ACHILLES TENDONITISAND RUPTURE

Dr Carl Clinton(no conflict of interests)

Will not include such pathologies:-a) Retrocalcanel Bursitisb) Haglund’s Deformityc) Impingement Syndromee) ‘Pump Bump’e) Ankle O/Af) Ruptured Bakers’s Cystg) DVT

a) Attaches the plantaris/ gastrocnemius and soleus muscles to the calcaneusb) Thickest and strongest tendon in the bodyc) Achilles muscle reflex tests the integrity of the S1 spinal rootd) About 15cm (6in) long

ANATOMY 1

e) The tendon can receive a load stress 3.9 times body weight during walking and7.7 times body weight during running

f) The tendon is surrounded by a connective tissue sheath (paratenon) rather than a true synovial sheath

ANATOMY 2

g) Arterial anatomy of Achilles - supplied by two arteries - the posterior tibial

- the peroneal arteries - 3 vascular territories - the midsection supplied by the peroneal artery - promixal and distal section supplied by the posterior tibial arteryThe midsection of Achilles markedly more hypovascular (risk rupture and surgical complications at its midsection).

ANATOMY 3

a) OVERUSE - too long/too fast/too steep/ too explosiveb) MISALIGNMENT - gait (excessive pronation)c) IMPROPER FOOTWEAR - saddle too low/extra dorsiflexione) MEDICAL SIDE EFFECTS - quinolone group of A/B (ciprofloxacin)e) CORTISONE- indirect - weakened Achilles feels too comfortableg) ACCIDENTS - laceration/crushh) GENETICS - individuals with the single nuclear plymorphism (SNP) TT genotype of the GDF5rs 143383 variant have twice the risk of developing Achilles problemsi) SYSTEMIC CONDITIONS - gout/RA/SLE/Cushing’s syndrome

EPIDEMIOLOGY AND CAUSES

a) ACHILLES TENDONITIS- gradual onset pain/stiffness - improves with heat and exercise ‘able

to run off symptoms’- may with strenuous activity get worse

or experience calf pain- tenderness of the tendon on palpation- there may be crepitus and swelling- may be pain on active movement of the

ankle joint

PRESENTATION

b) ACHILLES RUPTURE- rupture can occur at any age but most

common 30 - 50 year old

- acute onset of pain in tendon- sudden ‘sharp pain’- snap ‘heard’

- may have PMH of Achilles Tendonitis- inability to stand on tiptoe- altered gait ‘inability to push off’- swelling/ GAP

PRESENTATION

- observe gait- look for swelling/bruising- may have a palpable GAP- active plantar flexion is weak or absent- ‘Thompson’s Test’ ‘calf squeeze test’- fusiform swelling with pain to palpation- gout/RA/SLE/Cushings’ Syndrome/DVT/ ruptured Bakers’s Cyst/O/A ankle (examine ankle/knee/calf)

EXAMINATION

INVESTIGATIONS

- UTRASOUND- MRI

ACHILLES TENDONITISInsufficient evidence from randomised controlled trials to determine which method of treatment is the most appropriate.

MANAGEMENT

a) abstain from aggravating activitiesb) NICER - ?? Use NSAID (inflammation v degenerate)c) physio + relative rest (alternative exercise)

Podiatrist- ‘stretching/strengthening’

Hip/back muscles tightCalf muscles tightStrengthening anterior tibialis- massage- eccentric exercises- orthotics (gait) / review footwear

d) physical therapy - US/electric stimulation/laser photo stimulation

e) other treatments- heparin- steriod injections/sclerosant injections- glycosaminoglycan sulfate- actovegin- GTN patches- electronic wave shock treatment- extra corporeal shockwave therapy- blood letting/blood injections- needling- casting

f) surgery -? last resort- ? after six months- ? plantaris wrap around- ? foot in equinus in plaster 6/52- ? degenerate v inflammatory

MANAGEMENT

ACHILLES RUPTURESURGICAL V CONSERVATIVE

a) surgery v non surgery‘NO CONSENSUS’ :- b) best surgical approach

c) best non-surgical approach

Surgical treatment of Acute Achilles Rupture significantly reduces the risk of re-rupture compared with non-surgical treatment, but produces significantly higher risks of other complications such as infection, adhesions and disturbed skin sensibility/breakdown.

PROGNOSIS

ACHILLES TENDONITIS

a) no consensus on best treatmentb) recovery can take weeks or monthsc) surgery is possible

PROGNOSIS

ACHILLES RUPTURE

a) no consensus on best treatmentb) surgical treatment decreased

risk of re- rupturec) may take 1 year to recoverd) may be left with slight loss of

functione) usually good prognosis however

POSSIBLE EXPLANATION:-

ANY QUESTIONS ?

July 2013