ACHILLES TENDONITIS
AND RUPTURE
Dr Carl Clinton
(no conflict of interests)
Will not include such pathologies:a)
b)
c)
e)
e)
f)
g)
Retrocalcanel Bursitis
Haglund’s Deformity
Impingement Syndrome
‘Pump Bump’
Ankle O/A
Ruptured Bakers’s Cyst
DVT
ANATOMY 1
a)
b)
c)
d)
Attaches the plantaris/ gastrocnemius
and soleus muscles to the calcaneus
Thickest and strongest tendon in the
body
Achilles muscle reflex tests the integrity
of the S1 spinal root
About 15cm (6in) long
ANATOMY 2
e) The tendon can receive a load stress
3.9 times body weight during walking
and
7.7 times body weight during running
f) The tendon is surrounded by a
connective tissue sheath (paratenon)
rather than a true synovial sheath
ANATOMY 3
g) Arterial anatomy of Achilles
- supplied by two arteries - the posterior tibial
- the peroneal arteries
- 3 vascular territories - the midsection supplied by
the peroneal artery
- promixal and distal section
supplied by the posterior
tibial artery
The midsection of Achilles markedly more
hypovascular (risk rupture and surgical
complications at its midsection).
EPIDEMIOLOGY AND CAUSES
a) OVERUSE - too long/too fast/too steep/ too explosive
b) MISALIGNMENT - gait (excessive pronation)
c) IMPROPER FOOTWEAR - saddle too low/extra
dorsiflexion
e) MEDICAL SIDE EFFECTS - quinolone group of A/B
(ciprofloxacin)
e) CORTISONE- indirect - weakened Achilles feels too
comfortable
g) ACCIDENTS - laceration/crush
h) GENETICS - individuals with the single nuclear
plymorphism (SNP) TT genotype of the GDF5rs 143383
variant have twice the risk of developing Achilles problems
i) SYSTEMIC CONDITIONS - gout/RA/SLE/Cushing’s syndrome
PRESENTATION
a) ACHILLES TENDONITIS
- gradual onset pain/stiffness
- improves with heat and exercise ‘able to run off
symptoms’
- may with strenuous activity get worse or
experience calf pain
- tenderness of the tendon on palpation
- there may be crepitus and swelling
- may be pain on active movement of the ankle
joint
PRESENTATION
b) ACHILLES RUPTURE
- rupture can occur at any age but most common
30 - 50 year old
- acute onset of pain in tendon
- sudden ‘sharp pain’
- snap ‘heard’
- may have PMH of Achilles Tendonitis
- inability to stand on tiptoe
- altered gait ‘inability to push off’
- swelling/ GAP
EXAMINATION
- observe gait
- look for swelling/bruising
- may have a palpable GAP
- active plantar flexion is weak or absent
- ‘Thompson’s Test’ ‘calf squeeze test’
- fusiform swelling with pain to palpation
- gout/RA/SLE/Cushings’ Syndrome/DVT/ ruptured
Bakers’s Cyst/O/A ankle (examine ankle/knee/calf)
INVESTIGATIONS
- UTRASOUND
- MRI
MANAGEMENT
ACHILLES TENDONITIS
Insufficient evidence from randomised controlled
trials to determine which method of treatment is the
most appropriate.
a) abstain from aggravating activities
b) NICER - ?? Use NSAID (inflammation v degenerate)
c) physio + relative rest (alternative exercise)
Podiatrist
- ‘stretching/strengthening’
Hip/back muscles tight
Calf muscles tight
Strengthening anterior tibialis
- massage
- eccentric exercises
- orthotics (gait) / review footwear
d) physical therapy - US/electric stimulation/laser photo
stimulation
e) other treatments
- heparin
- steriod injections/sclerosant injections
- glycosaminoglycan sulfate
- actovegin
- GTN patches
- electronic wave shock treatment
- extra corporeal shockwave therapy
- blood letting/blood injections
- needling
- casting
f) surgery
-? last resort
- ? after six months
- ? plantaris wrap around
- ? foot in equinus in plaster 6/52
- ? degenerate v inflammatory
MANAGEMENT
ACHILLES RUPTURE
SURGICAL V CONSERVATIVE
a) surgery v non surgery
‘NO CONSENSUS’ :- b) best surgical approach
c) best non-surgical approach
Surgical treatment of
Acute Achilles Rupture
significantly reduces the
risk of re-rupture
compared with nonsurgical treatment, but
produces significantly
higher risks of other
complications such as
infection, adhesions and
disturbed skin
sensibility/breakdown.
PROGNOSIS
ACHILLES TENDONITIS
a) no consensus on best treatment
b) recovery can take weeks or months
c) surgery is possible
PROGNOSIS
ACHILLES RUPTURE
a) no consensus on best treatment
b) surgical treatment decreased risk of rerupture
c) may take 1 year to recover
d) may be left with slight loss of function
e) usually good prognosis however
POSSIBLE EXPLANATION:-
ANY QUESTIONS ?
July 2013