Achilles Tendon Injury Peter J Briggs, BSc, MD, FRCS Newcastle upon Tyne

Aims Anatomy and function Classification Aetiology Pathology Clinical features Management

Anatomy

Micro-Anatomy Kastelic et al, 1978

Function Plantar-flexion of the ankle in late stance 700N on heel elevation Up to 4000N in running Elasticity

Classification of Disorders Insertional –Retrocalcaneal bursitis –Insertional tendinopathy Non-Insertional –Paratendinitis –Paratendinitis with tendinopathy –Tendinopathy

Retrocalcaneal Bursitis Pain Swelling Footwear Tenderness

Retrocalcaneal Bursitis Ice Anti-inflammatories Heel lift Low/cushioned heel counter Surgical resection

Retrocalcaneal Bursitis Ice Anti-inflammatories Heel lift Low/cushioned heel counter Surgical resection –Bursa –Haglund’s deformity

Retrocalcaneal Bursitis Ice Anti-inflammatories Heel lift Low/cushioned heel counter Surgical resection –Bursa –Haglund’s deformity

Insertional Tendinitis Pain Swelling Footwear Tenderness

Insertional Tendinitis Ice Anti-inflammatories Heel lift Heel cushions Splints Immobilisation

Insertional Tendinitis Resection –Spur –Degenerate tendon Osteotomy Reconstruction –Eg. FHL tendon transfer

Insertional Tendinitis Resection –Spur –Degenerate tendon Osteotomy Reconstruction –Eg. FHL tendon transfer

Insertional Tendinitis Resection –Spur –Degenerate tendon Osteotomy Reconstruction –eg. FHL tendon transfer

Non-Insertional Tendinitis Aetiology –Overuse –Hypovascularity –Tendon twist –Heel pronation –Small Achilles tendon –Diabetes –Steroid use Oakes, 2003

Non-Insertional Tendinitis Heat generation

Prevention Exercise Hydration Orthoses

Non-Insertional Tendinitis Paratendinitis Paratendinitis with tendinopathy Tendinopathy

Non-Insertional Tendinitis Paratendinitis Paratendinitis with tendinopathy Tendinopathy

Pathology Inflammation / Repair –Bleeding –Phagocytosis –Vascular ingrowth –Fibroblast proliferation –Collagen production Type III then Type I

Pathology Effect of movement –Detrimental to collagen orientation in first three weeks leading to weaker repair –After first three weeks beneficial for collagen orientation and ultimate tensile strength of repair

Pathology Remodelling / Maturation –Reduced cell numbers –Reduced water content –Collagen concentration reduced, but total amount increased –Shortening of repair, probably by myofibroblasts

Tendon Repair

Non-Insertional Tendinitis Ice Anti-inflammatories Modified activity Heel lift Stretching programme ? Immobilisation

Surgery Paratendinitis –Excision of thickened paratenon Tendinopathy –Debridement of diseased tendon –Reconstruction

Achilles Tendon Rupture Tendinopathy Excessive force

Achilles Tendon Rupture Sudden pain Swelling Bruising Weakness 75% in sporting activity Age Male predominance

Achilles Tendon Rupture Swelling Gap in tendon Calf squeeze test

Management Conservative or Surgical ?

Management Conservative –Re-rupture (10-30%) –Stiffness –Weakness Surgery –Wound dehiscence (10%) –Sural nerve injury

Management Long-leg equinus plaster –Historical interest only –Achilles tendon tension not affected by knee position if the foot is in equinus Davis et al, 1999

Management Options –Immobilisation –Early mobilisation –Weight bearing –Open surgery –Percutaneous surgery

Management Options –Immobilisation (various forms) –Early mobilisation (different stages) –Weight bearing (different degrees and stages) –Open surgery (various incisions) –Percutaneous surgery (various techniques)

What Makes Sense ? Short period of immobilisation in equinus –3 to 4 weeks Early mobilisation with restricted dorsiflexion –6 to 8 weeks Early weight bearing Heel lift Graduated return to sport

Surgery or Not ? Repair is stronger Less risk of re-rupture Earlier return to activity Open or percutaneous

Surgery or Not ? Taylor your treatment to the patient

Chronic Rupture Reconstruction –Turn-down flaps V-Y plasty Turn-down flap –Tendon transfer FHL FDL Peroneus Brevis –Artificial materials

Chronic Rupture FHL Transfer

Chronic Rupture Wound healing –Bulky repair –Loss of achilles retinaculum –Bow-stringing of tight repair –Precarious blood supply

Reversed Z-Plasty Skin Incision a b x’ y’ a b x y Green and Briggs, 2002

Reversed Z-Plasty Green and Briggs, 2002

Reversed Z-Plasty Green and Briggs, 2002

Conclusions Anatomy and function of the Achilles tendon Types of tendon injury Tendon repair process Management of Achilles tendon injury

Questions ?