Achilles Tendon Injuries: Presentation and Management

Achilles tendon injuries can manifest in several ways, including:
Tendonitis: Inflammation and irritation of the Achilles tendon, often due to overuse.
Tears or Ruptures: Sudden severe pain, often described as a pop, indicating a tear or rupture that requires immediate medical attention.
Symptoms: Common signs include pain above the heel, especially when stretching the ankle or standing on toes, which may worsen over time.
Types of Injuries: These include Achilles tendinitis (inflammation) and tendinosis (degeneration).
Treatment: Options may include rest, physical therapy, and in some cases, surgery, depending on the severity of the injury.

1. Achilles Tendon Injuries Dr Junaid Khurshid MBBS, MS, MCh, DrNB, MNAMS Fellowship Aesthetic Surgery Fellowship Reconstructive Microsurgery Department of Plastic, Reconstructive and Aesthetic Surgery Ujala Cygnus Kashmir, Superspeciality Hospital

2. Name Origin The  tendon  is named after the ancient Greek mythological figure  Achilles   Lies at the only part of his body that was still vulnerable after his mother had dipped him (holding him by the heel) into the River Styx.

3. Name Origin He was considered invulnerable, but he did have one weak spot : his heel. Achilles was hit there by an arrow during the Trojan War, which is why he lost his life. This legend is the reason why the Achilles heel has become synonymous for a vulnerable spot and gave its name to the human Achilles tendon.

4. Anatomy The  Achilles tendon  is the strongest and largest  tendon  in the body. It is the conjoined  tendon  of the gastrocnemius and the soleus  muscles , and may have a small contribution from the plantaris . The  muscles  and the  Achilles tendon  are in the posterior, superficial compartment of the calf.

5. Facts The tendon at the heel is an infamous  weak spot , above all in runners. Many athletes know the Achilles tendon pain syndrome, so-called  achillodynia Usual site of spontaneous rupture 6 cm above insertion as this is the watershed area of vascularity.

6. Remarkable response to stress Exercise induces increase in tendon diameter Inactivity causes rapid atrophy Age-related decreases in cell density& collagen Facts

7. Gastrocnemius-soleus-Achilles complex, Acts on 3 joints Flexion of knee Plantarflexion of tibiotalar joint Supination of subtalar joint. Facts

8. Risk Factors Recreational athlete : Basketball , Volleyball , Rugby , Soccer Age 30 -50 years Obesity Diabetes Mellitus Previous tendon injury Fluoroquinolone use Industrial Accidents Steroid injection

9. Classification Of TA Rupture Open Close Acute Athletics injuries Neglected Degenerative Injuries e

10. PATHOPHYSIOLOGY OF DEGENERATIVE TENDON INJURY Repetitive microtrauma Relatively hypovascular area. Reparative process inadequate Most ruptures occur in “Watershed area” Antecedent tendinitis/tendinosis in15%

11. ATHLETIC INJURY Indirect : Eccentric force applied to dorsiflexed foot ; Sudden unexpected dorsiflexion of ankle Direct : May occur as the result of direct trauma

12. Acute Rupture Feels like being kicked in the leg Feeling of sudden Snap in the lower calf Acute sever pain Walk with a limp, unable to run, climb stairs, or stand on their toes Loss of plantar flexion power

13. Contd. The back of the heel will be swollen. Decreased active plantar flexion of the ankle. Increased passive dorsiflexion Inability to heel raise Impaired gait A positive Thompson Test

14. Swelling , nodularity due to thickening and calcification crepitation along the tendon sheath

15. Partial tear :- fusiform swelling Physical Examination

16. Physical Examination Palpation of entire length of muscle-tendon unit during active and passive ROM

17. Special Tests Thompson test  - this test is especially useful for diagnosing complete Achilles tendon ruptures and less useful for the diagnosis of partial Achilles Tendon rupture.

18. Contd. Matles Test  - the patient lies in a prone position and is asked to actively flex the knee through 90 degrees. The therapist observes the feet and ankles throughout the movement. The test is negative when the foot displays slight plantarflexion ; the test is positive if the footfalls into the neutral position or the movement result in dorsiflexion . Maffulli reports a sensitivity of 0.88  and considered the most reliable test 

19. Achilles Tendon Total Rupture (ATR-score) - the Achilles Tendon rupture-score is an important questionnaire that refers to the limitations/difficulties a patient with a tendon rupture will face.  Realtime Achilles ultrasound Thompson test - this test is as the Thompson test, but under ultrasound visualization. It can be used by surgeons with minimal training in ultrasonography. It provides improved diagnostic characteristics compared with static ultrasound.

20. “ Hyperdorsiflexion ” sign: With the patient prone and knees flexed to 90º, maximal passive dorsiflexion of both feet may reveal excessive dorsiflexion of the affected leg. O’Brien needle test: insert a needle 10 cm proximal to the calcaneal insertion of the tendon. With passive dorsiflexion of the foot, the hub of the needle will tilt rostrally when the Achilles tendon is intact.

21. Classification Type I: partial ruptures ≤50% - typically treated with conservative management Type II: complete rupture with tendinous gap ≤3 cm - typically treated with end-end anastomosis Type III: complete rupture with tendinous gap 3 to 6 cm - often requires tendon/synthetic graft Type IV: complete rupture with a defect of >6 cm (neglected ruptures) - often requires tendon/synthetic graft and gastrocnemius recession.

22. Imaging Avulsion fracture at the insertion , with marked separation of fragments.

23. Kager fat pad  ( precalcaneal fat pad  or  preAchilles fat pad ) refers to the fat within the  Kager triangle, which normally appears lucent (fat density) Pathologies affecting nearby structures result in loss of the normal margins and increased density in the triangle.  

24. Kager’s Fat pad

25. Ultrasound Inexpensive fast, reproducable , dynamic examination possible Best to measure thickness and gap Good screening test for complete rupture

26. MRI • Expensive, not dynamic •Better at detecting partial ruptures •Staging of degenerative changes,(monitor healing)

27. Contd. Magnetic resonance imaging (MRI) is the modality of choice for radiological evaluation. It is accurate to assess the status and integrity of the tendon with well documented features Understanding of the healing process in post-operative period may prevent overestimation of tendon gap and misdiagnosis of re-tear. 

28. Rupture

29. Xanthoma With Gout Infiltration

30. Achilles tendon rupture with retracted ends of its torn fibers (yellow arrows). Few remaining intact fibers are seen along its medial aspect (red arrow).

31. Markedly lengthening of Achilles tendon due to chronic tendinosis .

32.   2 months after open surgery for Achilles repair in Patient A. PD-weighted and fat suppressed T2-weighted sagittal images show apparent tendon discontinuity at the operative site. Sutures are present at both ends with no significant separation.

33.  6 months after open surgery for Achilles repair in Patient A. The outline of repaired tendon is now well defined with hypointense scar tissue across the surgical site on PD-weighted and fat suppressed T2-weighted sagittal images.

34. Caution MR evaluation of the Achilles tendon with post-operative changes requires the knowledge of serial changes in different stages of healing response. Caution has to be made to avoid misdiagnosis of tendon re-rupture, especially early after the surgery.

35. Management Goals Optimize gastro- soleous strength and function Restore musculotendinous length and tension. Avoid ankle stiffness

36. Management There is still considerable controversy as the most optimal treatment plan Nonoperative  vs  surgical repair  for acute ruptures Minimally invasive vs traditional open repair Early functional rehabilitation protocols instead of a more traditional rehabilitation program

37. Dependent on personal factors such as age, desire to return to sport and individual preference An operative repair was considered to reduce the risk of a future re-rupture Therefore younger persons were recommended to choose the operative repair Elderly, patients with co-morbidities such as diabetes, and peripheral neuropathies, and less active patients were recommended a conservative approach with immobilization in a cast.

38. Acute Achilles Tendon rupture High complication rate after open surgical repair, including wound infection, abnormal sensation, adhesion and thrombosis Minimal invasive techniques and percutaneous repair become more and more common because they reduce complications and have both a good outcome.

39. Sural Nerve entrapment in the stitching and  Tibial nerve involvement are common complications following surgical, specifically endoscopic operations.

40. Conservative Management Cast In Plantar flexion…. 2 Weeks CAM Walker or cast in plantar flexion .. 2 Weeks Allow progressive weight bearing in removable Cast 2 to 4 weeks (Start physio for ROM Exercises) WBAT and foot is plantigrade Remove cast walk with shoe lift 2* 1 cm one month followed by 1*1 cm one month ( Start strengthening program)

41. Controlled Ankle Movement CAM stands for  Controlled Ankle Movement . It works by both keeping your foot and ankle fixed in place, and offloading (removing) some of the weight off your foot and ankle while you continue to walk.

42. CAM Walker

43. Disadvantage 40% Re-Rupture rate

44. Surgical management

45. Principles Preserve anterior paratenon bl. Supply Beware of sural nerve Debride and approximate tendon ends Use 2-4 stranded locked suture technique Close paratenon separately

46. Defects of 1 cm or less Direct end to end repair without augmentation Bunnell Suture Modified Kessler Many techniques available

47. Defects 1 - 2 cm Muscle mobilization augmentation ( plantaris ) Can gain up to 2 cm with mobilization

48. Defects 2 - 5 cm Semi-T tendon transfer Flexor hallucis longus (FHL) tendon transfer loss of great toe flexion(Not acceptable in Athletes) Others: FDL , Peroneus Brevis V-Y myotendinous lengthening FHL transfer

49. CASE OF TENDOACHILLES RUPTURE •M/28 •3 Months old injury •USG : 25 mm gap , 38 mm proximal to calcaneal tuberosity

50. Chronic rupture with fibrosed tissue

51. Plantaris Gap 5 cm

52. Semi T Harvested

53. Semi-T passed through the proximal Musculo-Tendinous junction

54. Semi-T passed through Calcaneum

55. Semi T fixed to Calcaneum using IF Screw

56. Semi T and Plantaris are sutured with distal & proximal TA using nonaborbable suture

57. Cast in Equinus for 3 Weeks

58. Defects > 5 cm SemiT Transfer V-Y myotendinous lengthening

59. PERCUTANEOUS VS. OPEN Percutanious Less wound complications Higher re-rupture rate Better cosmesis Open Return to preinjury level Decreased calf atrophy Better motion Less re-rupture

60. Mini Incision Minimal  incision Achilles tendon repair  is indicated for acute mid-substance ruptures. It is not indicated in ruptures at the musculotendinous junction, avulsions involving bone, re-ruptures or chronic ruptures. It also requires the distal portion of the  tendon  to be a minimum of 2 cm in length.

61. Suture Techniques Modified Kessler Suture Technique

62. Bunnell suture

63. Krakow Suture

64. Karakow Suture 3 rows of interlocking sutures Both sides of both cut ends Core sutures tied with each other

65. Gift Box Suture Technique Modification of traditional Krakow Technique Knots tied away from repair site Twice strong

66. Fixation Of Tendon to bone Interference screw fixation

67. Screws Used Tenodesis Screws Eliminate need of intraosseous channels

68. Screws Used

69. Changes in Understanding Post surgically , early weight-bearing and early ankle mobilisation are now widely accepted However more recently, it has been demonstrated that a conservative and accelerated functional rehabilitation approach is more effective than a surgical approach

70. Outcome Measure Objective measures: parameters directly registered by the physiotherapist, such as ankle range of motion (ROM) or calf muscle strength measurements. These objective data, derived from the patient’s physical examination, have traditionally formed the basis of functional assessment following an Achilles Tendon rupture.

71. Patient-reported measures: over the past two decades, it has become increasingly recognized that the patient’s own appraisal of outcome is of the most important when judging the results of treatment.

72. Patient Reported Measures ATRS in combination with a generic measure, such as the SF-36  The 36-item Short Form (SF-36) is a commonly used instrument for measuring the Health-Related Quality of Life, it is a valid and reliable tool. Scales focus on the patient’s perception of his/her health status, which has to be considered as the most important indicator of the success of treatment.

73. Acknowledgements Our Teachers Anesthesia Team All theatre staff Technical staff Patients for giving consent Thank you