42: Achilles Tendon Pathology - Yoho Flashcards
At heel contact the ... knee ankle tibial rotation subtalar motion
- knee is flexing
- ankle is plantarflexing
- tibia is internally rotating
- subtalar motion is pronating
*** forefoot varus is related to …
compensatory calcaneal valgus (STJ pronation)
subtalar joint motion
pronation or supination
pathologic supination is compensational for. ..
rearfoot varus
forefoot valgus
with which achilles pathology are supination and pronation associated?
insertional achilles tendonitis
non-insertion (2-6 cm proximal in watershed zone)
why do people over-pronate?
- equinus
- forefoot varus
describe achilles tendon anatomy
- 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)
most common area of achilles tendon rupture
watershed area
paratenon vs. tendon sheath
- paratenon (straight line) *achilles tendon
- tendon sheath (curved line)(fluid filled)
- both are peritendinosus tissues
describe the functional anatomy of achilles tendon
- internally rotates to insertion into the os calcis
- watershed zone 2-6 cm proximal to insertion
how much blood flow comes through mesotenon?
1/3
- do not deglove the tendon or you will lose this blood supply
where is watershed area?
- 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
non-insertional achilles tendinitis
- peritendinitis
- peritendinitis with tendinosis
- finally rupture
risk factors non-insertional achilles tendinitis
- Overuse/poor training habits
- Mechanical imbalances
- Body weight and height
- Pharmaceuticals
- Systemic diseases
- Age (reduces blood glow)
- Genetic predisposition
what drugs pose an achilles tendon risk?
fluorquinolones (because can cause vascuilitis)
corticosteriods also (interfere with healing, hide damage)
what happens with overuse?
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
top two reasons for non-insertional achilles damaage
overuse and biomechanical issue
genetic predisposition for achilles tendon injry
- blood group O dominance
- HLA-B27 factor
PE non-insertional achilles tendinitis
- 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)
thompson test
squeeze gastrocsoleus - if not plantarflex might be rupture of tendon
Kager’s triangle
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.
non-insertional radiographic and ancillary study findings
- soft tissue swelling
- irregularity in kager’s triangle
- intratendinous calcification (type III)
tendon healing ***
impact
- activation of complement cascade
- platelet aggregation
- cytokines
inflammatory
- cellular infiltration
proliferative
- fibroblasts and collagen production
remodeling
- systematic organization of collagen bundles
non-operative tx
- tx inflammation
- physical medicine (eccentric stretching)
- biomechanical (orthotics)
surgical tx options non-insertional achilles tendinitis
- Debridement of affected tissues
- Debridement with tendon augmentation
- Tendon transfer
calcification of achilles tendon types
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
