ACHILLES TENDONITIS AND RUPTURE

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ACHILLES TENDONITISAND RUPTURE

• Dr Carl Clinton
• (no conflict of interests)

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• Will not include such pathologies-
• a) Retrocalcanel Bursitis
• b) Haglunds Deformity
• c) Impingement Syndrome
• e) Pump Bump
• e) Ankle O/A
• f) Ruptured Bakerss Cyst
• g) DVT

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ANATOMY 1

• a) Attaches the plantaris/ gastrocnemius and
  soleus muscles to the calcaneus
• b) Thickest and strongest tendon in the body
• c) Achilles muscle reflex tests the integrity of
  the S1 spinal root
• d) About 15cm (6in) long

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ANATOMY 2

• e) The tendon can receive a load stress
• 3.9 times body weight during walking
• and
• 7.7 times body weight during running
• f) The tendon is surrounded by a connective
  tissue sheath (paratenon) rather than a true
  synovial sheath

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ANATOMY 3

• g) Arterial anatomy of Achilles
• - supplied by two arteries - the posterior
  tibial
• - the peroneal arteries
• - 3 vascular territories - the midsection
  supplied by the peroneal artery
• - promixal and distal section
  supplied by the posterior tibial
  artery
• The midsection of Achilles markedly more
  hypovascular (risk rupture and surgical
  complications at its midsection).

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EPIDEMIOLOGY AND CAUSES

• a) OVERUSE - too long/too fast/too steep/ too
  explosive
• b) MISALIGNMENT - gait (excessive pronation)
• c) IMPROPER FOOTWEAR - saddle too low/extra
  dorsiflexion
• e) MEDICAL SIDE EFFECTS - quinolone group of A/B
  (ciprofloxacin)
• e) CORTISONE- indirect - weakened Achilles feels
  too comfortable
• g) ACCIDENTS - laceration/crush
• h) GENETICS - individuals with the single nuclear
  plymorphism (SNP) TT genotype of the GDF5rs
  143383 variant have twice the risk of developing
  Achilles problems
• i) SYSTEMIC CONDITIONS - gout/RA/SLE/Cushings
  syndrome

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PRESENTATION

• a) ACHILLES TENDONITIS
• - gradual onset pain/stiffness
• - improves with heat and exercise able to run
  off symptoms
• - may with strenuous activity get worse or
  experience calf pain
• - tenderness of the tendon on palpation
• - there may be crepitus and swelling
• - may be pain on active movement of the ankle
  joint

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PRESENTATION
b) ACHILLES RUPTURE - rupture can occur at any
age but most common 30 - 50 year old - acute
onset of pain in tendon - sudden sharp pain -
snap heard - may have PMH of Achilles
Tendonitis - inability to stand on tiptoe -
altered gait inability to push off - swelling/
GAP
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EXAMINATION
- observe gait - look for swelling/bruising - may
have a palpable GAP - active plantar flexion is
weak or absent - Thompsons Test calf squeeze
test - fusiform swelling with pain to
palpation - gout/RA/SLE/Cushings Syndrome/DVT/
ruptured Bakerss Cyst/O/A ankle (examine
ankle/knee/calf)
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INVESTIGATIONS
- UTRASOUND - MRI
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MANAGEMENT
ACHILLES TENDONITIS Insufficient evidence from
randomised controlled trials to determine which
method of treatment is the most appropriate.
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a) abstain from aggravating activities b) NICER -
?? Use NSAID (inflammation v degenerate) c)
physio relative rest (alternative
exercise) Podiatrist - stretching/strengthenin
g Hip/back muscles tight Calf muscles
tight Strengthening anterior tibialis -
massage - eccentric exercises - orthotics
(gait) / review footwear
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d) physical therapy - US/electric
stimulation/laser photo stimulation e) other
treatments - heparin - steriod
injections/sclerosant injections -
glycosaminoglycan sulfate - actovegin - GTN
patches - electronic wave shock treatment -
extra corporeal shockwave therapy - blood
letting/blood injections - needling - casting
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f) surgery -? last resort - ? after six months -
? plantaris wrap around - ? foot in equinus in
plaster 6/52 - ? degenerate v inflammatory
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MANAGEMENT
ACHILLES RUPTURE SURGICAL V CONSERVATIVE a)
surgery v non surgery NO CONSENSUS - b) best
surgical approach c) best non-surgical approach
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Surgical treatment of Acute Achilles Rupture
significantly reduces the risk of re-rupture
compared with non-surgical treatment, but
produces significantly higher risks of other
complications such as infection, adhesions and
disturbed skin sensibility/breakdown.
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PROGNOSIS
ACHILLES TENDONITIS a) no consensus on best
treatment b) recovery can take weeks or months c)
surgery is possible
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PROGNOSIS
ACHILLES RUPTURE a) no consensus on best
treatment b) surgical treatment decreased risk
of re- rupture c) may take 1 year to
recover d) may be left with slight loss of
function e) usually good prognosis however
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POSSIBLE EXPLANATION-
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ANY QUESTIONS ?
July 2013