42: Achilles Tendon Pathology - Yoho

Question 1

At heel contact 
the ...
knee 
ankle
tibial rotation
subtalar motion

Answer 1

• knee is flexing
• ankle is plantarflexing
• tibia is internally rotating
• subtalar motion is pronating

Question 2

*** forefoot varus is related to …

Answer 2

compensatory calcaneal valgus (STJ pronation)

Question 3

subtalar joint motion

Answer 3

pronation or supination

Question 4

pathologic supination is compensational for. ..

Answer 4

rearfoot varus

forefoot valgus

Question 5

with which achilles pathology are supination and pronation associated?

Answer 5

insertional achilles tendonitis

non-insertion (2-6 cm proximal in watershed zone)

Question 6

why do people over-pronate?

Answer 6

• equinus

- forefoot varus

Question 7

describe achilles tendon anatomy

Answer 7

• dense pliable tissue
• high tensile strength
• noncontractile
• blood supply (less than the tissues around it - decreased blood flow naturally to tendon b/c not contracting)
  tissues)

Question 8

most common area of achilles tendon rupture

Answer 8

watershed area

Question 9

paratenon vs. tendon sheath

Answer 9

• paratenon (straight line) *achilles tendon
• tendon sheath (curved line)(fluid filled)
• both are peritendinosus tissues

Question 10

describe the functional anatomy of achilles tendon

Answer 10

• internally rotates to insertion into the os calcis

- watershed zone 2-6 cm proximal to insertion

Question 11

how much blood flow comes through mesotenon?

Answer 11

1/3

- do not deglove the tendon or you will lose this blood supply

Question 12

where is watershed area?

Answer 12

• The vascular status of the Achilles tendon 2-6 cm proximal to the calcaneal insertion increases the vulnerability of tendon to injury.
• Tendon substance derangement exists prior to catastrophic failure

Question 13

non-insertional achilles tendinitis

Answer 13

• peritendinitis
• peritendinitis with tendinosis
• finally rupture

Question 14

risk factors non-insertional achilles tendinitis

Answer 14

• Overuse/poor training habits
• Mechanical imbalances
• Body weight and height
• Pharmaceuticals
• Systemic diseases
• Age (reduces blood glow)
• Genetic predisposition

Question 15

what drugs pose an achilles tendon risk?

Answer 15

fluorquinolones (because can cause vascuilitis)

corticosteriods also (interfere with healing, hide damage)

Question 16

what happens with overuse?

Answer 16

Repetitive and cumulative microtrauma associated with chronic overcharge causes degenerative changes in tendon

• also, disuse atrophy and behavioral habits are risk factors for Achilles tendon rupture

Question 17

top two reasons for non-insertional achilles damaage

Answer 17

overuse and biomechanical issue

Question 18

genetic predisposition for achilles tendon injry

Answer 18

• blood group O dominance

- HLA-B27 factor

Question 19

PE non-insertional achilles tendinitis

Answer 19

• tenderness over achilles tendon
• crepitus of soft tissues
• fusiform swelling of soft tissue
• thickening of soft tissue/nodules
• occasional palpable defect
• equinus
• hyperpronation ( forefoot varus) (pronation beyond 25% stance gait)

Question 20

thompson test

Answer 20

squeeze gastrocsoleus - if not plantarflex might be rupture of tendon

Question 21

Kager’s triangle

Answer 21

It is bordered anteriorly by the flexor hallucis longus (FHL) muscle and tendon, posteriorly by the Achilles tendon, and inferiorly by the calcaneus. The anteroinferior corner of the triangle is related to the posterior ankle joint, while posterolaterally it is related to the retrocalcaneal bursa.

Question 22

non-insertional radiographic and ancillary study findings

Answer 22

• soft tissue swelling
• irregularity in kager’s triangle
• intratendinous calcification (type III)

Question 23

tendon healing ***

Answer 23

impact

• activation of complement cascade
• platelet aggregation
• cytokines

inflammatory
- cellular infiltration

proliferative
- fibroblasts and collagen production

remodeling
- systematic organization of collagen bundles

Question 24

non-operative tx

Answer 24

• tx inflammation
• physical medicine (eccentric stretching)
• biomechanical (orthotics)

Question 25

surgical tx options non-insertional achilles tendinitis

Answer 25

• Debridement of affected tissues
• Debridement with tendon augmentation
• Tendon transfer

Question 26

calcification of achilles tendon types

Answer 26

Type I:
continuous with calcaneal insertion (microtrauma, biomechanical
related, SNA)

Type II:
insertion zone, separated from the os calcis (ACC, pseudogout)

Type III:
proximal to insertion zone (trauma, post-surgical, Wilson disease, ischemia