Johan Myburgh
September 2011
Achilles
Tendon
Injuries
Hippocrates
“ this tendon if bruised or cut, causes the most
acute fevers, induces choking, deranges the
mind and at length brings death.”
PATIENT
• 31 year old male
• Recreational soccer player
• Work - oilfield worker
• Healthy - no significant past hx
• Played varsity soccer and football till 23 years old
Injury
• Came directly from work , no warm up
• Previous tightness and tenderness calf few days
• 5 minutes into game:
Pushed off back to leg drive forward
Sudden pain and weakness left leg
3 Stage Assessment
1. Clinical:
• 80% acute partial Achilles tendon rupture
• Previous sprain of Triceps surea
• Improper warm up before activity
3 stage assessment
2. Personal:
• concerned about the amount of time he is going to loose at
work- no income.
• positive about the outcome and wants to do proper
rehabilitation to speed up his recovery
3. Contextual:
• manager at work is supportive
• seasonal work - needs to recover before the work season is
over.
• family is very supportive.
Treatment
• Nonoperative treatment plan
o Immobilized equinis cast for 7 weeks
o Removable walking splint for 6 weeks
• Patient did 3 weeks
o Physiotherapy starting at week 7
Progression:
Week 13 physical exam:
o Dorsiflexion L 96° R 105°
o Tendon thickness L 30 mm R 19 mm
Achilles tendon
Anatomy
• Formed by tendinous portion of gastrocnemius and
soleus ( contribution varies)
• Progresses from round to flat distally to insert on
calcaneal tuberosity
• Distal rotational twist (90°)
o gastrocnemius fibers insert lateral
o soleus fibers insert medial
• Plantaris lies medial - distinct tendon (absent 6-8%)
• No synovial sheath – wrapped paratenon
Blood Supply
o Posterior tibial artery - majority of the blood supply
• Musculotendinous junction
• Bone-tendon junction
o Peroneal artery
• Surrounding connective tissue (paratenon/mesotenon)
Poor vascularization in midportion of tendon
o Angiographic and histological techniques showed Achilles
tendon has a poor blood supply throughout its length = small
number of blood vessels per cross-sectional area(1,4)
Histology
• Fibroblasts (Embedded in bundles of fibrils)
• Collagen comprises 70% of tendon
o 95% type I
o Ruptured tendon contains significant
type III collagen
• Collagen of granulation tissue - produced
quickly by young fibroblasts before
tougher type I collagen is synthesized
Wavy bundles collagen
Histology
Collagen organized into
parallel bundles of fibrils
Surrounded by endotenon
Units surrounded by
vascular epitenon
Pathology
Achilles tendon disorders and overuse injuries:
1. Inflammation of the peritendinous tissue
(peritendinitis,paratendinitis)
2. Degeneration of the tendon (tendinosis)
3. Tendon rupture
• Partial/Complete
• Acute/Chronic
4. Insertional disorders (retrocalcaneal bursitis and
insertional tendinopathy)
Tendinosis
Degeneration with no significant inflammation:
• Hypoxic or fibromatous:
o most frequently seen in ruptured tendons
• Myxoid
o 2nd most common
o May be silent prior to rupture
• Lipoid
o Age dependent fatty deposits that do not affect structural properties
• Calcific
o Calcium pyrophosphate
Acute Rupture
Achilles tendon
Etiology – Intrinsic Factors
• General
• Decreased perfusion
• Hyperthermia within relatively avascular Achilles tendon – more
prone rupture
• Systemic diseases
Inflammatory and autoimmune conditions
Collagen disorders
Infectious disease
Neurologic conditions
• Age >30
• Decrease in maximum diameter & density of collagen fibrils
Etiology – Extrinsic factors
o General
• Corticosteroids
Corticosteroid injection into rabbit tendons showed necrosis and
delayed healing. Several studies showed collagen damage with
injected steroids. Oral steroids also implicated(2)
• Fluoroquinolone(3)
Etiology – Extrinsic factors
• Biomechanical factors
o Rapid push off
Tendon obliquely loaded, muscle maximum contraction and initial short
tendon length
o Functional / Anatomical conditions
• Imbalance agonist muscle contractions (7)
• Functional overpronation on heel strike (midfoot) – whipping
action on Achilles – intratendinous microtears
• Poor flexibility gastroc/soleus - overpronation
Etiology – Extrinsic factors
• Biomechanical factors
o Unequal tensile forces of different parts tendon torsional ischemic affect (transient vasoconstriction of
intratendinous vessels, contribute vascular impairment already
present)
o Malfunction/Suppression of proprioceptive component of
skeletal muscle (athletes resume training after period rest)
Epidemiology
• Incidence increasing significantly
• 8.3 ruptures per 100 000 people(18)
• Gender
o Males 2:1 over females
• Age (two peaks)
o 30-50 – sports activity-related
o > 50 – non-athletes and women
• Sport
o abrupt repetitive jumping
o sprinting movements
• Race - increased African-Americans(8)
Histology of Rupture
• Collagen degeneration of tendon prior to rupture(4)
• Marked inflammatory reaction
• Hypertrophy of tunica media and narrowing of
lumen of large peritendinous vessels(1) - hypoxia
All based on biopsy at time of surgical repair
Site of Rupture
Myotendinous Junction
Midsubstance
2-6 cm proximal
to insertion
• Hypovascular
Avulsion
Diagnosis
History
Male between 30 and 50 years
Sedentary job but in athletic activity
“Weekend Warrior”
Pop, “kicked” in the back of the leg
Pain posteriorly in calf. Pain is variable
Bruising
Diagnosis
Clinical dx
Physical:
Palpable defect
Thompson Test
Single leg heel raise
Bruising/Swelling
Weakness
Thompson Test
Patient prone with feet dangling
- squeeze mid calf
NO plantar flexion = positive
Thompson test /Ruptured
tendon
Diagnosis
• Diagnostic Tests
o Ultrasound (Doubtful cases)
• Helpful with Non-operative treatment
Used to assess gap in tendon and
apposition of torn ends of tendon
o MRI (not routinely)
• Show extent of tendon degeneration
o X-rays
• Avulsion of calcaneus suspected
Ultrasound
= Hematoma in Achilles tendon
Most widely used U.K
+
Inexpensive
Readily available, fast
Dynamic assessment
Tendon thickness
Gap // torn ends
−
Operator dependent
Miss partial tears
MRI
Most widely used imaging U.S
+ Accurate
Partial tears
− Not readily available
High cost
No dynamic assessment
Classification of Achilles
tendon tear/rupture
(17)
Nonoperative Treatment
Effective for all age groups and both sedentary and sporting
individuals
• Wide variability among surgeons
o absolute immobilization
o initial range of movement exercises
o progression weight bearing status
• Cast immobilization 4-8 week (non-weight bearing)
• Functional brace 4-6 weeks
• Use ultrasound to ensure tendon apposition
Nonoperative Treatment
• Higher rerupture rate (13%) vs. operative
repair (4-5%)(10)
• Fewer overall complications ( wound
infection)
o Complications may be reduced with percutaneous surgery
Acute Complete Rupture
Surgical treatment
Two Decisions
Surgical technique
Postoperative regime
Surgical Technique
• Direct Open
(Incision 10-18 cm)
• Mini-invasive
(Incision 3-10 cm)
• Percutaneous
(multiple small incisions)
Percutaneous Achilles Repair
• vs. Open repair:
o Higher rerupture rate (6.4% vs 2.7%)
o Fewer complications
• Allow earlier mobilization
• Earlier functional rehabilitation
• Sural nerve entrapment
Open Repair
Postero-medial
incision
Incision site reduce risk injury
sural nerve and branches.
Easier access plantaris muscle
Plantaris tendon
Percutaneous Repair
Achillon Device
Complications of Surgical
Treatment
•
•
•
•
•
Wound healing problems/necrosis
Wound infection
Sural nerve injury
DVT and PE
Rerupture 2-5%
Wound necrosis
Chronic Rupture
Definition: 4-6 weeks from time of injury to diagnosis
and treatment
• Conservative management not recommended
• Fibrous tissue in gap between torn ends
• Poor plantar flexion strength (2° flexors foot)
• Open repair and reconstruction
Postoperative Regime
• Consensus
Early functional weight bearing and range of motion
decrease:
Inpatient stay
Time off from work
Faster return to sport
Lower complication rate
• No Consensus
DVT prophylaxis
DVT common after Achilles tendon rupture
No evidence to demonstrate benefit
•Start ROM exercises Day 10 /
earlier as per pt’s comfort
•Day 14 weight bearing with
restricted dorsiflexion
Rehab Principles
• Mobilization
o Cycle 10-15 min/day
• Loading
o Treadmill Incline Walk (pain free)
• Stretching
o Straight, bend knee
• Proprioception
• Ankle eversion/inversion
o Tubing
Healing and Repair
Mechanism
Achilles Tendon Healing
• Slow healing – hypovascularity + hypocellularity
• Phases
o
o
o
o
Inflammation
Proliferation
Repair
Remodeling
• Stress on tendon – remodeling ( similar to bones)
o Stronger , stiffer
o Achieved by increased collagen synthesis
alteration fibre alignment
• Mobilization increased inflammatory cells at rupture site(16)
Tendon Healing
bbbbbbbb
Remodeling/Maturation Phase
Remodeling/Consolidation Phase
Reparative (Proliferation ) Phase
Inflammatory Phase
24 hr
3 days
1
2
3
4
5
6
7
TIME - months
8
9
10
11
12
Histology healing
Microscopic view of a normal
Microscopic view of a tendon
tendon
undergoing healing
wavy pink material is the collagen
very few cells
the white "bubble" is the suture
note increase in cells
Achilles Tendon Healing
Important factors
Tension across repair
o speeds realignment fibres
o increases tensile strength
o minimize deformation
Early motion
o Accelerates nerve plasticity through regeneration and
release neuromediators
Sport Resumption
• Time to return to sport depends level sport
Average 20-24 weeks
Olympic level up to nine months
• Functional brace post-op 4 weeks earlier
• Signs to slow down /speed up rehabilitation
o Pain and swelling after activity
o Delayed tissue healing - Ultrasound
Sport Resumption
Levels
o Walking – Casted 12 weeks after surgery
Brace 8 weeks after surgery
o Recovery of force, speed and endurance
- 4-6 weeks
o Non-contact sport - 4-6 weeks
o Contact sport – 4-6 weeks
Take Home Message
o Degeneration present at time of rupture
o Early mobilization and weight bearing improved functional outcomes
THANK YOU
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
Ahmed, M. Lagopoulos, M., McConnell, P., Soarnes, R. W., Sefton, G. K Blood supply of the
Achilles tendon. J. Orthop. Res. 16:591-596, 1998.
Balasubramaniam P, Prathap K. The effectof injection of of hydrocortisone into rabbital
calcaneal tendons. J. Bone and Joint Surgery 1972;54-B:729-734
Royer RJ, Pierfitte c, Netter P. Features of tendon disorders with fluoroquinolones. Therapie
1994;49:75-76
Weatherall, J, Mroczek, K, & Tejwani, N 2010, 'Acute Achilles tendon ruptures', Orthopedics,
33, 10, pp. 758-764
Maffulli,n, Barrass, V, Stanley W.B. Ewen, Light Microscopic Histology of Achilles Tendon
Ruptures. A Comparison With Unruptured Tendons, Am J Sports Med November 2001 vol.
28 no. 6 857-863
Kannus, P., Jozsa, L. Histopathological changes preceding spontaneous rupture of a tendon.
1. Bone Joint Surg. 73-A:1507-1525, 1991.
Waterson S. Subcutaneous rupture of Achilles tendon: Basic science and some aspectes of
clinical practice. Br J Sports Med 1997;31:285-298
Davis JJ,Mason KT, Calrk DA. Achilles tendon ruptures stratified by age, race, and cause of
injury among active duty U.S. Military members. Mil Med 1999;164:872-873
Steven B. Weinfeld, MD, Associate Professor of Orthopaedic Surgery Chief Foot and Ankle
Service, Mount Sinai Medical Center, NY
References
10. Lo IK, Kirkley A, Nonweiler B, Kumbare DA. Operative treatment vs non-operative treatment
of acute Achilles tendon ruptures: A quantitative review. Clin J Sports Med1997;38:822-828
11. Forrester JC, ZederfeldtBH, Hayes TL. Wolff’s law in relation to the healing skin wound.
Journal of Trauma-Injury Infection & Critical care 1970;10: 770-779
12. Virchenko O, Skoglund B, Aspenberg P. Parecoxib inpair early tendon repair but improves
later remodeling. Am J Sports Med 2004;32;1743-1747
13. Virchenko O,Aspenberg P. How can one platelet injection after tendon injury lead to a
stronger tendon after 4 weeks? Interplay between early regeneration and mechanical
stimulation. Acta Orthopod 2006;77:806-812
14. Virchenko O, Lindahl T, Aspenberg P. Low Molecular Weight Heparin impairs tendon repair. J
Bone Joint Surg (B) 2007: in press
15. Burssens P, steyaert A, Forsyth R, van Ovost EJ, Depaepe Y, Verdonk R. Exogenously
administered substance P and neuropeptidase inhibitors stimulate fibroblast proliferation,
angiogenesis and collagen organization durinf Achilles tendon healing. Foot Ankle Int
2005;26:832-839
16. Palmes et al J of Orthopaedic Research 2002
17. Kuwada GT. Classification of teno Achilles rupture with consideration of surgical repair
techniques. J Foot Surg.1990;29:361-365
References
18. Suchak AA, Bostick G, Reid D, Blitz S. The incidence of Achilles tendon ruptures in Edmonton,
Canada. Foot Ankle Int. 2005;26(11):932-936