Achilles Tendinosis and Rupture





KEY FACTS


Achilles Tendinosis





  • Achilles tendinosis can be noninsertional or insertional, although it is the same pathology, i.e., degenerative tendinopathy.



  • Insertional tendinopathy can be associated with a Haglund deformity, insertional ossification, or both.



  • A heel lift and physical therapy are the mainstays of treatment and are often effective, although it tends to be more effective in noninsertional tendinopathy.



  • Operative treatment consists of tendon debridement and repair with patients having insertional tendinopathy often requiring resection of any insertional ossification as well as the Haglund deformity. Surgery is often successful in eliminating the patient’s symptoms.



Achilles Tendon Rupture





  • Achilles tendon rupture is on the same spectrum as Achilles tendinosis in that a rupture occurs when a tendinotic tendon is subjected to an eccentric contracture of sufficient force to rupture the tendon.



  • It often occurs with sporting activity; physical exam is often sufficient diagnostically.



  • The goal of treatment is restoration of appropriate tension, which can be accomplished with either nonoperative or operative means.



  • There is much debate as to the optimal treatment of Achilles tendon ruptures with the discussion generally framed by the increased risk of wound complications with surgical treatment on the one end and the increased risk of rerupture with nonoperative treatment on the other.







Notice the thickening of the tendon in a noninsertional position in this patient with noninsertional Achilles tendinopathy. This thickening is often readily apparent clinically and often tender to palpation.








Simply having the patient lay prone with the knees flexed to 90° will often allow for the diagnosis of Achilles tendon rupture, as the resting tension of the injured tendon will show relatively more dorsiflexion.








An Achilles tendon laceration is more difficult to get right than Achilles tendon ruptures, as the zone of injury is less diffuse. Special attention should be paid to matching the tension of the contralateral side.








The proximal stump is very retracted , and the distal stump is very degenerative . The tendon is often diffusely degenerative in those patients who rupture their tendons.






Clinical Anatomy





  • The Achilles tendon is formed from the confluence of the gastrocnemius and soleus tendons distally. The gastrocnemius originates from the posterior femoral condyles, while the soleus has its origin from the posterior tibia and fibula.




    • The Achilles tendon is notable for its “twisted” structure with longitudinal rotation from proximal to distal.




      • Right Achilles tendons rotate counterclockwise; left Achilles tendons rotate clockwise.




    • The Achilles inserts in a specific way onto the calcaneus.




      • Soleus and lateral gastrocnemius insert more proximally; medial gastrocnemius inserts more distally.




    • The sural nerve typically runs with the lesser saphenous vein from proximal posterior to more anterior and lateral.



    • Blood supply to the tendon is from the posterior tibial artery proximally and distally and the peroneal artery in its midsection.






Pathology


Achilles Tendinosis Is (Typically) Focal Degeneration of Achilles Tendon





  • The overt cause of Achilles tendinosis remains unclear, although many postulate a gastrocnemius equinus contracture can lead to Achilles degeneration and may be potentiated by activity. In this way, both intrinsic and extrinsic factors likely play a role.



  • Achilles tendinosis can be insertional or noninsertional




    • Noninsertional Achilles tendinopathy will often take the appearance of the “snake that swallowed the egg” with a focal swelling in the tendon that is tender to palpation.



    • Insertional Achilles tendinopathy is characterized by swelling in the distal tendon with ossification of the Achilles insertion into the calcaneus.




      • A Haglund deformity, which is a prominent supero-posterior aspect of calcaneus, may be a part of the pathology.





Achilles Tendinosis and Achilles Tendon Rupture Are at Different Ends of Same Spectrum of Disease





  • In order for an Achilles tendon to rupture, 2 things generally need to be present: A focus of degeneration in the tendon, or a focus of tendinosis, and an eccentric contracture of the tendon of sufficient force for the tendon to rupture.




    • Kannus and Jozsa noted that no ruptured tendons were healthy, and 97% of the pathological changes were notable for histologic degeneration, i.e., hypoxic degenerative tendinopathy, mucoid degeneration, tendolipomatosis, and calcifying tendinopathy. Also of note was the fact that ~ 1/3 of ostensibly normal tendons showed some evidence of histologic degeneration, implying that these tendons may have been at risk for rupture. Clinically, this fact makes sense given that patients rarely have any symptoms prior to Achilles tendon rupture.



    • Tallon et al histologically graded 3 sets of tendons for degeneration: Those from patients with no known tendon pathology, those from patients having surgery for Achilles tendinopathy, and those having surgery for a ruptured Achilles tendon. These 3 groups formed a clear hierarchy in which the ruptured tendons were significantly more histologically degenerative than the tendinopathic tendons, which were significantly more degenerative than the normal tendons.




  • Achilles tendon ruptures are historically much more common in men than women and tended to occur in young patients (mean age: Early 30s). Over the last 15-20 years, the mean age at which patients rupture their Achilles tendons has clearly increased. Moreover, although these tendons still rupture much more commonly in men, there has been a steady increase in the number of women rupturing their Achilles tendons.



Role of Gastrocnemius Contracture





  • While some debate the degree to which a gastrocnemius equinus contracture plays a role in some pathologies, most surgeons would agree that a tight gastrocnemius, as evidenced by the Silfverskiöld test, plays a role in the development of Achilles tendinopathy.



  • Gastrocnemius stretching is a universally accepted part of physical therapy (PT) protocols for Achilles tendinosis.



  • Many surgeons will treat refractory Achilles tendinosis with gastrocnemius recession with good success.



  • A related pathology that merits mention is a gastrocnemius tear, sometimes called tennis leg. With this pathology, the muscle belly is injured (most commonly the medial gastrocnemius) and can either partially or wholly rupture. This injury is less severe than an Achilles tendon rupture, as the muscle tendon unit is intact from top to bottom. Treatment is typically supportive; more aggressive treatment is only very rarely necessary.





History and Physical Exam Findings


Achilles Tendinosis





  • History




    • There is some overlap in the symptoms of noninsertional and insertional Achilles tendinosis with the obvious distinction that they typically hurt in different areas.



    • Patients will complain of activity-related pain with both pathologies; shoewear may be more difficult in those patients with insertional Achilles tendinosis.



    • So called “start-up” and early morning pain is common. It will often dissipate once the patient gets mobilized, and the tight Achilles tendon loosens up somewhat.



    • Women will often be more comfortable in heels, as these shoes decrease the pull of the tight gastrocnemius on the degenerative tendon.




  • Physical exam




    • As above, patients with noninsertional tendinopathy will have a focal, painful swelling in the tendon, whereas those with insertional tendinopathy will have swelling and fullness at the insertion with pain in that more distal aspect.




Achilles Tendon Rupture





  • History




    • Upward of 80% of patients that rupture their Achilles tendons do so as a result of some sporting activity.



    • Patients almost always note an audible and palpable “pop.” Often, patients will think that someone kicked them in the back of the leg.



    • Although degeneration of the tendon is necessary for rupture, patients rarely have clinical symptoms prior to rupture.




  • Physical exam




    • The Thompson test is well described, whereby a positive test occurs when there is a lack of plantarflexion of the ankle with mediolateral squeezing of the calf musculature.



    • Another, perhaps easier, test involves just looking at the resting tension of the Achilles tendon. In unilateral tendon ruptures, there will be a clear difference from side to side, whereby the resting tension of the injured side will show significantly more dorsiflexion.



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Oct 29, 2019 | Posted by in ORTHOPEDIC | Comments Off on Achilles Tendinosis and Rupture
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