Achilles Tendon

Achilles Tendon Rupture

Anatomy

 

Gastrocnemius tendon 10-25 cm long

- soleus 3-10 cm

- inserts superior calcaneal tuberosity

- fibres spiral 90°

- fibres that lie medially in proximal portion become posterior distally

- allows elastic recoil & energy storage

 

Plantaris present in 90% population

- medial to T Achilles

 

Poor blood supply midportion

- mesotenal vessels

- fewest at 2-6 cm

- other blood supply from osseous insertion

 

Epidemiology

 

Usually age > 40 years

- M:F = 12:1

- occasional sportsman

- 75% during sports

 

Aetiology

 

Calf contraction with forced dorsiflexion in setting of tendon degeneration

 

Combination of

 

1.  Repetitive microtrauma

2.  Hypovascularity

- occurs at watershed of vascular supply 

- an area of hypovascularity 5 cm proximal to tendon insertion

 

Factors

- corticosteroids - oral or injected

- anabolic steroids

- flouroquinolone / ciprofloxacin

- gout

- hyperthyroidism

- tendinitis

- cavus foot

- varus foot

 

Mechanical Overload

- footwear (low heel, inadequate shock absorption)

- sudden training increase

- cross training

 

Classification of Tendon Inflammation

 

1. Paratenonitis 

- inflammation of paratenon

- swelling, pain, crepitation, tenderness, warmth

 

2. Paratenonitis with tendinosis

 

3. Tendinosis 

- intratendinous degeneration due to atrophy

- aging, microtrauma, vascular compromise

- swelling absent

- +/- palpable nodule

 

Rupture Site

 

1.  Watershed area

- 5 cm proximal to insertion

- most common

 

2.  Insertion

- common with insertional tendonitis

 

3.  Musculotendinous juntion

- avulsion of medial or lateral head

- may present with chronic weakness

 

Medial Head Gastrocnemius RuptureMusculotendinous Gastrocnemius Rupture 2

 

NHx (if neglected)

 

Weakness / wasting

- difficulty with push off

- compromised running / jumping / stairs 

- can still walk with use of FHL / FDL / T posterior / Peroneals

 

Calf Wasting Left Leg

 

History

 

Sudden pain in calf

- with audible snap

- on unaccustomed exercise

- especially tennis / squash

 

Examination

 

Palpable gap

 

Achilles Tendon Rupture 1Achilles Tendon Rupture 1

 

Weak PF

- unable to perform single heel raise 

 

Positive Thompson Test

- patient prone

- squeezing calf doesn't produce plantarflexion of ankle

 

Thompson Sign Normal PreThompson Sign Normal Post

 

Chronic tear

- gap fills with scar tissue

- gap not palpable

- excessive DF compared with other side

 

TA rupture increased DF

 

Ultrasound

 

Cheap, dynamic, fast

- operator dependant

- check reduction of tendon ends with plantarflexion

 

Acute Achilles Tendon Rupture UltrasoundAcute Achilles Tendon Rupture Reduced with Plantarflexion

 

MRI

 

Indication

- incomplete rupture 

- signs of degeneration

- measurement of gap in chronic cases / information for reconstruction

 

MRI TA rupture chronic

 

Operative v Non-operative Management

 

Issues

 

1.  Complications 

- infection & skin necrosis with operative

- ? re-rupture with non operative

 

2.  Function

- strength & patient return to activity / sports

- ? better function with non operative

 

Kellam meta-analysis 

 

Operative

- 1% rupture in operative

- 85% return to pre-injury activity level

- 95% satisfied with treatment

 

Non Operative

- 18% rupture

- 70% return to pre-injury activity level

- 65% satisfied with treatment

 

Moller et al JBJS Br 2001

- 112 patients randomised non-operative & operative

- non-operative 20% rerupture & 3% complication rate (all minor)

- operative 2% rerupture & 25% complication rate (all minor)

 

Willits et al JBJS Am 2010 

- 144 patients randomised trial operative v non operative

- concept of accelerated functional rehabilitation in both groups

- 2 weeks NWB

- weight bear in aircast with 2 cm heel raise up to 8 weeks

- able to actively DF / PF below neutral

- no significant difference in rerupture rate or loss of motion / power

 

Non-operative

 

Indications

- elderly, DM, PVD, smokers

- non athlete

 

Technique

 

Equinus front slab 

- need to do within 24 hours

- try to close gap before haematoma forms

- change to full cast at 1 week

- debatable if need long leg cast v short leg

- 2 weeks

 

Functional Rehabilition

- heel raise 2 cm and air cast

- FWB for further 6 weeks

- active ROM below neutral

 

Achilles Tendon Boot and heel raise

 

Results

 

Rerupture

- rate unknown

- likely in order of 5%

- likely some minimall loss of plantarflexion strength

 

No risk of infection / wound breakdown

 

Operative

 

Indication

- young, active

- athlete 

 

Technique

 

Timing

- ? delay for one week to allow swelling to reduce

 

Position

- prone

- prep both feet to check tension

 

Posteromedial approach

- avoids sural nerve and short saphenous vein

- don’t place scar directly posteriorly / less scar discomfort

- full thickness skin to paratenon

 

Open paratenon and dissect off tendon

- want to repair at end of case on dorsum of tendon

- this reduces skin adhesions

- incise paratenon in the midline anteriorly / increases tissue available for closure

 

Tendon repair

- Bunnell Suture with No 2 Ethibond

- one in proximal and one in distal tendon ends

- tie via two knots with foot fully plantar flexed

- augment with circumferential  4.0 prolene to minimise bunching

 

Augmentation

- not usually needed acutely

 

Paratenon repair

- closure posteriorly to aid glide

- prevents adherence to scar

- use 3.0 vicryl

 

Careful skin closure

- LA with adrenalin

- front slab short leg

 

Post operative

- accelerated rehab as above

- jog at 3/12

- sports at 6/12

 

Complications

 

Wound breakdown

 

Debride, manage infection

- vac dressing

- free muscle flap (usually gracilis) + SSG

- fasciocutanous flap (radial or lateral thigh) has better wear characteristics

 

Rerupture

 

Case 1

 

Previously non operative management / new onset severe pain with bump

- intrasubstance / incomplete tear

 

Tendoachilles Nonoperative ReruptureAchilles Tendon Rerupture0001Achilles Tendon Rerupture0002

  

Case 2

 

Acute pain 8 weeks post non operative management rupture

- ultrasound demonstrates scar tissue

- no reduction with plantarflexion

 

Achilles Tendon Scar TissueAchilles Tendon Scar Tissue No Reduction Plantarflexion

 

Reconstruction / Augmentation

 

Indication

 

Unable to primary repair / chronic setting

 

Chronic TA rupture

 

Algorithm

 

< 3cm 

- turndown

 

3 - 5 cm 

- VY lengthening

 

VY Advancement

 

> 5 cm 

- FHL / FDL / peroneal transfer

- free gracilis graft

- allograft

 

Chronic TA rupture reconstruction with graft

 

Large gaps

- turndown + FHL

- FHL is most accessible / directly medial to T achilles

 

Techniques

 

VY advancement

 

Turndown / Bosworth technique

 

Harvest central third fascia

- from musculotendinus junction as far proximal as possible

- leave attached distally, detach proximally

- closure fascia above

- tubularise fascia with 2.0 ethibond

- drill hole through calcaneal tuberosity

- pass through calcaneum

- suture to itself

 

Can reinforce with plantaris / FHL / FDL / PB

 

Turndown and FHL Harvest

 

FDL / FHL transfer

 

Medial foot incision

- harvest tendon

- suture distal FDL stump to FHL

 

Medial calf incision

- pull tendon through

- through drill hole in calcaneum

- pass tendon through and suture to itself

 

FHL Transfer 2FHL Transfer 3

 

Peroneus brevis transfer

 

Lateral incision

- divide tendon

 

Standard Posteromedial calf incision

- pass through calcaneal drill hole

 

Augment with plantaris if needed

 

Free Gracilis tendon transfer

 

Achilles Tendonitis

Definition

 

Inflammation of achilles tendon at or near insertion into calcaneus

 

Epidemiology

 

1.  Runners / Tennis players / Dancers

 

2.  Sero -ve arthropathies / gout / RA

 

3.  Overweight middle aged diabetics

 

Spectrum

 

Tendonitis / Tendonosis / Rupture

 

Anatomy

 

Triceps surae

- medial and lateral gastrocnemius

- soleus

- surrounded by paratenon which allows gliding and supplies nutrition

 

Inserts middle 1/3 calcaneal tuberosity

- 2 x 2 cm area

- 90o rotation distally

 

Retrocalcaneal bursa (x2)

- proper is between tendon and calcaneum

- superficial is between tendon and skin

 

Aetiology

 

1.  Non-insertional form 

 

Younger / fitter / more active patients

- overuse and over training

 

Occurs in area of hypo-vascularity & fibre rotation

- 3-5 cm from insertion

- due to repetitive loading associated with jumping

- Angiofibrotic Dysplasia

 

Risk Factors

 

A.  Pronated foot 

- mid-foot pronation is coupled with IR force on tibia 

- opposite to the normal ER in knee extension

- forces are concentrated at the hypovascular area of TA producing high tensile stresses

 

B.  Heel cord tightness

 

C.  Changes in activity level 

 

2.  Insertional form 

 

Occurs at site of insertion

- more common in the overweight / middle aged / unfit / diabetics

- have combination of tendonitis / retrocalcaneal bursitis / spur

 

Risk factors

 

A. Poor women's shoe-wear

 

B. Bony protuberance of Os Calcis 

- Haglund's Deformity / Pump bump

- prominence of posterosuperior & lateral calcaneus

- causes impingement & mechanical abrasion of T achilles at insertion

 

Pump Bump Clinical Photo

 

C. Retrocalcaneal Bursitis

- retrocalcaneal bursa lies between tendon & posterior surface of calcaneum

- normal lubricating structure

- may become inflamed

 

Ankle Retrocalcaneal Bursa

 

DDx insertional

- seronegative enteropathy

- gout

- corticosteroids

- oral fluoroquinolones

- hyperlipidaemia

- DISH

 

Pathology

 

Peritendinitis

- inflammation limited to paratenon

 

Tendinosis

- tendon thickened

- focal areas of degeneration

- increased type 3 collagen

- may be partial tear

 

Clinical Features

 

Non Insertional

 

Presentation

- pain 2-6 cm proximal to insertion

- usually worse in morning & post exercise

- may present with tendon rupture

 

Findings

- localised tenderness

- tendon may be palpably thickened

- pain with DF and PF

- DF may be limited

 

Insertional

 

Presentation

- pain at bone-tendon interface

- worse after exercise

 

Findings

- localised tenderness & thickening

- bony lump

- DF may be limited

 

Note:

 

Some younger patients may present only with pump bump / Haglund's

- no tendonitis

- just problems with foot wear

 

X-ray

 

Haglund's Deformity

- may be calcification of bone-tendon interface with spur in insertional tendonitis

- can define with Pavlow lines / Fowler's angle

 

Achilles Insertional Tendonitis XrayTendoachilles insertional calcification

 

Pavlov 

- lateral weight bearing x-ray

- draw parallel pitch lines

- defines Haglund's deformity to be removed (above second line)

 

Achilles Haglund's and Pavlov lines

 

Fowler's angle  

 

Normal < 70°

Abnormal > 80°

 

MRI

 

Thickening of the tendon with some intra-substance degeneration

 

Tendoachilles Noninsertional Tendonitis Sagittal MRITendoachilles Noninsertional Tendonitis Axial MRI

 

Non-Insertional Management

 

Non-operative

 

Re-assurance / education / physio / orthotics

 

Phase 1:

- rest

- NSAID

- stretching programme - T Ach + plantar fasciitis

- soft heel cup with medial arch support

- night resting splints to stretch T Achilles

- HCLA contraindicated

 

Phase 2:

- eccentric exercises

- ECSW

 

Operative

 

Indication

- failure non operative > 12 months

 

Technique

 

Para-tenon resected

- tendon debrided

- tears in tendon repaired

 

Percutaneous vertical tenotomies

- may stimulate revascularisation

 

> 50% tendon degenerative

- may need augmentation

- FDL / FHL

 

Results

 

Rompe Am J Sports Med 2009

- RCT of eccentric v eccentric + ECSW

- improved results with combined treatment

 

Cochrane Review 2011

- weak evidence for NSAIDS

- no evidence for topical laser or peritendinous NSAID
- weak evidence for Actovegin

 

Kearney 2012 Foot Ankle Int

- systematic review

- some evidence for eccentric loading and ECSW

- minimal evidence for surgery / case series only

 

Insertional Management

 

Non-operative

 

As for non-insertional

 

Operative

 

Indication

- if fails to settle in one year

- high risk

- these patients have poor tendon and skin

 

Open / Arthroscopic Technique

 

Lateral approach

- preserve sural nerve

 

Retrocalcaneal bursa excised

 

Osteotome resection Haglund's if present

 

Resection of bone spur if present

 

Tendon debrided 

- remove inflammed paratenon

- vertical tenotomies

- if tendon severely compromised, transfer required