5. Blood supply
1) Musculotendinous junction
2) Osseous insertion on calcaneus
3) Multiple mesotenal vessels on
anterior surface of paratenon (in
adipose)
– Transverse vincula
Fewest @ 2 to 6 cm proximal to
osseous insertion
6. Remarkable response to stress
Exercise induces tendon diameter
increase
Inactivity or immobilization causes
rapid atrophy
Age-related decreases in cell
density, collagen fibril diameter and
density
Older athletes have higher injury
susceptibility
7. Gastrocnemius-soleus-Achilles
complex
Spans 3 joints
Flex knee
Plantar flex tibiotalar joint
Supinatesubtalar joint
Up to 10 times body weight through
tendon when running
8. 1. Close injury/rupture
2. Open injury/rupture
• Acute injury
• Neglected injury
11. Pathophysiology
Repetitive microtrauma
in a relatively
hypovascular area.
Reparative process
unable to keep up
May be on the
background of a
degenerative tendon
12. Antecedent tendinitis/tendinosis in 15%
75% of sports-related ruptures happen
in patients between 30-40 years of
age.
Most ruptures occur in watershed area
4cm proximal to the calcaneal
insertion.
13.
14. History
Feels like being kicked in the leg
Case reports of fluoroquinolone use,
steroid injections
Mechanism
Eccentric loading (running backwards in
tennis)
Sudden unexpected dorsiflexion of ankle
(Direct blow or laceration)
15.
16. Prone patient with feet over edge of
bed
Palpation of entire length of muscle-
tendon unit during active and
passive ROM
Compare tendon width to other side
Note tenderness, crepitation,
warmth, swelling, nodularity,
palpable defects
21. Diagnostic Pitfalls
23% missed by Primary Physician
(Inglis&Sculco)
Tendon defect can be masked by hematoma
Plantar-flexion power of extrinsic foot flexors
retained
Thompson test can produce a false-negative
if accessory ankle flexors also squeezed
22. This lateral x-ray of the
calcaneus shows an
avulsion fracture at the
insertion of the Achilles
tendon, with marked
separation of fragments.
.
23. Inexpensive, fast, reproducable,
dynamic examination possible
Operator dependent
Best to measure thickness and gap
Good screening test for complete
rupture
24. Expensive, not dynamic
Better at detecting partial
ruptures and staging
degenerative changes,
(monitor healing)
25. Restore
musculotendinous length
and tension.
Optimize gastro-soleous
strength and function
Avoid ankle stiffness
26. CAM Walker or cast with
2 wks plantarflexion q 2 wks
4 weeks
Start physio for ROM Allow progressive weight-
exercises bearing in removable cast
When WBAT and 2- 4 weeks
foot is plantigrade
Start a strengthening Remove cast and walk with shoe
program lift. Start with 2cm x 1 month,
then 1cm x1 month then D/C
27. Preserve anterior paratenon blood
supply
Beware of sural nerve
Debride and approximate tendon ends
Use 2-4 stranded locked suture
technique
May augment with absorbable suture
Close paratenon separately
28.
29. Acute case : usually end
to end repair is enough
Neglected case:
Advancement plasy (V-Y)
or reconstruction by
other tendons
30.
31.
32.
33. Assess strength of repair, tension and
ROM intra-op.
Apply long leg cast with ankle in the least
amount of planterflexion(gravityequinus) &
knee 60 degree flexion with window at
operated site.
Stitch removal after 2 wks.
Short leg cast after 3 wks with partial
equinus correction
34. 2 weekly plaster change with
gradual equinus correction (4-6
episode ).
Walking with heel raised shoe &
regular physiotherapy.
Reverse ankle stop brace up to 6
months.
35. Acute rupture of tendon Achilles. A prospective randomised
study ofcomparison between surgical and non-surgical treatment.
Moller M, et al. J Bone Joint Surg Br. 2001 Aug;83(5):863-8
112 patients
Casted x 8 wks Surgery +
Early functional rehab in
brace
21 % re-rupture 1.7% re-rupture
5% infection
No difference in
functional outcome 2% Sural nerve inj.