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Murphy's procedure with anterior advancement of the Achilles tendon for spastic conditions. Figure 24.17. Murphy's procedure with anterior advancement of the Achilles tendon for spastic conditions. Generally, Achilles tendon or gastrocnemius lengthening should be reserved for patients requiring significant foot reconstruction related to a tight gastroc-soleus complex, and for those needing to avoid forefoot ulceration such as diabetics. Diabetic patients benefit from Achilles...

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Bacterial infections, of complex Achilles tendon region wounds, 208 Badminton players, Achilles tendon ruptures in, 43 Becker's muscular dystrophy, 248-249 Biomechanics of the Achilles tendon, 5, 7, 12 of musculoskeletal disorders, 70-73 Boots, for Achilles tendon rupture management, 145 Bruising Achilles tendon rupture-related, 142, 153 calf muscle tear-related, 156, 157 anatomy of, 9, 10, 12, 29, 133 dimensions of, 34 function of, 133 imaging of, 10, 25, 34, 136 impingement of, 135...

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Years, the tendon was shortened approximately 1 cm, and patients were protected from dorsiflex-ion postoperatively. They cite only a few papers dealing with this subject.46 Alternatively, a deep posterior compartment release can be added to this procedure to decrease tension of the overlying paratenon or skin repair when necessary, and can also theoretically improve vascular inflow to the repair from the well-vascularized FHL muscle belly immediately adjacent when tenodesed to the Achilles...

Complications

Multiple Percutaneous Longitudinal Tenotomies Four patients developed a subcutaneous hematoma from one of the stab wounds, and a further patient suffered from a superficial infection of one of the stab wounds. This was treated by oral antibiotics for five days, and healed uneventfully. Three patients complained of hypersensitivity of the stab wounds. They were counseled to rub hand cream over the stab wounds several times a day, and were asymptomatic by six postoperative weeks. One patient...

Custom Foot Orthotics

Functional custom foot orthoses were initially developed between 1954 and 1966.18 These devices have long been prescribed to active individuals in their exercise shoes to increase comfort, to prevent complaints of injury, or to rehabilitate from injuries. The potential benefits of functional foot orthotics as an intervention between the foot and the ground reaction forces on the lower extremity allow individuals to pursue their sports and remain functionally active. The success rate of custom...

Do Corticosteroid Injections for Achilles Tendinopathy Increase the Risk of Subsequent Achilles Tendon Rupture

The use of corticosteroid injections in the management of soft-tissue injuries is widespread. Corticosteroids have been injected peri- or intratendinously for many decades, particularly by rheumatologists.35 Already in 1976, Clancy36 reported on the safe use of intratendinous Achilles injections for the management of early tendi-nopathy in athletes. However, the study was confined to 5 runners. More recently, orthopedic surgeons have tended to be more circumspect with regard to the use of...

Does the Use of NSAIDs Affect Achilles Tendon Healing

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used in soft-tissue disorders. Many different drugs exist within this category and their use is not without potential side-effects, such as gastrointestinal disturbances and renal damage. What is the evidence that they are helpful in the management of Achilles disorders, and is there any evidence that their use might be potentially harmful Physicians have frequently used nonsteroidal anti-inflammatory drugs (NSAIDs) in Achilles...

Etiology and Epidemiology of Achilles Tendon Problems

Young and Nicola Maffulli Rupture of the Achilles tendon is on the increase,1'2 and appears more common in men in the white-collar professions.3,4 Various hypotheses have been put forward as to why the Achilles tendon ruptures.3,5-8 Tendinopathy of the Achilles tendon is common both in athletic and nonathletic indi-viduals.9-12 As in ruptures of the Achilles tendon, its etiology is likely to be multifactorial.13,14 Two main theories are advocated, the degeneration theory and the...

Etiology and Pathophysiology

Tendon injuries can be acute or chronic and are caused by intrinsic or extrinsic factors, either alone or in combination. In acute trauma, extrinsic factors predominate. Overuse injuries generally have a multifactorial origin.4 In chronic tendon disorders, interaction between intrinsic and extrinsic factors is common.5 There is sparse scientific knowledge about the etiology and patho-physiology of chronic painful tendon conditions, and most hypotheses put forward have not been substantiated by...

Genetic Susceptibility to Achilles Tendon Injury

Genetic factors may be associated with an individual's susceptibility to Achilles tendon injury.810 This was originally proposed in studies reporting an association between the ABO blood group and Achilles tendon ruptures or chronic Achilles In a retrospective study, Jozsa et al.11 compared the frequencies of the ABO and Rh blood groups of 292 Hungarian patients with primary Achilles tendon ruptures or re-ruptures and 540 patients with various other tendon ruptures with a control group...

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Haglund's deformity, 115 clinical features of, 123 differentiated from Achilles insertional tendinopathy, 123, 130 Haglund's syndrome, 133 flexor hallucis longus tendon transfer treatment for, 101, 103 as heel pain cause, 113, 121 radiographic appearance of, 115-116,124 resection of, 125, 127, 128 surgical management of, 12, 117, 133 differentiated from Haglund's deformity, 133 Haglund's triad, 113, 115, 123 Heat therapy, 84 Heel, ulcers of, 245, 246 Heel lift, as phase of gait, 72, 73 Heel...

Info

Anterior curvature. (G) Here, both gastrocnemius and soleus have been partly removed so as to demonstrate the intramuscular tendon of soleus (arrow). MS, muscle belly of soleus. (H) The union of the tendons of soleus (TS) and gastrocnemius that form the Achilles tendon at mid-calf level. (I) A sagittal section through the calcaneus to show the Achilles tendon enthesis (E) and the prominent pre-Achilles fat pad (F). The tip of the fat pad is quite distinctive from the rest and protrudes into the...

Management of Achilles Paratendinopathy

Alleviation of pain and prevention of progression of acute to chronic paratendinopathy are the main goals of management in the acute phase. In chronic cases, the alleviation of pain predominates the management strategies, while predisposing factors and etiological causes are actively sought and corrective measures are taken. Little reliable experimental or clinical scientific work has been performed on the pathophysiology, etiology, natural course, and management of Achilles tendon overuse...

Neurological Conditions

Achilles tendon shortening or weakness is a feature of many neurological conditions affecting the central or peripheral nervous system (cerebral palsy, poliomyelitis, spina bifida, and hereditary neuropathies) and muscles (muscular dystrophy). Achilles tendon spasticity, weakness, or contracture in these conditions leads to gait abnormalities. Understanding the role played by the triceps surae in the unique coupling of ankle and knee motion is essential in the management of gait abnormalities...

Noninsertional Achilles Tendinopathy

With the patient prone, both feet are positioned at the end of the operating table. Epidural, spinal, or general anesthesia can be used. The short saphenous vein is marked on the lateral side of the Achilles tendon, the leg is exsanguinated, and the tourniquet inflated. The distal portal is located on the lateral border of the Achilles tendon, 2-3 cm distal to the thickened portion (nodule) of the Achilles tendon. The cranial portal is located 2-4 cm above the nodule on the medial border of the...

Operative Management

This procedure was reported by Abraham and Pankovich in 1975,62 and was applicable to neglected, chronic ruptures of the Achilles tendon. The aim of this procedure was to achieve end-to- end anastomosis of the Achilles tendon. This is made possible by a sliding tendinous flap developed over the proximal portion of the tendon, by making an inverted V incision that is then repaired in a Y fashion. Abraham and Pankovich reported on four patients,62 with three of the patients regaining full...

Operative Technique

The patient is placed prone with feet protruding over the edge of the operating table. Both legs are prepped and draped, allowing intraoperative comparison to adjust the tension of the reconstruction. If considered necessary, a tourniquet is applied to the thigh of the affected leg, the leg exsanguinated, and the tourniquet inflated to 250 mmHg. A 10- to 12-cm longitudinal skin incision is made just medial to the medial border of the Achilles tendon, and sharp dissection is carried out through...

Paralysis of Triceps Surae Muscle in Poliomyelitis

Flaccid lower motor neuron paralysis of triceps surae is very disabling. The patient lacks push-off, and walks with a calcaneus limp. The lack of push-off during the third foot rocker leads to an upward displacement of the anterior end of the calcaneum and head of talus. There is increase in the range of dorsiflexion and the normal posterior heel prominence disappears. Compensation by other plantarflexors such as tibialis posterior, long toe flexors, and the peronei result in equinus of the...

Postoperative Management

On admission, patients are taught to perform isometric contractions of their triceps surae. Patients are instructed to perform the isometric strength training at three different angles, namely at maximum dorsiflexion, at maximum plantarflexion, and at a point midway between the two. The foot is kept elevated on the first postoperative day, and oral analgesics are given for pain control. Early active dorsi- and plantarflexion of the foot are encouraged.54 On the second postoperative day,...

Presentation and Diagnosis of Insertional Tendinopathy

The symptoms of insertional Achilles tendinopa-thy are specific, and are related to pain at the bone-tendon junction, frequently worse after exercise, but which ultimately become constant. Although this is a fairly common finding in athletes, other conditions and medications that cause pain in the posterior aspect of the heel should be considered, including the various causes of insertional enthesopathy, seronegative spondyloar-thropathies, gout, systemic corticosteroids, orally administered...

Surgical Technique

The patient is placed in the prone position under general or regional anesthesia. If the feet are left on the operating table, there is a tendency to push the ankle joint in hyper-plantarflexion due to the weight of the leg. During the repair, this can lead to overtightening the repair. Instead, it can be helpful to bring both feet down off the end of the table or to place a soft roll underneath the distal tibia. Both feet will assume an unforced, more neutral position. Prior to the repair, the...

Tendo Achillis in Spina Bifida

Tendo Achilles Lengthening

Foot deformity is found in 75-90 of patients with spina bifida,52 depending on the level of the lesion. Lower lumbar and sacral lesions result in calcaneus deformity, while in upper lumbar and thoracic lesions equinus is more common. Equinus, calcaneus, equinovarus, vertical talus, and valgus ankle deformities are all seen in this condition.3 The loss of sensation makes children with this condition prone to pressure sores, particularly when casting is used. For the same reason, fractures of the...

The Anatomy of the Achilles Tendon

Suzuki, and H. Toumi The Achilles tendon (tendo calcaneus) is the strongest and thickest tendon in the body and serves to attach the triceps surae (soleus and the two heads of gastrocnemius) to the calcaneus (Fig. 2.1). It is a highly characteristic feature of human anatomy and it has even been suggested that the tendon has helped to shape human evolution. The emergence of man is critically linked to his ability to run, and man's unique combination of moderate...

Operative Technique Central Flap

The patient is placed in prone position. Anesthesia should ensure maximal muscle relaxation. Make a linear curvilinear medial incision (to minimize the risk of injuring the sural nerve) from the midcalf to the calcaneus, taking care not to cross the midline in the distal part, in order to avoid scarring the tendon (Fig. 19.1). Incise the deep fascia in the midline after freeing it from the skin, thus making sure that the fascial incision lies fully under the skin flap. The site of the Achilles...

Indications and Contraindications

A delay in presentation of Achilles tendon rupture of greater than 8 weeks results in filling up of the gap between the ruptured ends with fibrous nonfunctional scar that needs excision. If the gap with the ankle in maximum plantarflexion is between 5 and 9 cm, peroneus brevis transfer can be utilized. We do not use this technique if the gap between the ruptured ends of the Achilles tendon is greater than 8 cm, or the ipsilateral peroneus brevis has been used for other reconstructive procedures...

Lower Extremity Composite Free Flaps

Early composite grafts included free groin flaps with a sheet of external oblique aponeurosis, iliac bone, or abdominal fascia.27-29 Advantages of these groin flaps included the ability to transfer iliac bone with the graft for a calcaneal defect, as well as the location of the donor scar, which was usually hidden by underclothing. Disadvantages included a short and thin superficial circumflex iliac artery pedicle, the need for repair of the external oblique in the donor site with foreign...

Upper Extremity Composite Free Flaps

Radial forearm and lateral arm constructs have also been developed to address the problem of complex Achilles region reconstruction. A radial forearm flap raised with extensor carpi ulnaris and palmaris longus tendons was used to reconstruct an area of the posterior lower leg that did not require much tissue bulk.19 Other radial forearm composite flaps have included the tendons of the brachioradialis and palmaris longus as well as the superficial radial nerve or the lateral antebrachial...

What Are the Possible Complications Following Surgery for Chronic Achilles Tendinopathy

Paavola et al.61 studied 432 consecutive patients following surgery for Achilles tendinopathy. They reported an overall complication rate of11 , with the majority (54 ) due to problems with wound healing. However, other complications observed included sural nerve problems, scarring, rupture, and thrombo-embolic disorders. Overall, 3 of patients required further surgery to deal with complications. However, the authors stressed that, despite the complications, the long-term prognosis for pain...

Diagnosis of Achilles Paratendinopathy

Patients with Achilles paratendinopathy present with pain in the Achilles tendon region or posterior heel region. The severity of pain is used to classify the severity of the disorder and is also used as an outcome measure.1 Clinical examination reveals that the tendon is diffusely swollen on palpation, and is tender in the middle third of the tendon. A crepitus may be occasionally palpable in the acute phase 4,9 however, the swelling and tenderness does not move when the ankle joint is...

Management

In the early phase of Achilles tendinopathy, various forms of conservative management are normally used.5,70,71,109 Seeking medical attention at an early stage may improve outcome, as treatment becomes more complicated and less predictable when the condition becomes chronic.11,23 Surgical management is recommended for patients who do not adequately respond to a conservative program over 3 to 6 months.5,28,69,71 Conservative management is recommended as the initial strategy,72-81 with...

Paratendinopathy of the Achilles Tendon

Sayana, and Nicola Maffulli There has been a dramatic increase of Achilles tendon overuse injuries in the past four decades. This is in line with the increased prevalence of overuse sports injuries in Western countries due to increase in the demands on competitive and professional sports performances. Achilles tendon overuse injuries not only affect competitive athletes, but also affect recreational sports participants and individuals in occupations where the lower limbs...

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Force-relaxation (A), creep (B), and mechanical hysteresis (C). The arrows at the bottom graph indicate loading and unloading directions. In the first few loading-unloading cycles in a mechanical hysteresis test, the tendon resting length increases. This is referred to as conditioning. Figure 3.1. Typical force-elongation plot in a tendon tensile test to failure. I toe region II linear region III and IV failure regions. Stiffness is the slope of the curve in the linear region....

Complex Wounds

Complications from failed surgery, severe infection, or massive trauma may leave a complex wound involving the soft tissue around the Achilles tendon. A tendon defect in the setting of large tissue loss is a more difficult problem than simple repair of a ruptured or lacerated tendon. Successful reconstruction must include three essential elements (1) tendon repair sufficient to provide strength, durability, and tension (2) a soft tissue cushion thick enough to protect the area but thin enough...

Percutaneous Hemisection Achilles Tendon

Medial Calf Tightness

Figure 24.3. (A) Stretching with the knee straight creates tension on the gastrocnemius. (B) Stretching with the knee bent creates tension on the soleus and deep posterior muscle compartment. as well. Commonly prescribed stretching regimens designed long term to eliminate contracture are probably more effective at preventing further contracture than at decreasing the tightness already present. Eccentric strengthening for up to one year is beneficial in reducing pain and allows for increased...

Operative Details

As a prosthesis is used, intravenous antibiotic prophylaxis is necessary. General anesthesia is normally used and the operation is always undertaken under tourniquet control. The patient is placed prone on the operating table with a pillow under the mid-shin area with the foot and ankle sufficiently free of the end of the table to allow accurate assessment to be made of the range of dorsiflexion and plantarflexion at each stage of the operation. This is especially important when the polyester...