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

2. THE ACHILLES TENDON

4. 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

8. Tendonitis Area

9. 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

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

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

12. 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

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

14. Types of Achilles Tendonitis Noninsertional Insertional

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

16. 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

17. 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

18. Paratendonitis Diffuse fusiform swelling and tenderness

19. Achilles Tendonitis Normal

20. Achilles Tendonitis

21. Normal Achilles Abnormal Achilles

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

23. Nodular Tendonosis nodules

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

25. 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

26. 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

27. Clinical Picture of Insertional Achilles Tendonitis Heel Spur

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

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

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

31. Surgical Management

32. Spur Removed

33. AN OUNCE OF PREVENTION IS WORTH A POUND OF CURE

34. 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.

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

36. Uncomfortable Modalities

37. Comfortable and Effective Modality

38. 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

39. Plantar Fasciitis and the Achillease

40. 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)

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

43. 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

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

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

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

47. 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

48. 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

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

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

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

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

53. Treatment of Plantar Fasciitis Surgical (Endoscopic Plantar Fasciotomy)

54. 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.

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

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

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