Achilles Achilles Tendon Tendon InjuriesInjuries

Johan Myburgh September 2011

HippocratesHippocrates

“ this tendon if bruised or cut, causes the most

acute fevers, induces choking, deranges the

mind and at length brings death.”

PATIENTPATIENT

• 31 year old male

• Recreational soccer player

• Work - oilfield worker

• Healthy - no significant past hx

• Played varsity soccer and football till 23 years old

InjuryInjury

• Came directly from work , no warm up

• Previous tightness and tenderness calf few days

• 5 minutes into game:

Pushed off back to leg drive forward

Sudden pain and weakness left leg

3 Stage Assessment3 Stage Assessment1. Clinical: • 80% acute partial Achilles tendon rupture• Previous sprain of Triceps surea•Improper warm up before activity

3 stage assessment3 stage assessment2. Personal: •concerned about the amount of time he is going to loose at work- no income.•positive about the outcome and wants to do proper rehabilitation to speed up his recovery

3. Contextual:•manager at work is supportive• seasonal work - needs to recover before the work season is over.•family is very supportive.

Treatment Treatment • Nonoperative treatment plan

o Immobilized equinis cast for 7 weekso Removable walking splint for 6 weeks• Patient did 3 weeks

o Physiotherapy starting at week 7

Progression:Week 13 physical exam:

o Dorsiflexion L 96° R 105°o Tendon thickness L 30 mm R 19 mm

Achilles tendon Achilles tendon

AnatomyAnatomy• Formed by tendinous portion of gastrocnemius and

soleus ( contribution varies)

• Progresses from round to flat distally to insert on calcaneal tuberosity

• Distal rotational twist (90°)o gastrocnemius fibers insert lateral

o soleus fibers insert medial

• Plantaris lies medial - distinct tendon (absent 6-8%)

• No synovial sheath – wrapped paratenon

Blood SupplyBlood Supplyo Posterior tibial artery - majority of the blood supply• Musculotendinous junction• Bone-tendon junctiono Peroneal artery• Surrounding connective tissue (paratenon/mesotenon)Poor vascularization in midportion of tendon

o Angiographic and histological techniques showed Achilles tendon has a poor blood supply throughout its length = small number of blood vessels per cross-sectional area(1,4)

HistologyHistology• Fibroblasts (Embedded in bundles of fibrils)

• Collagen comprises 70% of tendono 95% type Io Ruptured tendon contains significant

type III collagen• Collagen of granulation tissue - produced

quickly by young fibroblasts before tougher type I collagen is synthesized

Wavy bundles collagen

HistologyHistology

Collagen organized into

parallel bundles of fibrils

Surrounded by endotenon

Units surrounded by

vascular epitenon

PathologyPathologyAchilles tendon disorders and overuse injuries:

1. Inflammation of the peritendinous tissue (peritendinitis,paratendinitis)

2. Degeneration of the tendon (tendinosis) 3. Tendon rupture• Partial/Complete • Acute/Chronic

o Insertional disorders (retrocalcaneal bursitis and insertional tendinopathy)

TendinosisTendinosisDegeneration with no significant inflammation: •Hypoxic or fibromatous:

o most frequently seen in ruptured tendons

•Myxoid o 2nd most common o May be silent prior to rupture

•Lipoido Age dependent fatty deposits that do not affect structural properties

• Calcifico Calcium pyrophosphate

Acute Rupture Acute Rupture Achilles tendonAchilles tendon

Etiology – Intrinsic FactorsEtiology – Intrinsic Factors• General

• Decreased perfusion• Hyperthermia within relatively avascular Achilles tendon – more

prone rupture

• Systemic diseasesInflammatory and autoimmune conditionsCollagen disordersInfectious diseaseNeurologic conditions

• Age >30 • Decrease in maximum diameter & density of collagen fibrils

Etiology – Extrinsic factorsEtiology – Extrinsic factorso General• CorticosteroidsCorticosteroid injection into rabbit tendons showed necrosis and

delayed healing. Several studies showed collagen damage with injected steroids. Oral steroids also implicated(2)

• Fluoroquinolone(3)

Etiology – Extrinsic factorsEtiology – Extrinsic factors• Biomechanical factors

o Rapid push offTendon obliquely loaded, muscle maximum contraction and initial short

tendon length

o Functional / Anatomical conditions• Imbalance agonist muscle contractions (7)

• Functional overpronation on heel strike (midfoot) – whipping action on Achilles – intratendinous microtears

• Poor flexibility gastroc/soleus - overpronation

Etiology – Extrinsic factorsEtiology – Extrinsic factors• Biomechanical factors

o Unequal tensile forces of different parts tendon - torsional ischemic affect (transient vasoconstriction of intratendinous vessels, contribute vascular impairment already present)

o Malfunction/Suppression of proprioceptive component of skeletal muscle (athletes resume training after period rest)

EpidemiologyEpidemiology• Incidence increasing significantly

• 8.3 ruptures per 100 000 people(18)

• Gendero Males 2:1 over females

• Age (two peaks)o 30-50 – sports activity-relatedo > 50 – non-athletes and women

• Sport o abrupt repetitive jumpingo sprinting movements

• Race - increased African-Americans(8)

Histology of RuptureHistology of Rupture• Collagen degeneration of tendon prior to rupture(4)

• Marked inflammatory reaction

• Hypertrophy of tunica media and narrowing of

lumen of large peritendinous vessels(1) - hypoxia

All based on biopsy at time of surgical repair

Site of RuptureSite of Rupture

Myotendinous Junction

Midsubstance2-6 cm proximal to insertion

• Hypovascular

Avulsion

Diagnosis Diagnosis

HistoryMale between 30 and 50 yearsSedentary job but in athletic activity

“Weekend Warrior”Pop, “kicked” in the back of the legPain posteriorly in calf. Pain is variableBruising

DiagnosisDiagnosisClinical dx Physical:

Palpable defectThompson TestSingle leg heel raiseBruising/SwellingWeakness

Thompson TestThompson TestPatient prone with feet dangling - squeeze mid calf

NO plantar flexion = positive Thompson test /Ruptured tendon

DiagnosisDiagnosis• Diagnostic TestsoUltrasound (Doubtful cases)

• Helpful with Non-operative treatment Used to assess gap in tendon and apposition of torn ends of tendon

oMRI (not routinely)

• Show extent of tendon degeneration

oX-rays• Avulsion of calcaneus suspected

Ultrasound Ultrasound = Hematoma in Achilles tendon

Most widely used U.K

+ Inexpensive Readily available, fast Dynamic assessment Tendon thickness Gap // torn ends

− Operator dependent Miss partial tears

MRI MRI Most widely used imaging U.S

+ Accurate Partial tears

− Not readily available High cost No dynamic assessment

Classification of Achilles Classification of Achilles tendon tear/rupturetendon tear/rupture(17)(17)

Nonoperative TreatmentNonoperative TreatmentEffective for all age groups and both sedentary and sporting

individuals

•Wide variability among surgeonso absolute immobilization

o initial range of movement exercises

o progression weight bearing status

•Cast immobilization 4-8 week (non-weight bearing)

•Functional brace 4-6 weeks

•Use ultrasound to ensure tendon apposition

Nonoperative TreatmentNonoperative Treatment

• Higher rerupture rate (13%) vs. operative

repair (4-5%)(10)

• Fewer overall complications ( wound

infection)o Complications may be reduced with percutaneous surgery

Acute Complete RuptureAcute Complete Rupture

Surgical treatmentSurgical treatmentTwo DecisionsTwo Decisions

Postoperative regime Surgical technique

Surgical TechniqueSurgical Technique

• Direct Open (Incision 10-18 cm)

• Mini-invasive (Incision 3-10 cm)

• Percutaneous (multiple small incisions)

Percutaneous Achilles RepairPercutaneous Achilles Repair

• vs. Open repair:

o Higher rerupture rate (6.4% vs 2.7%)

o Fewer complications

• Allow earlier mobilization

• Earlier functional rehabilitation

• Sural nerve entrapment

Open RepairOpen Repair

Incision site reduce risk injury sural nerve and branches.Easier access plantaris muscle

Postero-medial incision

Plantaris tendon

Percutaneous RepairPercutaneous Repair

Achillon Device

Complications of Surgical Complications of Surgical TreatmentTreatment

• Wound healing problems/necrosis• Wound infection• Sural nerve injury• DVT and PE• Rerupture 2-5%

Wound necrosis

Chronic RuptureChronic RuptureDefinition: 4-6 weeks from time of injury to diagnosis

and treatment

•Conservative management not recommended

•Fibrous tissue in gap between torn ends

•Poor plantar flexion strength (2° flexors foot)

•Open repair and reconstruction

Postoperative RegimePostoperative Regime• ConsensusEarly functional weight bearing and range of motion

decrease:Inpatient stayTime off from workFaster return to sportLower complication rate

• No ConsensusDVT prophylaxis

DVT common after Achilles tendon ruptureNo evidence to demonstrate benefit

•Start ROM exercises Day 10 /

earlier as per pt’s comfort

•Day 14 weight bearing with

restricted dorsiflexion

Rehab PrinciplesRehab Principles• Mobilization

o Cycle 10-15 min/day

• Loadingo Treadmill Incline Walk (pain free)

• Stretchingo Straight, bend knee

• Proprioception• Ankle eversion/inversion

o Tubing

Healing and Repair Healing and Repair MechanismMechanism

Achilles Tendon HealingAchilles Tendon Healing• Slow healing – hypovascularity + hypocellularity• Phases

o Inflammationo Proliferationo Repair o Remodeling

• Stress on tendon – remodeling ( similar to bones)o Stronger , stiffero Achieved by increased collagen synthesis

alteration fibre alignment

• Mobilization increased inflammatory cells at rupture site(16)

Tendon HealingTendon Healing bbbbbbbb

Inflammatory Phase

Reparative (Proliferation ) Phase

Remodeling/Consolidation Phase

Remodeling/Maturation Phase

TIME - months

24 hr

3 days 1 2 3 4 5 6 7 8 9 10 11 12

Histology healingHistology healing

Microscopic view of a tendon undergoing healing the white "bubble" is the suture note increase in cells

Microscopic view of a normal tendonwavy pink material is the collagen very few cells

Achilles Tendon HealingAchilles Tendon Healing

Important factors Tension across repair

o speeds realignment fibreso increases tensile strengtho minimize deformation

Early motion o Accelerates nerve plasticity through regeneration and

release neuromediators

Sport ResumptionSport Resumption

• Time to return to sport depends level sportAverage 20-24 weeks

Olympic level up to nine months• Functional brace post-op 4 weeks earlier• Signs to slow down /speed up rehabilitation

o Pain and swelling after activityo Delayed tissue healing - Ultrasound

Sport ResumptionSport ResumptionLevelsoWalking – Casted 12 weeks after surgery Brace 8 weeks after surgeryo Recovery of force, speed and endurance - 4-6 weekso Non-contact sport - 4-6 weekso Contact sport – 4-6 weeks

Take Home Message Take Home Message o Degeneration present at time of ruptureo Early mobilization and weight bearing -

improved functional outcomes

THANK YOU THANK YOU

References References 1. Ahmed, M. Lagopoulos, M., McConnell, P., Soarnes, R. W., Sefton, G. K Blood supply of the

Achilles tendon. J. Orthop. Res. 16:591-596, 1998.2. Balasubramaniam P, Prathap K. The effectof injection of of hydrocortisone into rabbital

calcaneal tendons. J. Bone and Joint Surgery 1972;54-B:729-7343. Royer RJ, Pierfitte c, Netter P. Features of tendon disorders with fluoroquinolones. Therapie

1994;49:75-76 4. Weatherall, J, Mroczek, K, & Tejwani, N 2010, 'Acute Achilles tendon ruptures', Orthopedics,

33, 10, pp. 758-7645. Maffulli,n, Barrass, V, Stanley W.B. Ewen, Light Microscopic Histology of Achilles Tendon

Ruptures. A Comparison With Unruptured Tendons, Am J Sports Med November 2001 vol. 28 no. 6 857-863

6. Kannus, P., Jozsa, L. Histopathological changes preceding spontaneous rupture of a tendon. 1. Bone Joint Surg. 73-A:1507-1525, 1991.

7. Waterson S. Subcutaneous rupture of Achilles tendon: Basic science and some aspectes of clinical practice. Br J Sports Med 1997;31:285-298

8. Davis JJ,Mason KT, Calrk DA. Achilles tendon ruptures stratified by age, race, and cause of injury among active duty U.S. Military members. Mil Med 1999;164:872-873

9. Steven B. Weinfeld, MD, Associate Professor of Orthopaedic Surgery Chief Foot and Ankle Service, Mount Sinai Medical Center, NY

References References 10. Lo IK, Kirkley A, Nonweiler B, Kumbare DA. Operative treatment vs non-operative treatment

of acute Achilles tendon ruptures: A quantitative review. Clin J Sports Med1997;38:822-82811. Forrester JC, ZederfeldtBH, Hayes TL. Wolff’s law in relation to the healing skin wound.

Journal of Trauma-Injury Infection & Critical care 1970;10: 770-77912. Virchenko O, Skoglund B, Aspenberg P. Parecoxib inpair early tendon repair but improves

later remodeling. Am J Sports Med 2004;32;1743-174713. Virchenko O,Aspenberg P. How can one platelet injection after tendon injury lead to a

stronger tendon after 4 weeks? Interplay between early regeneration and mechanical stimulation. Acta Orthopod 2006;77:806-812

14. Virchenko O, Lindahl T, Aspenberg P. Low Molecular Weight Heparin impairs tendon repair. J

Bone Joint Surg (B) 2007: in press 15. Burssens P, steyaert A, Forsyth R, van Ovost EJ, Depaepe Y, Verdonk R. Exogenously administered substance P and neuropeptidase inhibitors stimulate fibroblast proliferation,

angiogenesis and collagen organization durinf Achilles tendon healing. Foot Ankle Int 2005;26:832-839

16. Palmes et al J of Orthopaedic Research 200217. Kuwada GT. Classification of teno Achilles rupture with consideration of surgical repair techniques. J Foot Surg.1990;29:361-365

References References 18. Suchak AA, Bostick G, Reid D, Blitz S. The incidence of Achilles tendon ruptures in Edmonton, Canada. Foot Ankle Int. 2005;26(11):932-936