CME- on Tendo Achillis Injury

2.  Largest tendon in the
body
 Origin from
gastrocnemius and
soleus muscles
 Insertion on
calcanealtuberosity

3. Lacks a true synovial
sheath-
 Paratenon has visceral
and parietal layers
 Allows for 1.5cm of
tendon glide

4. Paratenon
 Anterior – richly vascularized
 The remainder – multiple thin
membranes

5. Blood supply
1) Musculotendinous junction
2) Osseous insertion on calcaneus
3) Multiple mesotenal vessels on
anterior surface of paratenon (in
adipose)
– Transverse vincula
 Fewest @ 2 to 6 cm proximal to
osseous insertion

6.  Remarkable response to stress
 Exercise induces tendon diameter
increase
 Inactivity or immobilization causes
rapid atrophy
 Age-related decreases in cell
density, collagen fibril diameter and
density
 Older athletes have higher injury
susceptibility

7.  Gastrocnemius-soleus-Achilles
complex
 Spans 3 joints
 Flex knee
 Plantar flex tibiotalar joint
 Supinatesubtalar joint
 Up to 10 times body weight through
tendon when running

8. 1. Close injury/rupture
2. Open injury/rupture
• Acute injury
• Neglected injury

9. 1. Accidental cut injury
(bath room injury, road
traffic injury)
2. Social/political
Violence

10. 1. Diagnosis and
assessment of extend
of injury.
2. Primary care
3. Operative treatment

11.  Pathophysiology
 Repetitive microtrauma
in a relatively
hypovascular area.
 Reparative process
unable to keep up
 May be on the
background of a
degenerative tendon

12.  Antecedent tendinitis/tendinosis in 15%
 75% of sports-related ruptures happen
in patients between 30-40 years of
age.
 Most ruptures occur in watershed area
4cm proximal to the calcaneal
insertion.

14. History
 Feels like being kicked in the leg
 Case reports of fluoroquinolone use,
steroid injections
 Mechanism
 Eccentric loading (running backwards in
tennis)
 Sudden unexpected dorsiflexion of ankle
 (Direct blow or laceration)

16. Prone patient with feet over edge of
bed
Palpation of entire length of muscle-
tendon unit during active and
passive ROM
Compare tendon width to other side
Note tenderness, crepitation,
warmth, swelling, nodularity,
palpable defects

17.  Partial
Localized tenderness +/-
nodularity
 Complete
Defect
Cannot heel raise
Positive Thompson test

21.  Diagnostic Pitfalls
 23% missed by Primary Physician
(Inglis&Sculco)
 Tendon defect can be masked by hematoma
 Plantar-flexion power of extrinsic foot flexors
retained
 Thompson test can produce a false-negative
if accessory ankle flexors also squeezed

22. This lateral x-ray of the
calcaneus shows an
avulsion fracture at the
insertion of the Achilles
tendon, with marked
separation of fragments.
.

23.  Inexpensive, fast, reproducable,
dynamic examination possible
 Operator dependent
 Best to measure thickness and gap
 Good screening test for complete
rupture

24.  Expensive, not dynamic
 Better at detecting partial
ruptures and staging
degenerative changes,
(monitor healing)

25.  Restore
musculotendinous length
and tension.
 Optimize gastro-soleous
strength and function
 Avoid ankle stiffness

26. CAM Walker or cast with
2 wks plantarflexion q 2 wks
4 weeks
Start physio for ROM Allow progressive weight-
exercises bearing in removable cast
When WBAT and 2- 4 weeks
foot is plantigrade
Start a strengthening Remove cast and walk with shoe
program lift. Start with 2cm x 1 month,
then 1cm x1 month then D/C

27.  Preserve anterior paratenon blood
supply
 Beware of sural nerve
 Debride and approximate tendon ends
 Use 2-4 stranded locked suture
technique
 May augment with absorbable suture
 Close paratenon separately

29.  Acute case : usually end
to end repair is enough
 Neglected case:
Advancement plasy (V-Y)
or reconstruction by
other tendons

33.  Assess strength of repair, tension and
ROM intra-op.
 Apply long leg cast with ankle in the least
amount of planterflexion(gravityequinus) &
knee 60 degree flexion with window at
operated site.
 Stitch removal after 2 wks.
 Short leg cast after 3 wks with partial
equinus correction

34.  2 weekly plaster change with
gradual equinus correction (4-6
episode ).
 Walking with heel raised shoe &
regular physiotherapy.
 Reverse ankle stop brace up to 6
months.

35. Acute rupture of tendon Achilles. A prospective randomised
study ofcomparison between surgical and non-surgical treatment.
Moller M, et al. J Bone Joint Surg Br. 2001 Aug;83(5):863-8
112 patients
Casted x 8 wks Surgery +
Early functional rehab in
brace
21 % re-rupture 1.7% re-rupture
5% infection
No difference in
functional outcome 2% Sural nerve inj.