Insertional Achilles Tendon Pathology 2024 PDF

Outline Anatomy 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 Plan...

Outline Anatomy 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 Occurs 8-10 cm proximal to insertion 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 and anterior than gastrocnemius Rotation allows for decreased fiber buckling with relaxation of tendon 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 attaches to calcaneus in deltoid-type fashion Anterior to the tendon and posterior to the calcaneus lies the retrocalcaneal bursa https://foot-ankle-surgeon.co.uk/superficial-calcaneal-bursitis/ Insertional Achilles Tendinopathy Etiology Common secondary to overuse Thought to be related to mechanical overload Often have spurring to posterior calcaneus Equinus often associated with insertional pain h ttp s :/ / c o m p l e te - p h y s i o.c o.u k / s h o c k w a v e - th e r a p y - f o r - i n s e r ti o n a l - a c h i l l e s - te n d i n o p a th y / Insertional Achilles Tendinopathy History & Clinical Exam History: Commonly in 40 years and older Seronegative arthropathy “First step pain” in posterior heel Pain after extended periods of activity/weight bearing, specifically with steps or inclined surfaces Shoe irritation/wearing open-backed shoes Exam: Neurovascular status Soft tissue and osseous enlargement Osseous prominence proximal to insertion if coexisting Haglund's https://www.vascularhealthclinics.org/institutes-divisions/podiatry-foot-and-ankle-surgery/heel-problems/haglunds-deformity/ Insertional Achilles Tendinopathy Clinical Exam Elicit pain with squeezing soft tissue between Achilles and posterior calcaneus, consider retrocalcaneal bursitis Evaluate pain with passive dorsiflexion and plantarflexion Silfverskiold exam for equinus Knee extended Knee flexed Side-to-side compression of calcaneus Rule out calcaneal stress fracture Achilles Tendon Imaging Radiographs Ultrasound MRI Achilles Tendon Radiographs Normal tendon should have defined margins Visualize Kager’s triangle Can be obscured with pathology 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://www.jem-journal.com/article/S0736-4679(17)30719-9/fulltext Achilles Tendon Radiographs Helpful in evaluating osseous structures Can evaluate for intra-tendinous calcification Diagnose Haglund’s deformity Large posterosuperior prominence High calcaneal inclination angle Fowler Philip angle Parallel pitch lines https://radiopaedia.org/cases/achilles-tendon-tear-6?lang=us Achilles Tendon Radiographs Fowler Philips Angle Normal 44° to 69° Measurement 75° or more is consistent with Haglund’s deformity or retrocalcaneal bursitis https://radiopaedia.org/cases/fowler-philip-angle Achilles Tendon Radiographs Parallel Pitch Lines Pathologic if spur extends dorsal to the more proximal line https://www.semanticscholar.org/paper/Clinics-in-diagnostic-imaging-(170).-Shah-Wong/576dda174d0e29c92a1b30e5d79f231afd55ac9d/figure/6 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 Can identify spurring within tendinous structures or calcaneal prominence Limitations: Learning curve Operator dependent https://reader.elsevier.com/reader/sd/pii/S1083751505000070?token=EEA89907657639ED6ADB2C20C92F67A6B409FBD227C7991D1A40EFAAF47366B29FF85A9E7073816C491AB3F4D99E0D2A&originRegion=us-east-1&originCreation=20220508161943 Insertional Achilles Tendon Pathology MRI Multiplanar imaging Sagittal and axial planes most helpful Combinations of T1 and T2 imaging Normal image is low intensity on both T1- and T2-weighted images Helpful to evaluate inflammatory changes at tendinous insertion site May identify tearing within the tendinous structure Can identify bursitis https://radiopaedia.org/cases/retrocalcaneal-bursitis-4?lang=us Treatment Options Conservative Therapy for Insertional Achilles Tendinosis RICE therapy Immobilization Sparingly Anti-inflammatories symptomatic treatment only Orthotics Correct/address biomechanical abnormalities Heel lifts Physical Therapy Less successful than in NIAT https://www.amazon.com/Adjustable-Discrepancies-Inserts-Insoles-Balancer/dp/B07R41KTHJ Conservative Therapy for Insertional Achilles Tendinosis Steroids Contra-indicated for tendon injection, acceptable for bursal injection Oral steroids may be beneficial Posterior muscle column stretching Especially with coexisting equinus Eccentric training (Alfredson) not as effective Dry needling has shown to be beneficial Surgical Management of Insertional Achilles Tendon Pathology Surgical debridement of thickened, degenerative tendon Debridement of posterior osteophyte/spurring Excision of retrocalcaneal bursa Detachment/re-attachment of Achilles tendon Requires non-weight bearing postoperatively https://www.tristatespecialists.com/blog/what-is-the-treatment-for-painful-achilles-tendon Surgical Management of Insertional Achilles Tendon Pathology Surgical detachment with reattachment of tendon Utilizes suture anchors commonly May also use screw(s) with washer(s) Isolated gastrocnemius recession https://www.opnews.com/2015/12/treatment-options-for-chronic-achilles-tendon-disorders-2/11808 Protected weight bearing allowed post-operatively https://www.semanticscholar.org/paper/Lengthening-of-the-gastrocnemius-soleus-complex%3A-an-Firth-M cM ullan/9a9a887a8bbee9db44730f08d9bcdf82dcebf19c/figure/1 Retrocalcaneal Bursitis History: Can occur in any age group More common in older age groups Generally uncommon in isolation Rule out seronegative arthropathies Exam: Pain with squeeze between Achilles tendon and posterior calcaneus May have swelling focally at the level of the bursa Retrocalcaneal Bursitis: Treatment Conservative: Anti-inflammatories Steroid injection to bursa only, avoid tendon Post-injection immobilization Physical Therapy Heel lifts Opened-backed shoes Surgical: Excision of bursa through posteriorlateral incision Can perform endoscopic excision as well Weight bearing as tolerated postoperatively https://www.researchgate.net/figure/Clinical-image-A-and-radiograph-B-of-a-patient-with-a-retrocalcaneal-bursitis-The_fig3_44580635 Haglund’s Deformity Enlarged superior lateral aspect of the calcaneal tuberosity Not within the Achilles tendon insertion “Pump bump” Symptomatic deformity tends to occur in younger and middle-aged groups Pressure over superior lateral calcaneus leads to irritation and inflammation https://radiopaedia.org/cases/haglund-deformity-6 Haglund’s Deformity: Clinical Exam Enlarged osseous prominence located laterally and superior on the posterior calcaneus Pain when shoe rubs on posterior heel Skin breakdown may occur Haglund’s Deformity: Treatment Conservative: Localized off-loading with padding Open-backed shoes Ice painful areas Local wound care if needed Orthotic management for foot/rearfoot deformities Topical anti-inflammatories Haglund’s Deformity: Treatment Surgical Removal of posterior prominence Can be performed open or endoscopically Remove bursa if present https://pbuy2e.tk/products.aspx?cname=haglund+deformity&cid=180 Haglund’s Deformity: Treatment Surgical: Dorsal closing wedge osteotomy of calcaneus Remove bursa if present https://josr-online.biomedcentral.com/track/pdf/10.1186/s13018-020-01687-6.pdf Questions https://www.flickr.com/photos/wingedwolf/5471047557 References 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.