Non-Insertional Achilles Tendon Pathology PDF 2024

Outline Anatomy Normal Mechanism and Function Clinical Exam Achilles Tendon Imaging Achilles Tendon Pathology Treatment of Achilles Tendon Pathology Conservative Management Surgical Management https://www.physio-pedia.com/Achilles_Tendon Achilles Tendon Anatomy Achilles tendon composition: Gastrocne...

Outline Anatomy Normal Mechanism and Function Clinical Exam Achilles Tendon Imaging Achilles Tendon Pathology Treatment of Achilles Tendon Pathology Conservative Management Surgical Management https://www.physio-pedia.com/Achilles_Tendon Achilles Tendon Anatomy Achilles tendon composition: Gastrocnemius muscle Soleus muscle Plantaris muscle Make up the superficial compartment of posterior lower leg Each muscle has individual aponeurosis Combine to form Achilles tendon Largest and strongest tendon h ttp s :/ / s u z i m a h l e r y o g a.c o m / 2 0 2 1 / 0 1 / 2 5 / a n a to m y - n o te s / Achilles Tendon Anatomy Tendon rotates 90 degrees before insertion on calcaneus Attachment of the soleus is more medial than gastrocnemius Attaches to middle third of posterior calcaneus http://sites.nd.edu/biomechanics-in-the-wild/2019/03/05/back-against-the-john-wall/ Achilles Tendon Anatomy Achilles tendon is innervated by the sural nerve with small branches from the tibial nerve Vascular supply via posterior tibial artery and peroneal artery Tendon blood supply via: Musculotendinous junction Insertion site Paratenon Avascular zone 2-6 cm proximal to insertion https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/calcaneous/approach/extended-lateral-approach-to-the-calcaneus Achilles Tendon Normal Biomechanics Main plantarflexor of the foot and ankle Active during stance phase Act as stabilizer playing a significant role in balance Stabilizing forces transition to propulsive role at end of stance phase https://www.ruperthealth.com/blog/chiro/achilles-tendinitis/ Achilles Tendon Biomechanics Inactive after toe off in swing phase Weakness in posterior muscle group leads to weakness and imbalance Weakness of posterior muscle groups results in compensation from flexor muscles May result in foot and digital deformities Equinus leads to pronatory compensation resulting in multiple foot pathologies Achilles Tendon Pathology Achilles Paratenonitis Inflammation of the paratenon Tenosynovitis not appropriate as the AT has no synovial sheath Commonly seen in athletic population Likely overuse injury Increased prevalence in runners as mileage increases Associated with over pronation and supination Pain does not move with active range of motion Paratenon does not move with tendon significantly May be focal thickening if underlying tendinosis present Non-Insertional Achilles Tendinopathy Etiologies Commonly associated with equinus deformity, increased traction on the fibers of the Achilles tendon lead to degeneration Limb length discrepancy have been associated with disruption of tendon structure Poor athletic form and/or overuse Medication reactions Steroids Fluoroquinolones Achilles Non-Insertional Tendinopathy Non-athletic population more frequently involved May or may not have history of trauma Associated with interstitial and partial tendon ruptures Have been associated with repetitive microtrauma Associated with increased activity Over pronated and cavus foot types Achilles Tendon Physical Exam History Neurovascular evaluation Palpate area of maximal tenderness Nodular or fusiform thickening of the tendon Evaluate plantarflexion strength Range of motion Plantarflexion Dorsiflexion Equinus Silfverskiold exam https://www.v2mshop.com/?category_id=4139210 Achilles Tendon Physical Exam Evaluate the patient standing Look at RCSP Gait exam Antalgic gait Early heel off Check for palpable delve Thompson squeeze test https://www.verywellfit.com/pronation-definition-3436329 Evaluate for tearing of the tendon Normally, should plantarflex when squeezed https://www.footbionics.com/Patients/The+Gait+Cycle.html Achilles Tendon Imaging Radiographs Ultrasound MRI Achilles Tendon Radiographs Normal tendon should have defined margins Visualize Kager’s triangle Can be obscured with pathology Can visualize thickened tissue Good for evaluating calcification or ossification of the tendon Ossification common after previous injury (rupture/tear) Can use to evaluate rearfoot/leg relationship Standing exam https://onlinelibrary.wiley.com/doi/10.1111/j.1440-1673.2006.01622.x Achilles Tendon Ultrasonography Multiple advantages to other imaging modalities: Easily accessible Dynamic evaluation Compare to contralateral limb Patients tolerate well Can be used to local specific pain/symptoms Limitations: Learning curve Operator dependent https://reader.elsevier.com/reader/sd/pii/S1083751505000070?token=EEA89907657639ED6ADB2C20C92F67A6B409FBD227C7991D1A40EFAAF47366B29FF85A9E7073816C491AB3F4D99E0D2A&originRegion=us-east-1&originCreation=20220508161943 Achilles Tendon MRI Multiplanar imaging Sagittal and axial planes most helpful Combinations of T1 and T2 imaging Normal image is hypo-intensity on both T1- and T2-weighted images Achilles Tendon MRI Mid-substance tendinosis characterized by fusiform shape of tendon Tendon thickening Partial or complete intrasubstance tearing noted on by T1- and T2-weighted images Achilles Tendon MRI Complete tear demonstrated by: Full discontinuity of fibers High-signal intensity on T2-weighted imaging Treatment Options Conservative Therapy for Non-Insertional Achilles Tendinosis Immobilization Longer periods may be necessary with tendinosis compared to isolated tendinitis Anti-inflammatories Orthotics Correct/address biomechanical abnormalities Heel lifts Physical Therapy Eccentric training is most effective Steroids Contra-indicated https://www.amazon.com/Adjustable-Discrepancies-Inserts-Insoles-Balancer/dp/B07R41KTHJ Alfredson Protocol for Non-Insertional Tendinopathy (Eccentric Training) Standing on edge of steps, rise to toes with uninvolved limb Transfer weight to involved limb Eccentrically lower injured limb below level of step Transfer weight back to uninvolved limb to raise back up 3 sets of 15 with knee extended and flexed twice daily Acceptable to perform with pain https://www.mskscienceandpractice.com/article/S1356-689X(07)001154/fulltext Surgical Management of NIAT Debulking of pathological tissues Potential need to reinforce repair Can use plantaris May need tendon transfer if significant amount of pathological tissue is removed Flexor Hallucis Longus Repair paratenon when possible http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2015000400008 Achilles Tendon Ruptures https://www.orthopedia.com/achilles-tendon-pathologies Achilles Tendon Ruptures Commonly occur in 3rd-5th decades of life “Weekend warrior” Male predilection Occur 2-6 cm from insertion most commonly Mechanism: Sudden, violent dorsiflexion on plantarflexed foot Other risk factors include: Systemic/local steroids Gout Hypothyroidism Rheumatoid arthritis Fluoroquinolone use https://sunvalleyfoot.com/achilles-tendon-rupture/ Achilles Tendon Rupture: History and Physical Patient reports feeling a “pop” Felt like they were hit with something on back of leg Difficulty walking Subjective weakness Pain, swelling to posterior lower leg Palpable gap Visual gap “hatchet strike defect” Thompson test Lack of plantarflexion with calf squeeze https://txfootandankleconsultants.com/what-is-achilles-tendon-disorders/ Achilles Tendon Rupture Conservative Management Traditional conservative therapy: Cast immobilization for 6-8 weeks Initial 4 weeks in plantarflexed positioned 2-4 weeks additional casting in neutral position Modified protocol: Shortened immobilization period Functional rehabilitation with earlier mobilization Improved dorsiflexion Earlier return to activity Re-rupture rate lower in surgical repair (higher complication rate), but functional scores are equivalent https://journalfeed.org/article-a-day/2020/cast-or-weight-bearing-brace-for-non-op-achilles-tendon-rupture/ Classification of Achilles Tendon Ruptures Kuwada Classification: Type I: Tear < 50% of tendon Type II: Defect < 3 cm Type III: Defect 3-6 cm Type IV: Defect > 6 cm Achilles Tendon Ruptures Surgical Management Treatment recommendations based on defect size Type I Cast immobilization Type II End-to-end anastomosis Type III End-to-end anastomosis or synthetic graft Type IV Gastrocnemius recession End-to-end anastomosis with graft Tendon transfer Open Achilles Tendon Repairs End-to-end Anastomosis: Bunnell Intra-tendinous repair, figure of 8/weave Kessler Box repair approach Krackow Inter-locking loop technique Gastrocnemius Recession for Achilles Tendon Repair Gastrocnemius recession may be helpful for shortened tendon repair from large gaps V-Y lengthening provides adequate length Allows for direct repair at rupture site Achilles Tendon Repair: Tendon Transfer Flexor Tendon Transfer Commonly utilize FHL Harvest from directly posterior or Master Knot of Henry Move to dorsal aspect of calcaneus In-phase transfer https://www.arthrex.com/resources/surgical-technique-guide/QKlb3z2NuESTJQFtP5ze4w/flexor-hallucis-longus-tendon-transfer-with-dx-button-and-tension-slide-technique Questions https://www.flickr.com/photos/wingedwolf/5471047557 Resources Thompson, Jonathan C. and Bob Baravarian. “Acute and chronic Achilles tendon ruptures in athletes.” Clinics in podiatric medicine and surgery 28 1 (2011): 117-35. Bleakney RR, White LM. Imaging of the Achilles tendon. Foot Ankle Clin. 2005 Jun;10(2):239-54. doi: 10.1016/j.fcl.2005.01.006. PMID: 15922916. Landsman AS. Mcglamry's comprehensive textbook of foot and ankle surgery, 3rd ed (banks et al, eds). Journal- american podiatric medical association. 2004;94:216-216. Pearce, Christopher J, and Audrey Tan. “Non-insertional Achilles tendinopathy.” EFORT open reviews vol. 1,11 383-390. 13 Mar. 2017, doi:10.1302/2058-5241.1.160024