Disorders of the Achilles Tendon Jamal Ahmad, M.D. Orthopaedic Foot & Ankle Surgery March 2018
Disclosure Statement American Academy of Orthopaedic Surgeons (AAOS) Committee member American Orthopaedic Foot & Ankle Society (AOFAS) Committee member
Anatomy of the Achilles Tendon Strongest, largest tendon Originates from distal gastrocnemius-soleus muscle Inserts at postero-superior calcaneal tuberosity 2 cm x 2 cm Pekala P et al.: Bone Joint Res 2017; 6: 446-451.
Plantarflexion Function Gastrocnemius flexes the ankle with the knee extended Soleus flexes the ankle with the knee flexed Eccentric lengthening Concentric contracture Freedman B et al. Muscles Ligaments Tendons J 2014; 4: 245-255.
Distally from calcaneus Proximally from gastrocnemius-soleus muscle Peritenon Blood Supply At 2-6 cm from insertion Twists 90 o on itself Watershed zone of decreased vascularity Most common site of rupture (75%) Matusz P. Clin Anat 2010; 23: 243-244.
Tendinopathy Rupture
Achilles Tendinopathy Peritendinitis Tendinitis Tendinosis
Staging Stage 1 = Peritendinitis Inflamed peritenon & bursae Tendon is normal Reversible Stage 2 = Tendinitis With tendon inflammation & thickening Reversible Stage 3 = Tendinosis Mucoid degeneration + calcific changes No inflammatory response & irreversible Puddu G et al. Am J Sports Med 1976; 4: 145-150.
Classification Duration Acute = Less than 2 weeks Subacute = 2-6 weeks Chronic = 6 weeks + Location Insertional Midsubstance
Extrinsic factors Surface conditions Shoe wear Over-activity» Work vs. exercise Intrinsic factors Age Medical conditions» Obesity & hypertension Medications» Steroids Epidemiology Holmes G et al. Foot Ankle Int 2006; 27: 952-959.
Symptoms Activity-related pain History & Physical Exam Location of tenderness Swelling or protuberance» Haglund s deformity at the postero superior calcaneus? Strength Thompson test Saini S et al. J AM Osteopath Assoc 2015; 115: 670-676.
1 st line of imaging Radiographs Weightbearing anteroposterior (AP) & lateral of ankle Screen for Calcification within the tendon Haglund s deformity Measure Phillip-Fowler s angle Kang S et al. Foot Ankle Int 2012; 33: 487-491.
Further Imaging MRI Gold standard for tendon visualization Important for surgical planning US Increased use recently» Less expensive? Increased role is surgical revision situations Foure A. Front Physiol 2016; 7: 324.
Nonoperative Treatment 1 st stage Rest Immobilization» Cast vs. Achilles boot Non-steroidal antiinflammatory (NSAIDs) 2 nd stage Eccentric stretching Physical therapy (PT) Heel lifts as needed Most successful in early stages Alfredson H et al. Sports Med 2000; 29: 135-146.
Other Nonoperative Treatments? Steroid injections? Risk of Achilles rupture! Platelet rich plasma (PRP) injections? Many studies show no difference compared to placebo Extracorporeal shock wave therapy (ESWT)? 30-90% successful Boesen A et al. Am J Sports Med 2017; 45: 2034-2043. Lee J et al. Ann Rehabil Med 2017; 41: 42-50.
Surgical Treatment of Insertional Tendinopathy Debridement & repair Repair the Achilles also back to the calcaneal insertion Haglund s exostectomy as needed Posterior midline incision splitting the Achilles Miao X et al. J Foot Ankle Surg 2016; 55: 529-534.
Surgical Treatment of Midsubstance Tendinopathy Debridement & repair Posteromedial incision Adjacent to the tendon s medial border Splitting the Achilles Scott A et al. Foot Ankle Int 2008; 29: 759-771.
When to Augment the Repair? Absolute indications > 50% of tendon width resected Relative indications Based on age, weight, & activity level Flexor hallucis longus (FHL) Located anterior to the Achilles Large muscle belly In phase with the Achilles tendon Schon L et al. J Bone Joint Surg 2013; 95A: 54-60.
Traditional [Long] Harvest of the FHL 2 nd incision at the plantarmedial foot Harvested at the knot of Henry Tenodesis of distal FHL to the flexor digitorum longus (FDL) Mao H et al. Surg Radiol Anat 2015; 37: 639-647.
[Short] Harvest of the FHL More recent alternative Through the Achilles incision» No additional incisions needed Harvested at the posteromedial hindfoot» Less length of tendon harvested without tenodesis of the distal FHL to the FDL Elias I et al. Foot Ankle Int 2009; 30: 197-204.
Fixation of the FHL Direct tenodesis to the Achilles Weaved through bone tunnels in the calcaneus Interference screw fit through a bone tunnel in the calcaneus My preference
Postoperative Care Weeks 0-2 Non-weightbearing in splint Weeks 2-6 Non-weightbearing in Achilles boot Weeks 6-12 Weightbearing in boot PT Week 12-onwards Discontinue boot Return to activity with a home exercise program (HEP) PT?
Results 85+% success Improvement of pain Return to function Education Home stretching Avoid overuse Lohrer H et al. BMC Musculoskeletal Disord 2016; 17: 1061-1064.
Complications Infection Wound problems Nerve injury Sural nerve Achilles rupture Recurrent tendinitis Inadequate exostectomy or tendon debridement?
Achilles Rupture Most common tendon rupture in lower extremity Viscoelastic with rapid loading Stiffness occurs with increased Young s modulus Prone to rupture Hunt K et al. Foot Ankle Spec 2014; 7: 199-207.
Epidemiology Activities involved Athletics Age Peak incidence in 3 rd 5 th decades Physical conditioning Weekend warriors Sex Male: female is 5: 1 Side Left > Right Raikin S et al. Foot Ankle Int 2013; 34: 475-480.
Classification Myotendinous 4-14% Midsubstance 75% Insertional 14-24%
Classification cont. Acute = 0-2 weeks Subacute = 2-6 weeks Chronic = 6+ weeks Make note of those that are neglected or missed! Chiodo C et al. J Am Acad Orthop Surg 2010; 18: 503-510.
Etiology - Indirect Trauma Strong ankle dorsiflexion force with contraction of the gastrocnemius-soleus Strong ankle dorsiflexion force while plantarflexed Push off of the foot with the knee extended Vosseller J et al. Foot Ankle Int 2013; 34: 49-53.
Etiology - Direct Trauma Direct blow Crush Laceration Said M et al. Eur J Orthop Surg Traumatol 2015; 25: 591-593.
Predisposing Factors Inflammatory arthritides Endocrine dysfunction Pharmacologic Corticosteroids» Oral vs. intravenous Fluoroquinolones Achilles tendinopathy Supported by intra-operative histology Claessen F et al. Sports Med 2014; 44: 1241-1259.
Activity involved Predisposing factors Initial pain Pop or Explosion Often subsides History Difficulty weightbearing Difficulty walking Weakened plantarflexion Stair climbing Boyd R et al. Br J Gen Pract 2015; 65: 668-669
Physical Examination Decreased strength Palpable gap at tendon Ecchymoses Swelling Can obscure the gap! Abnormal Thompson test
Radiographs 1 st line of imaging AP & lateral of ankle Blurring of Kager s triangle Screen for Calcaneal fracture Sleeve vs. posterior tuberosity Dams O et al. Injury 2017; 48: 2383-2399.
MRI US Further Imaging Gold standard for tendon visualization Useful for» Determining location of rupture» Measuring the gap between tendon ends in subacute/chronic ruptures Increased use recently Increased role is surgical revision situations? Garras D et al. Clin Orthop Relat Res 2012; 470: 2268-2273. Westin O et al. Orthop J Sports Med 2016; 14: ecollection.
Myotendinous Achilles Ruptures Should be confirmed with MRI vs. US Nonsurgical treatment Minimal displacement occurs Highly vascular at the myotendinous junction Protocol Nonweightbearing in Achilles boot x 2-4 weeks Weightbearing in Achilles boot x 4 weeks» With HEP vs. PT Wean out of boot by 6-8 weeks» Further PT? Return to activity Good functional results Ahmad J et al. Foot Ankle Int 2013; 34: 1074-1078.
Mid-Substance Achilles Ruptures Nonsurgical treatment Strong indications in patients with Significant illness with medical co-morbidities» Peripheral vascular disease (PVD)» Poorly controlled diabetes mellitus (DM)» Physically debilitated» Highly advanced age Poor skin condition High risk for post-surgical complications Relative indications As an alternative to surgery in a reliable patient population Kadakia A et al. J Am Acad Orthop Surg 2017; 25: 23-31.
Nonoperative Treatment with Functional Rehabilitation Short leg cast with the ankle in resting equinus x 2-4 weeks Nonweightbearing CAM boot immobilization x 4 weeks Progressive weightbearing Heel wedges in the boot with gradual removal Gentle motion & stretching Removable brace x 4-8 weeks PT
Expectations of Nonsurgical Treatment Most comparative studies show Higher risk of Achilles re-rupture Decreased gastrocnemius strength
Insertional Achilles Ruptures Nonsurgical treatment? Lacking in outcome studies May be considered in patients with» Significant illness with medical co-morbidities PVD & brittle DM Physically debilitated + highly advanced age» Poor skin condition» High risk for post-surgical complications Expect poor healing potential between calcaneal periosteum & insertional Achilles Surgical treatment Traditional for healthy, active patients Huh J et al. Foot Ankle Int 2016; 37: 596-604.
Surgical Treatment of the Acute Rupture Traditional = primary open repair Incision Posterior Medial to the tendon mid-substance Midline at the insertion Technique Krackow vs. Bunnell Epitendinous repair Suture anchors if insertional
Percutaneous Repair of the Acute Rupture Alternative to an open repair Advantages Smaller wound with decreased wound complications Disadvantages Mixed results compared to open repair Learning curve Sural nerve injury
Augmenting the Acute Repair? Plantaris tendon augmentation? Relative indications if intact FHL augmentation? Indicated only if repair is unstable PRP? Mixed results Further study required
Postoperative Treatment of Tendon Repair Weeks 0-2 Nonweightbearing in splint Weeks 2-4 Non- vs. partial weightbearing in Achilles boot Progression to neutral alignment Weeks 4-8 Progressive weightbearing in Achilles boot HEP vs. PT Weeks 8-12 Wean from boot PT
Postoperative Treatment After 12 Weeks Week 12 Continue therapy to optimize strength After Week 16 Begin return to sports
Results 92+% success overall Improvement of pain Return to function For professional athletes 1/3 never return to professional play 1/2 of those that do return play at decreased strength
Complications Infection Wound problems Superficial vs. deep Sural nerve injury Achilles re-rupture < 2% Deep vein thrombosis Holm C et al. Scand J Med Sci Sports 2015; 25: e1-e10.
Subacute & Chronic Ruptures Most commonly occurs due to delay in diagnosis Sequelae Tendon proximal to the rupture retracts Gap develops at the rupture site Inefficient scar fills the gap Decreased strength Fatigue Inefficient gait Kraeutler M et al. Foot Ankle Int 2017; 38: 921-929.
Nonsurgical Treatment - Accommodative High-topped shoes Lace-up braces Ankle foot orthosis (AFO) Molded AFO (MAFO) Dorsiflexion-assist Reddy S et al. J Am Acad Orthop Surg 2009; 17: 3-14.
Surgical Reconstruction To restore strength To restore Achilles continuity Involves excision of scar Bridging the gap Technique depends on length of the gap
When the Gap is < 2 cm End-to-end repair with longitudinal traction applied to the tendon edges Creep Buckley P et al. Orthopedics 2016; 39: e1223-e1225.
When the Gap is 2-6 cm V-Y gastrocnemius lengthening Elias I et al. Foot Ankle Int 2007; 28: 1238-1248.
When the Gap is 6-12 cm Achilles turndown Historical techniques» Bosworth» Arner & Lindholm Modern techniques» Ahmad et al. Ahmad J et al. Foot Ankle Spec 2016; 9: 400-408.
When the Gap is > 12 cm FHL tendon transfer into the posterior calcaneus? WITHOUT bridging the gap at the ruptured Achilles Tendon allograft? Achilles vs. hamstrings Requires further study Limited to scant case studies Hollawell S et al. J Foot Ankle Surg 2015; 54: 1146-1150
When to Use the FHL? To augment the reconstruction Regardless of gap size As a sole tendon transfer WITHOUT bridging the gap Amlang M et al. Unfallchirurg 2008; 111: 499-506. Elgohary H et al. Injury 2016; 47: 2833-2837.
Weeks 0-2 Postoperative Treatment Nonweightbearing in splint Weeks 2-6 Nonweightbearing in Achilles boot vs. cast Weeks 6-12 Progression to full weightbearing in boot Physical therapy Week 12 Discontinue Achilles boot Continue therapy to optimize strength
Results 85+% success overall Improvement of pain Improvement of strength Better chances of return to pre-injury levels of activity with tendon reconstruction & FHL augmentation? Comparative studies are lacking
Complications Infection Higher than for acute repair Wound problems Longer incisions Higher than for acute repair Sural nerve injury Achilles re-rupture < 2% Deep vein thrombosis Foreign body reactions Ahmad J et al. Submitted for publication in Foot Ankle Int in 2018.
Conclusion The Achilles tendon is critical to efficient gait Ankle function Stair climbing Its blood supply makes it vulnerable to pathology Watershed area at the mid-substance
Achilles Tendinopathy Nonsurgical treatments are beneficial in early stages Surgical treatment involves debridement & repair With a Haglund s exostectomy when there is insertional Achilles involvement + FHL augmentation with significant de-bulking of the Achilles
Achilles Tendon Ruptures Nonsurgical treatment Myotendinous ruptures Mid-substance ruptures» In patients not suitable for surgery» As an alternative in healthy patients to avoid complications
Achilles Tendon Ruptures cont. Surgical treatment Acute repair» Insertional ruptures» Mid-substance ruptures To avoid muscle atrophy & re-rupture Reconstruction + FHL transfer» Technique depends on the amount of gapping between the ends of the ruptured Achilles
Questions?
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