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Largest tendon in the body Origin from gastrocnemius and soleus muscles Insertion on calcaneal tuberosity Lacks a true synovial sheath- Paratenon has visceral and parietal layers Allows for 1.5cm of tendon glide Paratenon Anterior – richly vascularized The remainder – multiple thin membranes 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 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 Gastrocnemius-soleus-Achilles complex Spans 3 joints Flex knee Plantar flex tibiotalar joint Supinate subtalar joint Up to 10 times body weight through tendon when running 1. Close injury/rupture 2. Open injury/rupture • Acute injury • Neglected injury 1. Accidental cut injury (bath room injury, road traffic injury) 2. Social/political Violence 1. Diagnosis and assessment of extend of injury. 2. Primary care 3. Operative treatment Pathophysiology Repetitive microtrauma in a relatively hypovascular area. Reparative process unable to keep up May be on the background of a degenerative tendon 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. 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) 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 Partial Localized tenderness +/- nodularity Complete Defect Cannot heel raise Positive Thompson test 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 This lateral x-ray of the calcaneus shows an avulsion fracture at the insertion of the Achilles tendon, with marked separation of fragments. . Inexpensive, fast, reproducable, dynamic examination possible Operator dependent Best to measure thickness and gap Good screening test for complete rupture Expensive, not dynamic Better at detecting partial ruptures and staging degenerative changes, (monitor healing) Restore musculotendinous length and tension. Optimize gastro-soleous strength and function Avoid ankle stiffness 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 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 Acute case : usually end to end repair is enough Neglected case: Advancement plasy (V- Y) or reconstruction by other tendons Assess strength of repair, tension and ROM intra-op. Apply long leg cast with ankle in the least amount of planterflexion(gravity equinus) & knee 60 degree flexion with window at operated site. Stitch removal after 2 wks. Short leg cast after 3 wks with partial equinus correction 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. 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.
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