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

2. Aims Anatomy and function Classification Aetiology Pathology Clinical features Management

3. Anatomy

4. Micro-Anatomy Kastelic et al, 1978

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

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

7. Retrocalcaneal Bursitis Pain Swelling Footwear Tenderness

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

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

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

11. Insertional Tendinitis Pain Swelling Footwear Tenderness

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

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

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

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

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

17. Non-Insertional Tendinitis Heat generation

18. Prevention Exercise Hydration Orthoses

19. Non-Insertional Tendinitis Paratendinitis Paratendinitis with tendinopathy Tendinopathy

20. Non-Insertional Tendinitis Paratendinitis Paratendinitis with tendinopathy Tendinopathy

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

22. 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

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

24. Tendon Repair

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

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

27. Achilles Tendon Rupture Tendinopathy Excessive force

28. Achilles Tendon Rupture Sudden pain Swelling Bruising Weakness 75% in sporting activity Age 30-40 Male predominance

29. Achilles Tendon Rupture Swelling Gap in tendon Calf squeeze test

30. Management Conservative or Surgical ?

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

32. 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

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

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

35. 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

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

37. Surgery or Not ? Taylor your treatment to the patient

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

39. Chronic Rupture FHL Transfer

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

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

42. Reversed Z-Plasty Green and Briggs, 2002

43. Reversed Z-Plasty Green and Briggs, 2002

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

45. Questions ?