The Achillease Device for Treatment of Achilles Tendonitis Rod Tomczak, MD, DPM, EdD July 10, 2013

THE ACHILLES TENDON

Functional and Gross Anatomy Two heads of the Gastrocnemius originating from the femoral condyles The Soleus originates from the posterior proximal Tibia and Fibula These merge and insert into the middle third of the posterior calcaneus The tendon is surrounded by a paratenon which allows it to glide

Tendonitis Area

Why is this the lone area of Achilles Tendonitis The tendon is vascularized by anterior muscular branches as well as vessels near the insertion The region of the tendon 3 to 5 centimeters proximal to the insertion is relatively avascular (weak blood supply) This hypovascularity is the main reason this area is prone to tendonitis and rupture

Other Anatomical Features in the Area Haglund’s Deformity –Posterior lateral enlargement of the calcaneus

Retrocalcaneal Bursitis Two small fluid filled sacks, one between the calcaneus and the tendon and one between the tendon and the skin

Function of the Gastrocnemius and Soleus The Gastroc supplies power for propulsion –Walking –Running –Jumping The Soleus stabilizes the leg on the foot The Achilles tendon is subject to forces 6 to 8 times body weight

Achilles Tendonitis Overuse beyond the tendon’s ability to healOveruse beyond the tendon’s ability to heal

Types of Achilles Tendonitis Noninsertional Insertional

Noninseretional Achilles Tendonitis Noninsertional Achilles Tendonitis In Tendonosis there are pain and inflammation without degeneration Tendonitis

Puddu’s Classification of Noninsertional Achilles Tendonitis Paratendonitis –Characterized by inflammation of only the lining of the tendon Paratendonitis with tendonosis –Inflammation of the paratenon and noninflammatory, atrophic, intratendonous degeneration due to aging, microtrauma or decrease in vasculature of the tendon Tendonosis

Explaining Achilles Tendonitis Increased intensity of training and running Change in duration, intensity and frequency Change in running surface Change in shoe Pain associated with swelling, warmth and tenderness 3 to 5 cm proximal to the insertion

Paratendonitis Diffuse fusiform swelling and tenderness

Achilles Tendonitis Normal

Achilles Tendonitis

Normal Achilles Abnormal Achilles

Paratendonitis/Tendonosis Paratenon inflammation with intratendonous degeneration Marked pain when the tendon is squeezed Marked weakness with push off –Main distinguishing characteristic Palpable nodules

Nodular Tendonosis nodules

Sequella of Achilles Tendon Injuries Paratendonitis Achilles Tendonitis Paratendonitis/ Tendonosis Achilles Rupture

Insertional Achilles Tendonitis Symptoms are related to pain at the bone tendon junction Common in athletes, but other conditions –Arthropathies –Gout –Fluoroquinolones (Cipro) –Familial hyperlipidemia –Sarcoidosis (immune disease with clumps of macrophages –Skeletal hyperostosis

Insertional Achilles Tendonitis Aggravated by running uphill There is a history of POOR STRETCHING Osteophyte formation The tendon is not attached to the broad spur osteophyte

Clinical Picture of Insertional Achilles Tendonitis Heel Spur

Conservative Treatment of Insertional Achilles Tendonitis Rest, Ice, Elevation Stretching

Conservative Treatment of Insertional Achilles Tendonitis Whirlpool Injections Topical anti-inflammatory (NSAIDs) Ultrasound Massage Air Massage

Who is Likely to Treat Achilles Tendonitis? Podiatrist (DPM) Orthopaedic Surgeon (MD) General Practitioner Physical Therapist Physiatrist Chiropractor Sports Medicine

Surgical Management

Spur Removed

AN OUNCE OF PREVENTION IS WORTH A POUND OF CURE

Why Stretch? The motion of stretching a muscle or tendon realigns disorganized muscle and connective tissue fibers. Injuries and stiff muscles cause misaligned connective tissue fibers.

Pathophysiology Inflammation Irritation Swelling Tendon loses elasticity Stretching causes the fibers to realign into normal configuration Lead to misalignment of fibers

Uncomfortable Modalities

Comfortable and Effective Modality

Comfortably The Juzo Achillease Comfortably Holds the Ankle in Slight Dorsi- flexion Allowing for Continuous Stretching of the Achilles Tendon When to Wear the Achillease

Plantar Fasciitis and the Achillease

What is Plantar Fascia? The plantar fascia is a broad band of connective tissue that runs from the plantar aspect of the calcaneus (heel bone) up to the base of the proximal phalanges (toes)

What is the purpose of the plantar fascia or plantar aponeurosis?

The Plantar Fascia Supports the arch of the foot Bears a tremendous amount of force The fibers of the insertion of the Achilles tendon may be confluent with the origin of the plantar fasciaThe fibers of the insertion of the Achilles tendon may be confluent with the origin of the plantar fascia

Plantar Fasciitis Inflammation of the origin of the plantar fascia at the Plantar Medial Tubercule of Calcaneus

Heel Spur It is estimated that 1/3 of the population has heel spurs without any symptoms

Heel Spurs Do Not impinge on the plantar fascia The Plantar Fascia originates below the heel spur Plantar Fascia Origin

Heel Spur/Plantar Fasciitis Diagnosis of plantar fasciitis is based on history and physical examination History –Exquisite pain at heel on getting out of bed in morning –Exquisite pain when resuming ambulation after being seated for awhile Get up to go to the refrigerator after watching TV

Heel Spur/Plantar Fasciitis History (cont.) –Change in physical activity Seated  Standing 4 miles  10 miles Physical Examination –Thumb pressure to the medial calcaneal tubercle

Who treats plantar fasciitis/heel spur syndrome? Your neighbor –Self-limited problem 6 months Pharmacist Barber/surgeon Physical therapist Lastly, a physician

Treatment of Plantar Fasciitis Weight Bearing Treatment is directed at supporting the arch

Treatment of Plantar Fasciitis Weight Bearing Treatment is directed at supporting the arch Support the Arch

Treatment of Plantar Fasciitis Medical –Cortisone –Ultrasound –Whirlpool –NSAIDs

Treatment of Plantar Fasciitis Surgical (Endoscopic Plantar Fasciotomy)

Surgical Treatment of Plantar Fasciitis Tomczak, RL, et al. A Retrospective Comparison of Endoscopic Plantar Fasciotomy to Open Plantar Fasciotomy with Heel Spur Resection for Chronic Plantar Fascitis/Heel Spur Syndrome, Journal of Foot and Ankle Surgery, 35, 101, 1995.

Treatment of Plantar Fasciitis Stretching Plantar Fascia and Achilles Seem Confluent Achilles

Stretching Some patients report relief of plantar fasciitis with sustained dorsiflexion of the foot

The Achillease and Plantar Fasciitis Stretching of the plantar fascia allows to degenerated and inflamed fibers of the fascia to realign and heal