TENDO - ACHILLIS

Largest tendon in the body

Origin from gastrocnemius and soleus muscles

Insertion on calcaneal tuberosity

Anatomy

Lacks a true synovial sheath-

Paratenon has visceral and parietal layers

Allows for 1.5cm of tendon glide

Anatomy

Paratenon

Anterior – richly vascularized

The remainder – multiple thin membranes

Anatomy

Blood supply1) Musculotendinous junction2) Osseous insertion on calcaneus3) Multiple mesotenal vessels on

anterior surface of paratenon (in adipose)

– Transverse vincula Fewest @ 2 to 6 cm proximal

to osseous insertion

Anatomy

Remarkable response to stress Exercise induces tendon

diameter increase Inactivity or immobilization

causes rapid atrophy Age-related decreases in cell

density, collagen fibril diameter and density Older athletes have higher injury

susceptibility

Physiology

Gastrocnemius-soleus-Achilles complex Spans 3 joints

Flex knee Plantar flex tibiotalar joint Supinate subtalar joint

Up to 10 times body weight through tendon when running

Biomechanics

1. Close injury/rupture 2. Open injury/rupture

• Acute injury• Neglected injury

Classification Of Tendo Achillis injury-

1. Accidental cut injury (bath room injury, road traffic injury)

2. Social/political Violence

Open Tendo Achilles injury

1. Diagnosis and assessment of extend of injury.2. Primary care3. Operative treatment

Management of open injuries

PathophysiologyRepetitive

microtrauma in a relatively hypovascular area.

Reparative process unable to keep up

May be on the background of a degenerative tendon

Achilles Tendon Rupture(close injury)

Antecedent tendinitis/tendinosis in 15%

75% of sports-related ruptures happen in patients between 30-40 years of age.

Most ruptures occur in watershed area 4cm proximal to the calcaneal insertion.

Achilles Tendon Rupture: Textbook Facts

History Feels like being kicked in the leg Case reports of fluoroquinolone use,

steroid injections

Achilles Tendon Rupture

Mechanism

Eccentric loading (running backwards in tennis)

Sudden unexpected dorsiflexion of ankle

(Direct blow or laceration)

A case of Tendo-achilis injury (closed)-

Prone patient with feet over edge of bedPalpation of entire length of muscle- tendon unit during active and passive ROMCompare tendon width to other sideNote tenderness, crepitation, warmth, swelling, nodularity, palpable defects

Physical Examination-

Partial

Localized tenderness +/- nodularity

CompleteDefectCannot heel raisePositive Thompson test

Achilles Tendon Rupture-

Physical-

Positive Thompson test-

NEGATIVE THOMPSON TEST IN UNINJURED TENDOACHILIS-

Gap in rupture Tendo-achillis injury-

Diagnostic Pitfalls 23% missed by Primary Physician

(Inglis & Sculco) Tendon defect can be masked by

hematoma Plantar-flexion power of extrinsic foot

flexors retained Thompson test can produce a false-

negative if accessory ankle flexors also squeezed

Achilles Tendon Rupture-

X-RAY-

This lateral x-ray of the calcaneus shows an avulsion fracture at the insertion of the Achilles tendon, with marked separation of fragments..

Imaging

Inexpensive, fast, reproducable,

dynamic examination possible Operator dependent Best to measure thickness and

gap Good screening test for

complete rupture

Imaging

Ultrasound

Expensive, not dynamic Better at detecting partial

ruptures and staging degenerative changes, (monitor healing)

Imaging

MRI

Restore musculotendinous length and tension.

Optimize gastro-soleous strength and function

Avoid ankle stiffness

Management Goals-

Cast in Plantarflexion cast with plantarflexion q 2 wks2 wks

Allow progressive weight-bearing in removable cast

Remove cast and walk with shoe lift. Start with 2cm x 1 month, then 1cm x1 month then D/C

4 weeks

Start physio for ROM exercises

When WBAT and foot is plantigrade

Start a strengthening program

2- 4 weeks

Conservative Management

Preserve anterior paratenon blood supply

Beware of sural nerve Debride and approximate tendon

ends Use 2-4 stranded locked suture

technique May augment with absorbable

suture Close paratenon separately

Surgical Management-

Exposed ruptured tendoachilis-

Acute case : usually end to end repair is enough

Neglected case: Advancement plasy (V-Y) or reconstruction by other tendons

Surgical Management (cont.)

V-Y plasty and repair Tendoachilis-

After repair of Tendo-achilis-

IMMOBILIZATION, POSITIONING & CAST-

Assess strength of repair, tension and ROM intra-op.

Apply long leg cast with ankle in the least amount of planterflexion(gravity equinus) & knee 60 degree flexion with window at operated site.

Stitch removal after 2 wks. Short leg cast after 3 wks with partial

equinus correction

Surgical Management : Post Operative Care-

2 weekly plaster change with gradual equinus correction (4-6 episode ).

Walking with heel raised shoe & regular physiotherapy.

Reverse ankle stop brace up to 6 months.

Post-op. management(continue)-

AFTER CARE-