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Achilles Tendon Injury
Peter J Briggs, BSc, MD, FRCS
Newcastle upon Tyne
Aims
• Anatomy and function
• Classification
• Aetiology
• Pathology
• Clinical features
• Management
Anatomy
Micro-Anatomy
Kastelic et al, 1978
Function
• Plantar-flexion of the ankle in late stance
• 700N on heel elevation
• Up to 4000N in running
• Elasticity
Classification of Disorders
• Insertional– Retrocalcaneal bursitis– Insertional tendinopathy
• Non-Insertional– Paratendinitis– Paratendinitis with tendinopathy– Tendinopathy
Retrocalcaneal Bursitis
• Pain
• Swelling
• Footwear
• Tenderness
Retrocalcaneal Bursitis
• Ice
• Anti-inflammatories
• Heel lift
• Low/cushioned heel counter
• Surgical resection
Retrocalcaneal Bursitis
• Ice
• Anti-inflammatories
• Heel lift
• Low/cushioned heel counter
• Surgical resection– Bursa– Haglund’s deformity
Retrocalcaneal Bursitis
• Ice
• Anti-inflammatories
• Heel lift
• Low/cushioned heel counter
• Surgical resection– Bursa– Haglund’s deformity
Insertional Tendinitis
• Pain
• Swelling
• Footwear
• Tenderness
Insertional Tendinitis
• Ice
• Anti-inflammatories
• Heel lift
• Heel cushions
• Splints
• Immobilisation
Insertional Tendinitis
• Resection– Spur– Degenerate tendon
• Osteotomy
• Reconstruction– Eg. FHL tendon
transfer
Insertional Tendinitis
• Resection– Spur– Degenerate tendon
• Osteotomy
• Reconstruction– Eg. FHL tendon
transfer
Insertional Tendinitis
• Resection– Spur– Degenerate tendon
• Osteotomy
• Reconstruction– eg. FHL tendon transfer
Non-Insertional Tendinitis
• Aetiology– Overuse– Hypovascularity– Tendon twist– Heel pronation– Small Achilles tendon– Diabetes– Steroid use
Oakes, 2003
Non-Insertional Tendinitis
• Heat generation
Prevention
• Exercise
• Hydration
• Orthoses
Non-Insertional Tendinitis
• Paratendinitis
• Paratendinitis with tendinopathy
• Tendinopathy
Non-Insertional Tendinitis
• Paratendinitis
• Paratendinitis with tendinopathy
• Tendinopathy
Pathology
• Inflammation / Repair– Bleeding– Phagocytosis– Vascular ingrowth– Fibroblast proliferation– Collagen production
• Type III then Type I
Pathology
• Effect of movement
– Detrimental to collagen orientation in first three weeks leading to weaker repair
– After first three weeks beneficial for collagen orientation and ultimate tensile strength of repair
Pathology
• Remodelling / Maturation– Reduced cell numbers– Reduced water content– Collagen concentration reduced, but total
amount increased– Shortening of repair, probably by
myofibroblasts
Tendon Repair
Non-Insertional Tendinitis
• Ice
• Anti-inflammatories
• Modified activity
• Heel lift
• Stretching programme
• ? Immobilisation
Surgery
• Paratendinitis– Excision of thickened paratenon
• Tendinopathy– Debridement of diseased tendon– Reconstruction
Achilles Tendon Rupture
• Tendinopathy
• Excessive force
Achilles Tendon Rupture
• Sudden pain• Swelling• Bruising• Weakness
• 75% in sporting activity
• Age 30-40• Male predominance
Achilles Tendon Rupture
• Swelling
• Gap in tendon
• Calf squeeze test
Management
• Conservative or Surgical ?
Management
• Conservative– Re-rupture (10-30%)– Stiffness– Weakness
• Surgery– Wound dehiscence (10%)– Sural nerve injury
Management
• Long-leg equinus plaster– Historical interest only– Achilles tendon tension not affected by knee
position if the foot is in equinus
Davis et al, 1999
Management
• Options– Immobilisation– Early mobilisation– Weight bearing
– Open surgery– Percutaneous surgery
Management
• Options– Immobilisation (various forms)– Early mobilisation (different stages)– Weight bearing (different degrees and stages)
– Open surgery (various incisions)– Percutaneous surgery (various techniques)
What Makes Sense ?
• Short period of immobilisation in equinus– 3 to 4 weeks
• Early mobilisation with restricted dorsiflexion– 6 to 8 weeks
• Early weight bearing
• Heel lift
• Graduated return to sport
Surgery or Not ?
• Repair is stronger
• Less risk of re-rupture
• Earlier return to activity
• Open or percutaneous
Surgery or Not ?
• Taylor your treatment to the patient
Chronic Rupture
• Reconstruction– Turn-down flaps
• V-Y plasty• Turn-down flap
– Tendon transfer• FHL• FDL• Peroneus Brevis
– Artificial materials
Chronic Rupture
• FHL Transfer
Chronic Rupture
• Wound healing– Bulky repair– Loss of achilles retinaculum– Bow-stringing of tight repair– Precarious blood supply
Reversed Z-Plasty Skin Incision
ab
x’
y’ab
x
y
Green and Briggs, 2002
Reversed Z-Plasty
Green and Briggs, 2002
Reversed Z-Plasty
Green and Briggs, 2002
Conclusions
• Anatomy and function of the Achilles tendon
• Types of tendon injury
• Tendon repair process
• Management of Achilles tendon injury
Questions ?