ACHILLES TENDINITIS & ACHILLES TENDON RUPTURE-TREATMENT, DIAGNOSIS AND CAUSES- 2020

ACHILLES TENDINITIS
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ACHILLES TENDINITIS

It is an overuse injury of the Achilles tendon, the band of tissue that connects calf muscles at the posterior side of the lower leg to your heel bone.

Achilles tendinitis is most commonly occurs in runners who have suddenly ↑sed the intensity or duration of their runs. It is also occur common in middle-aged people who play sports, such as basketball or tennis, only on the weekends.

HISTORY

Mechanism
➣ Overuse, muscle imbalance, poor exercise biomechanics
 Initial complaints
➣ Pain, swelling, decreased activity tolerance
 Chronic complaints
➣ Pain with activity, difficulty running and jumping
➣ Swelling
Common in runners

PHYSICAL EXAM
 Acute
➣ Diffuse swelling, pain with palpation, pain with dorsiflexion
➣ Lateral pain – Associated with supination
➣ Medial pain – Associated with pronation
 Chronic
➣ Pain, decreased dorsiflexion, atrophy
➣ Longitudinal swelling rather than well localized
 Classification
➣ Insertional vs. noninsertional

STUDIES
 Radiographs
➣ AP, lateral, mortise views (lateral most important)
➣ Radiographs generally normal
➣ Calcifications, traction spurs – Degenerative changes, degenerative changes or partial tear

 MRI
➣ Tendinitis – Peritendinous fluid/edema, no tendinous signal
changes
➣ Differential diagnosis using MRI

  • Tendinosis (intrasubstance signal changes)
  •  Partial tear
  • Retrocalcaneal bursitis

DIFFERENTIAL DIAGNOSIS
 Achilles tendinosis
 Partial tear
 Haglund’s deformity
 Retrocalcaneal bursitis

TREATMENT
Nonoperative
➣ Types of nonoperative treatment

  • Immobilization (cast, walking boot)
  • Heel lift
  • Anti-inflammatory medications
  • Achilles stretching
  • Physical therapy (including ice massage)
  • Steroids contraindicated due to risk of rupture

 Operative
➣ Debridement if refractory to conservative measures
➣ Lysis of adhesions

PROGNOSIS
 Pure tendinitis without associated tendinosis usually responds well to conservative measures.
 Surgical results for insertional Achilles tendinitis are worse than those for noninsertional Achilles tendinitis.
 Long-term complications
➣ Tendon ruptures after steroids by mouth or injection
➣ Chronic swelling or pain can result even after debridement.

CAVEATS AND PEARLS
 MRI very useful in distinguishing between tendinosis and tendinitis.

 

ACHILLES TENDON RUPTURE

HISTORY
 Mechanism
➣ Sudden contraction
➣ Susceptible tendons are weakened by degenerative disease such as obesity, diabetes, hypertension, and the effects of corticosteroids, all of which lead to vascular compromise.
 Acute rupture: complaints
➣ Stabbing pain in posterior calf
➣ Pts often complain that they were “kicked” in calf
➣ Pain, swelling, decreased or absent push-off
Chronic rupture: complaints
➣ Difficulty walking, inability to run, chronic weakness, altered
gait, pain and swelling.

PHYSICAL EXAM
 Acute
➣ Palpable defect in posterior calf in area of Achilles tendon, along with ecchymosis and swelling.
➣ Thompson test
 Chronic
➣ ± palpable defect of posterior calf
➣ Weakness in pure plantarflexion of foot
 Classification
➣ Acute ruptures

  •  Diagnosis within 0–4 weeks of injury

➣ Chronic ruptures

  • Diagnosis 1–3 months after injury

STUDIES
 Radiographs
➣ AP, lateral, mortise views (lateral most important)
➣ Radiographs generally normal
➣ Calcifications, traction spurs – Degenerative changes, degenerative changes or partial tear (indicative of longstanding disease
of the tendon)

 MRI
➣ Generally not necessary for diagnosis of acute ruptures
➣ May be useful in cases of suspected chronic ruptures
➣ Useful in differential diagnosis

  • Partial tendon tear
  •  Localization of tear
  • Gastrocsoleus tear
  • Plantaris tear

DIFFERENTIAL DIAGNOSIS
 Achilles tendinosis
 Partial tear
 Avulsion
 Ankle sprain
 Isolated plantaris tear
 Gastrocsoleus muscle tear

TREATMENT
 Acute
➣ Nonoperative for acute ruptures

  • Cast or brace immobilization (nonweight-bearing, 6–8 weeks)

➣ Operative for acute ruptures

  •  Open vs. percutaneous repair (Ma procedure)
  •  Ma (lower incidence of wound problems)
  • Lower rate of rerupture with direct repair

 Chronic
➣ Nonoperative for chronic ruptures

  • AFO or similar bracing (palliative care

➣ Operative for chronic ruptures

  • Achilles reconstruction using graft (salvage procedure)
  • Flexor hallucis longus
  • Fascial graft
  • Peroneus brevis

➣ Rehabilitation

  • Goals of physical therapy: ROM and strengthening
  •  5–6 months before return to contact sports
  •  Role of earlier ROM gaining greater popularity

PROGNOSIS
Results of conservative or operative repair generally good (greater strength with repair)
 Results of treatment after chronic rupture not as good as with acute repair.
➣ Reconstruction generally does not allow for return to competitive sports
 Complications
➣ Rerupture (greater with conservative treatment)
➣ Equinus (heel cord tightness)
➣ Skin slough, infection, painful scar

CAVEATS AND PEARLS
 Careful handling of the soft tissue is imperative to avoid wound complications.


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