Achilles Tendon Injury

Peter J Briggs, BSc, MD, FRCS

Newcastle upon Tyne

Aims

• Anatomy and function

• Classification

• Aetiology

• Pathology

• Clinical features

• Management

Anatomy

Micro-Anatomy

Kastelic et al, 1978

Function

• Plantar-flexion of the ankle in late stance

• 700N on heel elevation

• Up to 4000N in running

• Elasticity

Classification of Disorders

• Insertional– Retrocalcaneal bursitis– Insertional tendinopathy

• Non-Insertional– Paratendinitis– Paratendinitis with tendinopathy– Tendinopathy

Retrocalcaneal Bursitis

• Pain

• Swelling

• Footwear

• Tenderness

Retrocalcaneal Bursitis

• Ice

• Anti-inflammatories

• Heel lift

• Low/cushioned heel counter

• Surgical resection

Retrocalcaneal Bursitis

• Ice

• Anti-inflammatories

• Heel lift

• Low/cushioned heel counter

• Surgical resection– Bursa– Haglund’s deformity

Retrocalcaneal Bursitis

• Ice

• Anti-inflammatories

• Heel lift

• Low/cushioned heel counter

• Surgical resection– Bursa– Haglund’s deformity

Insertional Tendinitis

• Pain

• Swelling

• Footwear

• Tenderness

Insertional Tendinitis

• Ice

• Anti-inflammatories

• Heel lift

• Heel cushions

• Splints

• Immobilisation

Insertional Tendinitis

• Resection– Spur– Degenerate tendon

• Osteotomy

• Reconstruction– Eg. FHL tendon

transfer

Insertional Tendinitis

• Resection– Spur– Degenerate tendon

• Osteotomy

• Reconstruction– Eg. FHL tendon

transfer

Insertional Tendinitis

• Resection– Spur– Degenerate tendon

• Osteotomy

• Reconstruction– eg. FHL tendon transfer

Non-Insertional Tendinitis

• Aetiology– Overuse– Hypovascularity– Tendon twist– Heel pronation– Small Achilles tendon– Diabetes– Steroid use

Oakes, 2003

Non-Insertional Tendinitis

• Heat generation

Prevention

• Exercise

• Hydration

• Orthoses

Non-Insertional Tendinitis

• Paratendinitis

• Paratendinitis with tendinopathy

• Tendinopathy

Non-Insertional Tendinitis

• Paratendinitis

• Paratendinitis with tendinopathy

• Tendinopathy

Pathology

• Inflammation / Repair– Bleeding– Phagocytosis– Vascular ingrowth– Fibroblast proliferation– Collagen production

• Type III then Type I

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

Pathology

• Remodelling / Maturation– Reduced cell numbers– Reduced water content– Collagen concentration reduced, but total

amount increased– Shortening of repair, probably by

myofibroblasts

Tendon Repair

Non-Insertional Tendinitis

• Ice

• Anti-inflammatories

• Modified activity

• Heel lift

• Stretching programme

• ? Immobilisation

Surgery

• Paratendinitis– Excision of thickened paratenon

• Tendinopathy– Debridement of diseased tendon– Reconstruction

Achilles Tendon Rupture

• Tendinopathy

• Excessive force

Achilles Tendon Rupture

• Sudden pain• Swelling• Bruising• Weakness

• 75% in sporting activity

• Age 30-40• Male predominance

Achilles Tendon Rupture

• Swelling

• Gap in tendon

• Calf squeeze test

Management

• Conservative or Surgical ?

Management

• Conservative– Re-rupture (10-30%)– Stiffness– Weakness

• Surgery– Wound dehiscence (10%)– Sural nerve injury

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

Management

• Options– Immobilisation– Early mobilisation– Weight bearing

– Open surgery– Percutaneous surgery

Management

• Options– Immobilisation (various forms)– Early mobilisation (different stages)– Weight bearing (different degrees and stages)

– Open surgery (various incisions)– Percutaneous surgery (various techniques)

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

Surgery or Not ?

• Repair is stronger

• Less risk of re-rupture

• Earlier return to activity

• Open or percutaneous

Surgery or Not ?

• Taylor your treatment to the patient

Chronic Rupture

• Reconstruction– Turn-down flaps

• V-Y plasty• Turn-down flap

– Tendon transfer• FHL• FDL• Peroneus Brevis

– Artificial materials

Chronic Rupture

• FHL Transfer

Chronic Rupture

• Wound healing– Bulky repair– Loss of achilles retinaculum– Bow-stringing of tight repair– Precarious blood supply

Reversed Z-Plasty Skin Incision

ab

x’

y’ab

x

y

Green and Briggs, 2002

Reversed Z-Plasty

Green and Briggs, 2002

Reversed Z-Plasty

Green and Briggs, 2002

Conclusions

• Anatomy and function of the Achilles tendon

• Types of tendon injury

• Tendon repair process

• Management of Achilles tendon injury

Questions ?