Achilles Tendon Disorders: Daniel Penello Foot & Ankle Rounds
Achilles Tendon Disorders: Daniel Penello Foot & Ankle Rounds
Achilles Tendon Disorders: Daniel Penello Foot & Ankle Rounds
Daniel Penello
Foot & Ankle Rounds
Anatomy
Largest tendon in
the body
Origin from
gastrocnemius and
soleus muscles
Insertion on
calcaneal
tuberosity
Anatomy
Paratenon
Anterior – richly vascularized
The remainder – multiple thin membranes
Anatomy
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
Physiology
Gastrocnemius-soleus-Achilles complex
Spans 3 joints
Flex knee
Plantar flex tibiotalar joint
Pathophysiology
Repetitive
microtrauma in a
relatively
hypovascular area.
Reparative process
unable to keep up
May be on the
background of a
degenerative tendon
Achilles Tendon Rupture:
Textbook Facts
Antecedent tendinitis/tendinosis in 15%
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)
Physical Exam
Prone patient with feet over edge of bed
Physical
Partial
Localized tenderness +/- nodularity
Complete
Defect
Cannot heel raise
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
Imaging
Ultrasound
Inexpensive, fast,
reproducable, dynamic
examination possible
Operator dependent
MRI
Expensive, not
dynamic
Better at detecting
partial ruptures
and staging
degenerative
changes, (monitor
healing)
Management Goals
4 weeks
Bunnell Suture
Modified Kessler
Many techniques
available
Surgical Management :
Post– op Care
Assess strength of repair, tension and
ROM intra-op.
Apply cast with ankle in the least amount
of plantarflexion that can be safely
attained.
Patient returns to fracture clinic 2 weeks
post-op.
Variations in Post-op Protocols
Functional Bracing
Post- Op Care
Cast applied in OR Remove sutures, apply a
2 wks walking cast with heel lift
Touch WB 2 weeks
112 patients