Apunte_Ruptura de Tendón de Aquiles PDF

## Rehabilitación en el posoperatorio de ruptura del tendón de Aquiles ### Introducción - The tendon has been the focus of numerous research projects in the last 20 years. - Studies have been conducted in many countries trying to understand the physiology of tendon pathology and the recovery of n...

## Rehabilitación en el posoperatorio de ruptura del tendón de Aquiles ### Introducción - The tendon has been the focus of numerous research projects in the last 20 years. - Studies have been conducted in many countries trying to understand the physiology of tendon pathology and the recovery of normal tendon function. - Tendon injuries have been a challenge for health professionals to define the physiology, treatment and prognosis. - Chronic tendon pain has been defined as a nightmare for patients, as it can lead to numerous failed treatment attempts. ### Ruptures - Acute ruptures are a unique setting for tendon surgery. - The Achilles tendon is one of the most commonly ruptured tendons. - This can affect the functionality of the limb and the capacity to push off during walking. - Surgery restores the continuity of the tendon, but healing, immobilisation and patient expectations require expertise from the physiotherapist. - The final goal is to restore a pain-free tendon that can be used for daily activities, work and sports. ### Anatomy and Biomechanics - The ankle includes not only the tibiotarsal joint, but also proximal and distal tibiofibular joints. - The foot structures are located distal to the tibia and fibula. - The talus bone is an important part of the ankle and the foot. - The foot is divided into three regions: posterior (calcaneus, talus), middle (metatarsals), and anterior (phalanges). - The main joints are the tibiotarsal, subtalar, and transverse tarsal joints. - The talus bone is involved in all three joints. - The tibiotarsal joint has one degree of freedom of movement (flexion and extension). - The subtalar joint has one degree of freedom of movement (pronation and supination). - The transverse tarsal joint has two degrees of freedom of movement (abduction-dorsiflexion and adduction-plantarflexion). ### The Achilles tendon - The tendon is formed by gastrocnemius and soleus muscles. - The tendon is about 15 cm long, with a maximum width of 6.8 cm. - The soleus muscle contributes to the anterior and medial parts of the tendon, and the gastrocnemius muscle contributes to the posterior and lateral parts of the tendon. - The tendon has a spiral structure, in which the tibial fibres run from deep to superficial, and from medial to lateral. - The tendon is twisted by 90° at a distance of 2-5 cm from the calcaneus. - The Kager triangle is the space between the tendon, the posterior tibia and the superior part of the posterior calcaneus; it contains blood vessels, nerves and Kager's fat. ### The Retrocalcaneal Bursa - It is located proximal to the tendon. - It has a horseshoe shape with branches extending distally onto the medial and lateral edges of the tendon. - It is bounded by the fibrocartilage in front of the tendon, by the posterior calcaneus, and by a free synovial border proximally. - The retroaquilean bursa is located between the skin and the tendon. ### Biomechanics - The gastrocnemius and soleus work together to dorsiflex the foot and flex the knee. - The gastrocnemius is a type II muscle, active during walking, jumping and running, while the soleus is a type I muscle, a stabiliser of the foot and knee. - The gastrocnemius and soleus contribute respectively 93% and 7% to plantar flexion. - The muscle-tendon unit elongates eccentrically until mid stance. - The subtalar joint pronates, which allows the transverse tarsal joint to lock into the subtalar joint’s valgus position. - The subtalar joint then inverts as the heel rises, which allows better propulsion of the body. ### Blood supply - The tendon is supplied by arteries on the anterior and deep surfaces (peroneal and tibial arteries). - The posterior surface receives a smaller blood supply. ### Innervation - The tendon is supplied by nerves in the surrounding muscles (gastrocnemius and soleus), by the sural nerve, and by the posterior tibial nerve. - The posterior tibial nerve supplies the most innervation. - There are four types of nerve endings: Ruffini (pressure), Vater-Paccini (movement), Golgi (force), and nociceptors (pain). ### Incidence, Mechanisms and Risk Factors - The first descriptions were made by Hippocrates, who said that this tendon, if injured or cut, caused the most severe fevers, asphyxiation, delirium, and death. - Ambroise Paré (1575) described the first documented rupture of the Achilles tendon. - The incidence of ruptures has increased steadily, especially in recent decades. - The mechanisms of injury include: (i) violent contraction of the gastrocnemius-soleus complex during push-off, usually when the knee is straight (e.g., running or taking off for a jump), (ii) sudden dorsiflexion of the ankle during high-impact activities, such as stumbling or landing a jump, and (iii) sudden dorsiflexion of the ankle while the foot is plantarflexed, usually when falling. - Risk factors include: intrinsic, which are anatomical or biomechanical, e.g., foot pronation, inadequate muscle length, and extrinsic, such as training errors and medication, e.g., fluoroquinolones and corticosteroids. ### Diagnosis and Treatment - The classic symptoms of a ruptured Achilles tendon include pain, inability to contract the calf muscles, a gap in the tendon, and a “toe-up” deformity of the foot. - The Thompson test, where the calf muscles are squeezed while the foot is off the bed, is a useful test for diagnosing a ruptured Achilles tendon. - The Matles test, where the knees are bent at 90° and the foot is tested for dorsiflexion, is also a useful test for diagnosing a ruptured Achilles tendon. - Radiographs can show the loss of the normal shape of the tendon and the Kager triangle. - Ultrasound is usually the primary imaging modality for diagnosing a ruptured Achilles tendon. - MRI is used to confirm the diagnosis and to assess details of the injury. ### Classification - Kuwada (1990) classified ruptures into four types, based on the extent of the tendon defect. - Type 1 is a partial rupture, type 2 is a complete rupture with a defect less than 3 cm, type 3 is a complete rupture with a defect between 3 and 6 cm, and type 4 is a complete rupture with a defect greater than 6 cm. ### Treatment - Treatment options for a ruptured Achilles tendon include: (i) conservative treatment, which involves immobilisation in a cast and non-weightbearing followed by a rehabilitation program, and (ii) surgical repair, which involves suturing the tendon and a rehabilitation program. - Conservative treatment has been shown to be effective in some patients, with similar outcomes to surgical treatment regarding healing. - Early active mobilisation following both conservative and surgical treatment is generally recommended. - The optimal treatment for a ruptured Achilles tendon continues to be debated, with some authors favouring surgery for athletes and younger patients, and others advocating conservative treatment for all patients. ### Post-treatment Assessment - Outcome measures used to assess post-treatment function include: (i) range of motion (ROM), e.g., dorsiflexion, plantarflexion, (ii) strength, e.g., heel-rise test, plantarflexion force, (iii) function, e.g., ATRS score, and (iv) proprioceptive function, e.g., single-limb stance test. - Assessment of post-treatment function is important to monitor progress, to identify potential issues, and to develop appropriate rehabilitation programs. ### References - [1] Donald A. 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Am J Sports Med. 2007 Mar;35(3):421-6 El material de estudio cuenta con el registro de la propiedad Intelectual de los autores. Dirección Nacional del Derecho del Autor. N° 5102126 31 ==End of OCR for page 31==