Y lengthening Central turndown Non-insertional Achilles Tendonopathy Degenerative changes within the midsubstance of the Achilles tendon Micro-tears of the bundles of the tendon or separation of the bundles of the tendon Leads to fibrosis and thickening of the tendon Degeneration of the tendon is not painful itself Thickening and inflammatory reaction irritate paratenon Generally occurs in the same watershed area as acute ruptures 5

6 Clinical Presentation Focal thickening of the tendon Decreased dorsiflexion initially due to fibrosis of the tendon Can see late increased dorsiflexion with repeated microtears Tenderness to palpation Diagnostic Imaging Plain radiographs Calcification Ultrasound MRI Cross-sectional anatomy of the tendon Conservative therapy NSAIDs Neutral heel lift Physical therapy Eccentric stretching protocols Modalities Eccentric protocols 6

7 Operative Treatment Debridement and repair FHL tendon transfer Insertional Achilles Tendonopathy Anatomic Considerations Dorsal calcaneal tuberosity Haglund s lesion Retro-calcaneal bursa Kagel s fat pad Insertional tendonopathy tends to have an overuse etiology Occurs more often after the 4 th or 5 th decade 7

8 Clinical Presentation Pain Difficulty with shoewear Prominence Physical Exam Tenderness over the medial and lateral calcaneal tuberosity, bursa or tendon insertion Limited dorsiflexion of the ankle Pain worse with dorsiflexion Diagnostic Imaging Plain radiographs Haglund s lesion Calcification Ultrasound MRI Cross-sectional area of the tendon involved Conservative Therapy NSAIDs Neutral heel lifts Silicone sleeves Physical therapy Eccentric stretching Operative Treatment Debridement of the Achilles Resection of Haglund s lesion and any calcification Re-attachment of the Achilles 8

9 Operative Treatment FHL tendon transfer with Haglund s resection 9

mechanical stresses on the tendon with repetitive loading

Tendinopathy.. How does it happen? mechanical stresses on the tendon with repetitive loading Impingement of the tendon between adjacent structures (bones, ligaments) and impaired blood supply Presentation