Disorders of the Achilles Tendon

Jamal Ahmad, M.D.Orthopaedic Foot & Ankle Surgery

March 2018

Disclosure Statement

• American Academy of Orthopaedic Surgeons (AAOS)

– Committee member

• American Orthopaedic Foot & Ankle Society (AOFAS)

– Committee member

Anatomy of the Achilles Tendon

• Strongest, largest tendon

• Originates from distal gastrocnemius-soleus muscle

• Inserts at postero-superior calcaneal tuberosity– 2 cm x 2 cm

Pekala P et al.: Bone Joint Res 2017; 6: 446-451.

Function

• Plantarflexion– Gastrocnemius flexes the ankle

with the knee extended– Soleus flexes the ankle with the

knee flexed

• Eccentric lengthening

• Concentric contracture

Freedman B et al. Muscles Ligaments Tendons J 2014; 4: 245-255.

Blood Supply• Distally from calcaneus

• Proximally from gastrocnemius-soleus muscle

• Peritenon

• At 2-6 cm from insertion– Twists 90o on itself– Watershed zone of decreased

vascularity– Most common site of rupture

(75%)

Matusz P. Clin Anat 2010; 23: 243-244.

Tendinopathy

Rupture

Achilles Tendinopathy

Peritendinitis

Tendinitis

Tendinosis

Staging• Stage 1 = Peritendinitis

– Inflamed peritenon & bursae– Tendon is normal– Reversible

• Stage 2 = Tendinitis– With tendon inflammation & thickening – Reversible

• Stage 3 = Tendinosis– Mucoid degeneration + calcific changes– No inflammatory response & irreversible

Puddu G et al. Am J Sports Med 1976; 4: 145-150.

Classification

• Duration– Acute = Less than 2 weeks– Subacute = 2-6 weeks– Chronic = 6 weeks +

• Location– Insertional– Midsubstance

Epidemiology

• Extrinsic factors– Surface conditions– Shoe wear– Over-activity

» Work vs. exercise

• Intrinsic factors– Age– Medical conditions

» Obesity & hypertension– Medications

» Steroids

Holmes G et al. Foot Ankle Int 2006; 27: 952-959.

History & Physical

• Symptoms– Activity-related pain

• Exam– Location of tenderness– Swelling or protuberance

» Haglund’s deformity at the postero superior calcaneus?

– Strength– Thompson test

Saini S et al. J AM Osteopath Assoc 2015; 115: 670-676.

Radiographs

• 1st line of imaging

• Weightbearing anteroposterior (AP) & lateral of ankle

• Screen for –– Calcification within the tendon– Haglund’s deformity

• Measure –– Phillip-Fowler’s angle

Kang S et al. Foot Ankle Int 2012; 33: 487-491.

Further Imaging

• MRI– Gold standard for tendon

visualization– Important for surgical

planning

• US– Increased use recently

» Less expensive?– Increased role is surgical revision situations

Foure A. Front Physiol 2016; 7: 324.

Nonoperative Treatment

• 1st stage– Rest– Immobilization

» Cast vs. Achilles boot– Non-steroidal anti-

inflammatory (NSAIDs)• 2nd stage

– Eccentric stretching– Physical therapy (PT)– Heel lifts as needed

• Most successful in early stages

Alfredson H et al. Sports Med 2000; 29: 135-146.

Other Nonoperative Treatments?

• Steroid injections?– Risk of Achilles rupture!

• Platelet rich plasma (PRP) injections?– Many studies show no difference compared to

placebo

• Extracorporeal shock wave therapy (ESWT) ?– 30-90% successful

Boesen A et al. Am J Sports Med 2017; 45: 2034-2043.Lee J et al. Ann Rehabil Med 2017; 41: 42-50.

Surgical Treatment of Insertional Tendinopathy

• Debridement & repair– Repair the Achilles also back to the calcaneal insertion

• Haglund’s exostectomy as needed

• Posterior midline incision splitting the Achilles

Miao X et al. J Foot Ankle Surg 2016; 55: 529-534.

Surgical Treatment of Midsubstance Tendinopathy

• Debridement & repair

• Posteromedial incision – Adjacent to the tendon’s medial border– Splitting the Achilles

Scott A et al. Foot Ankle Int 2008; 29: 759-771.

When to Augment the Repair?

• Absolute indications– > 50% of tendon width resected

• Relative indications– Based on age, weight, & activity level

• Flexor hallucis longus (FHL)– Located anterior to the Achilles– Large muscle belly– In phase with the Achilles tendonSchon L et al. J Bone Joint Surg 2013; 95A: 54-60.

[Long] Harvest of the FHL

• Traditional

– 2nd incision at the plantar-medial foot

– Harvested at the knot of Henry

– Tenodesis of distal FHL to the flexor digitorum longus (FDL)

Mao H et al. Surg Radiol Anat 2015; 37: 639-647.

[Short] Harvest of the FHL

• More recent alternative– Through the Achilles incision

» No additional incisions needed

– Harvested at the posteromedial hindfoot» Less length of tendon harvested without tenodesis of the

distal FHL to the FDL

Elias I et al. Foot Ankle Int 2009; 30: 197-204.

Fixation of the FHL

• Direct tenodesis to the Achilles

• Weaved through bone tunnels in the calcaneus

• Interference screw fit through a bone tunnel in the calcaneus– My preference

Postoperative Care

• Weeks 0-2– Non-weightbearing in splint

• Weeks 2-6– Non-weightbearing in Achilles boot

• Weeks 6-12– Weightbearing in boot– PT

• Week 12-onwards– Discontinue boot– Return to activity with a home exercise program

(HEP)– PT?

Results

• 85+% success– Improvement of pain– Return to function

• Education– Home stretching– Avoid overuse

Lohrer H et al. BMC Musculoskeletal Disord 2016; 17: 1061-1064.

Complications• Infection

• Wound problems

• Nerve injury– Sural nerve

• Achilles rupture

• Recurrent tendinitis– Inadequate exostectomy or

tendon debridement?

Achilles Rupture

• Most common tendon rupture in lower extremity

• Viscoelastic with rapid loading– Stiffness occurs with

increased Young’s modulus

– Prone to rupture

Hunt K et al. Foot Ankle Spec 2014; 7: 199-207.

Epidemiology• Activities involved

– Athletics• Age

– Peak incidence in 3rd – 5thdecades

– Physical conditioning– “Weekend warriors”

• Sex– Male: female is 5: 1

• Side– Left > Right

Raikin S et al. Foot Ankle Int 2013; 34: 475-480.

Classification

Myotendinous4-14%

Midsubstance75%

Insertional14-24%

Classification cont.

• Acute = 0-2 weeks

• Subacute = 2-6 weeks

• Chronic = 6+ weeks

Make note of those that are neglected or missed!

Chiodo C et al. J Am Acad Orthop Surg 2010; 18: 503-510.

Etiology - Indirect Trauma

• Strong ankle dorsiflexion force with contraction of the gastrocnemius-soleus

• Strong ankle dorsiflexion force while plantarflexed

• Push off of the foot with the knee extended

Vosseller J et al. Foot Ankle Int 2013; 34: 49-53.

Etiology - Direct Trauma

• Direct blow

• Crush

• Laceration

Said M et al. Eur J Orthop Surg Traumatol 2015; 25: 591-593.

Predisposing Factors• Inflammatory arthritides

• Endocrine dysfunction

• Pharmacologic– Corticosteroids

» Oral vs. intravenous– Fluoroquinolones

• Achilles tendinopathy– Supported by intra-operative

histology

Claessen F et al. Sports Med 2014; 44: 1241-1259.

History

• Activity involved• Predisposing factors• Initial pain

– “Pop” or “Explosion”– Often subsides

• Difficulty weightbearing• Difficulty walking

– Weakened plantarflexion– Stair climbing

Boyd R et al. Br J Gen Pract 2015; 65: 668-669

Physical Examination

• Decreased strength

• Palpable gap at tendon

• Ecchymoses

• Swelling– Can obscure the gap!

• Abnormal Thompson test

Radiographs

• 1st line of imaging

• AP & lateral of ankle– Blurring of Kager’s triangle

• Screen for –– Calcaneal fracture– Sleeve vs. posterior tuberosity

Dams O et al. Injury 2017; 48: 2383-2399.

Further Imaging

• MRI– Gold standard for tendon

visualization– Useful for –

» Determining location of rupture» Measuring the gap between tendon

ends in subacute/chronic ruptures

• US– Increased use recently– Increased role is surgical revision

situations?Garras D et al. Clin Orthop Relat Res 2012; 470: 2268-2273.Westin O et al. Orthop J Sports Med 2016; 14: eCollection.

Myotendinous Achilles Ruptures

• Should be confirmed with MRI vs. US

• Nonsurgical treatment– Minimal displacement occurs– Highly vascular at the myotendinous junction

• Protocol– Nonweightbearing in Achilles boot x 2-4 weeks– Weightbearing in Achilles boot x 4 weeks

» With HEP vs. PT– Wean out of boot by 6-8 weeks

» Further PT?– Return to activity

• Good functional resultsAhmad J et al. Foot Ankle Int 2013; 34: 1074-1078.

Mid-Substance Achilles Ruptures• Nonsurgical treatment

• Strong indications in patients with –– Significant illness with medical co-morbidities

» Peripheral vascular disease (PVD)» Poorly controlled diabetes mellitus (DM)» Physically debilitated» Highly advanced age

– Poor skin condition– High risk for post-surgical complications

• Relative indications– As an alternative to surgery in a reliable patient population

Kadakia A et al. J Am Acad Orthop Surg 2017; 25: 23-31.

Nonoperative Treatment with Functional Rehabilitation

• Short leg cast with the ankle in resting equinus x 2-4 weeks– Nonweightbearing

• CAM boot immobilization x 4 weeks– Progressive weightbearing– Heel wedges in the boot with gradual removal– Gentle motion & stretching

• Removable brace x 4-8 weeks– PT

Expectations of Nonsurgical Treatment

• Most comparative studies show –– Higher risk of Achilles re-rupture– Decreased gastrocnemius strength

Insertional Achilles Ruptures

• Nonsurgical treatment?– Lacking in outcome studies– May be considered in patients with –

» Significant illness with medical co-morbidities– PVD & brittle DM– Physically debilitated + highly advanced age

» Poor skin condition» High risk for post-surgical complications

– Expect poor healing potential between calcaneal periosteum & insertional Achilles

• Surgical treatment– Traditional for healthy, active patients

Huh J et al. Foot Ankle Int 2016; 37: 596-604.

Surgical Treatment of the Acute Rupture

• Traditional = primary open repair

• Incision– Posterior– Medial to the tendon mid-substance– Midline at the insertion

• Technique– Krackow vs. Bunnell– Epitendinous repair– Suture anchors if insertional

Percutaneous Repair of the Acute Rupture

• Alternative to an open repair

• Advantages– Smaller wound with decreased wound complications

• Disadvantages– Mixed results compared to open repair– Learning curve– Sural nerve injury

Augmenting the Acute Repair?

• Plantaris tendon augmentation?– Relative indications if intact

• FHL augmentation?– Indicated only if repair is unstable

• PRP?– Mixed results– Further study required

Postoperative Treatment of Tendon Repair

• Weeks 0-2– Nonweightbearing in splint

• Weeks 2-4– Non- vs. partial weightbearing in Achilles boot– Progression to neutral alignment

• Weeks 4-8– Progressive weightbearing in Achilles boot– HEP vs. PT

• Weeks 8-12– Wean from boot– PT

Postoperative Treatment After 12 Weeks

• Week 12– Continue therapy to optimize strength

• After Week 16– Begin return to sports

Results

• 92+% success overall– Improvement of pain– Return to function

• For professional athletes– 1/3 never return to professional play– 1/2 of those that do return play at decreased

strength

Complications

• Infection

• Wound problems– Superficial vs. deep

• Sural nerve injury

• Achilles re-rupture– < 2%

• Deep vein thrombosisHolm C et al. Scand J Med Sci Sports 2015; 25: e1-e10.

Subacute & Chronic Ruptures• Most commonly occurs due to delay in diagnosis

• Sequelae– Tendon proximal to the rupture retracts– Gap develops at the rupture site– Inefficient scar fills the gap– Decreased strength– Fatigue– Inefficient gait

Kraeutler M et al. Foot Ankle Int 2017; 38: 921-929.

Nonsurgical Treatment - Accommodative

• High-topped shoes

• Lace-up braces

• Ankle foot orthosis (AFO)– Molded AFO (MAFO)– Dorsiflexion-assist

Reddy S et al. J Am Acad Orthop Surg 2009; 17: 3-14.

Surgical Reconstruction

• To restore strength

• To restore Achilles continuity– Involves excision of scar – Bridging the gap

• Technique depends on length of the gap

When the Gap is < 2 cm

• End-to-end repair with longitudinal traction applied to the tendon edges

• Creep

Buckley P et al. Orthopedics 2016; 39: e1223-e1225.

When the Gap is 2-6 cm

• V-Y gastrocnemius lengthening

Elias I et al. Foot Ankle Int 2007; 28: 1238-1248.

When the Gap is 6-12 cm• Achilles turndown

– Historical techniques» Bosworth» Arner & Lindholm

– Modern techniques» Ahmad et al.

Ahmad J et al. Foot Ankle Spec 2016; 9: 400-408.

When the Gap is > 12 cm

• FHL tendon transfer into the posterior calcaneus?– WITHOUT bridging the gap at the ruptured

Achilles

• Tendon allograft?– Achilles vs. hamstrings

• Requires further study– Limited to scant case studies

Hollawell S et al. J Foot Ankle Surg 2015; 54: 1146-1150

When to Use the FHL?

• To augment the reconstruction– Regardless of gap size

• As a sole tendon transfer– WITHOUT bridging the gap

Amlang M et al. Unfallchirurg 2008; 111: 499-506.Elgohary H et al. Injury 2016; 47: 2833-2837.

Postoperative Treatment

• Weeks 0-2– Nonweightbearing in splint

• Weeks 2-6– Nonweightbearing in Achilles boot vs. cast

• Weeks 6-12– Progression to full weightbearing in boot– Physical therapy

• Week 12– Discontinue Achilles boot– Continue therapy to optimize strength

Results

• 85+% success overall– Improvement of pain– Improvement of strength

• Better chances of return to pre-injury levels of activity with tendon reconstruction & FHL augmentation?– Comparative studies are lacking

Complications

• Infection– Higher than for acute repair

• Wound problems– Longer incisions– Higher than for acute repair

• Sural nerve injury• Achilles re-rupture

– < 2%• Deep vein thrombosis• Foreign body reactions

Ahmad J et al. Submitted for publication in Foot Ankle Int in 2018.

Conclusion

• The Achilles tendon is critical to efficient gait

– Ankle function

– Stair climbing

• Its blood supply makes it vulnerable to pathology

– Watershed area at the mid-substance

Achilles Tendinopathy

• Nonsurgical treatments are beneficial in early stages

• Surgical treatment involves debridement & repair

– With a Haglund’s exostectomy when there is insertional Achilles involvement

– + FHL augmentation with significant de-bulking of the Achilles

Achilles Tendon Ruptures

• Nonsurgical treatment

– Myotendinous ruptures

– Mid-substance ruptures

» In patients not suitable for surgery

» As an alternative in healthy patients to avoid complications

Achilles Tendon Ruptures cont.

• Surgical treatment

– Acute repair» Insertional ruptures» Mid-substance ruptures

– To avoid muscle atrophy & re-rupture

– Reconstruction + FHL transfer» Technique depends on the amount of gapping between

the ends of the ruptured Achilles

Questions?

Thank you

Thank you.

http://upload.wikimedia.org/wikipedia/commons/8/82/Evanstonhospital.jpghttp://upload.wikimedia.org/wikipedia/commons/8/82/Evanstonhospital.jpg

Disorders of the Achilles TendonDisclosure StatementAnatomy of the Achilles TendonFunctionBlood SupplySlide Number 6Achilles TendinopathyStagingClassificationEpidemiologyHistory & PhysicalRadiographsFurther ImagingNonoperative TreatmentOther Nonoperative Treatments?Surgical Treatment of Insertional TendinopathySurgical Treatment of Midsubstance TendinopathyWhen to Augment the Repair?[Long] Harvest of the FHL[Short] Harvest of the FHLFixation of the FHLPostoperative CareResultsComplicationsAchilles RuptureEpidemiologyClassificationClassification cont.Etiology - Indirect TraumaEtiology - Direct TraumaPredisposing FactorsHistoryPhysical ExaminationRadiographsFurther ImagingMyotendinous Achilles RupturesMid-Substance Achilles RupturesNonoperative Treatment with Functional RehabilitationExpectations of Nonsurgical TreatmentInsertional Achilles RupturesSurgical Treatment of the Acute RupturePercutaneous Repair of the Acute RuptureAugmenting the Acute Repair?Postoperative Treatment of Tendon RepairPostoperative Treatment After 12 WeeksResultsComplicationsSubacute & Chronic RupturesNonsurgical Treatment - AccommodativeSurgical ReconstructionWhen the Gap is < 2 cmWhen the Gap is 2-6 cmWhen the Gap is 6-12 cmWhen the Gap is > 12 cmWhen to Use the FHL?Postoperative TreatmentResultsComplicationsConclusionAchilles TendinopathyAchilles Tendon RupturesAchilles Tendon Ruptures cont.Questions?Thank you