Achilles and Rearfoot pathology Flashcards
In plantar fasciitis what is the pathological process
Fibrofatty degeneration (not inflammation) of the plantar fascia origin with microtears and collagen nevrosis
Clinical presentation of plantar fasciitis
Poststatic dyskinesia
Pain reproduced with windlass mechanism
Deep achy pin point pain of plantar medial tubercle of calcaneus
Conservative treatments for plantar fasciitis (7)
- Suppression: NSAIDS, steroids
- Stretching
- Support: Goal is to reduce GRF. deep hel cup, stiff medial arch, heel cushion.
- Extracorpeal shock wave therapy
- Radiofrequency coblation
- Iontophoresis
- Platelet rich plasma
Biggest side effect of plantar fasciitis surgery
cuboid syndrome (lateral column pain)
Definition of ankle equinus
passive ankle DF <10 degrees
Compensation processes that occur with ankle equinus
- increased ROM at adjacent joints
- genu recurvatum
- Steppage gait
- Forefoot varus
What accurs to the first ray with ankle equinus
increased achilles load–> decreased PL strength–>hypermobile 1st ray
How to differentiate between soleal equinus and gastroc equinus
Silverskiold test
Surgical treatment options for gastroc equinus (6)
- Strayer
- Silverskiold
- Baumann
- McGlamry
- Baker
- Vulpius
Describe strayer procedure
- Transverse incision, suture proximal flap to soleus
- Caution: NV bundle posterior to PT muscle
In zone 1
Describe the Silverskiold
Release gastroc heads and reinsert to proximal tibia
Describe the Baumann procedure
Recession of gastroc or soleus aponeurosis
-In zone 1
Describe the McGlamery proceudre
proximal tongue in groove procedure
Describe the Baker procedure
distal tongue in groove
in zone 2
Describe the Vulpius procedure
V pointing proximally inverted V through gastroc aponeurosis
-in zone 2
Surgical treatment for gastroc soleus equinus (4)
Hoke TAL: in zone 3
Z Plasty
Hauser- not really used
Conrad and Frost-not really used
What is the etiology of sinus tarsi syndrome
Injury of interosseus talocalcaneal ligament
Also injury of cervical ligament
Status post inversion ankle sprain
-Iatrogenic from arthroeresis implant
Clinical presentation of sinus tarsi syndrome
-Pain with palpation of sinus tarsi, and eversion of foot
Treatment options for sinus tarsi syndrome
- steroid injection into sinus tarsi
- surgical excision of contents of sinus tarsi (remove contents of Hoke’s tonsil)
Etiology of cuboid syndrome (4)
- ankle sprain
- excessive lateral stress due to overuse
- Cavus foot
- post surgical medial band plantar fasciotomy
Haglund’s deformity definition
-painful bony prominence and bursitis of lateral posterior superior calcaneus above Achilles insertion
The triad of Haglund’s deformity
-postero-superolateral pump bump, AITC and bursitis
X-ray angles used to measure Haglund deformity (3)
Fowler Philip angle: abnormal >75
Parallel pitch line
Total angle of Ruch: abnormal is >90
Etiology of Haglund’s deformity
- compensated RF varus
- compensated FF valgus
- Rigid plantarflexed 1st ray
Conservative options for Haglund’s deformity
-open back shoes, heel lift, orthotics, NSAIDs, steroid injections
Surgical options for Haglund’s deformity
- Extracorporeal shock wave therapy with eccentric loading
- Achilles lengthening
- Remove bursa, resection of bony prominence
- Keck and Kelly osteotomy
Describe Keck and Kelly procedure
- remove sagittal wedge in calcaneus
- Useful for structural cavus and high CIA
Anatomy of the Achilles tendon
- strongest and thickest tendon in the body
- Tendon rotates 90 degrees as it courses distally to insert on calcaneus. Soleus inserts medially to gastroc.
- Achilles does not have synovial sheath but instead a paratenon to allow for gliding activity
- Sural nerve crosses tendon 11cm proximal to insertion
Describe paratenon
similar to tendon sheath, majority of blood supply, preserve during surgery
Describe mesotenon
tissue connection tendon to fibrous sheath
describe the epitenon
outer covering of tendon within sheath
describe the endotenon
tissue carrying blood vessels surrounding small collagen bundles
Stages of tendon healing (4)
1) Inflammatory: neutrophil/macrophage infiltration, increased vascularity (first week)
2) Proliferative: synthesis of type 3 collagen (second week)
3) Remodeling phase: decrease in collagen, alignment of collagen fibers in direction of stress (6-10weeks)
4) Maturation phase: fibrous (10weeks-1 year)
Major areas of blood supply for Achilles tendon
- Myotendinous junction
- Paratenon
- At the insertion of calcaneus
Etiology of achilles tendonitis /tendonosis
-mechanical overload due to :
—biomechanics- cavus foot, hyperpronation, equinus
—lifestyle- improper footwear, aging, systemic conditions
Clinical presentation for achilles tendinitis
- Noninsertional: noticeable posterior bump, thickened Achilles tendon at watershed area
- Insertional: fist step achy pain, pain worse going up a hill/stairs, shoe irritation
Conservative treatment options for Achilles tendinitis
- activity modifications
- Meds: NSAIDS, steroids, topical antiinflammatory
- Orthotics: CAM walker, Heel lift
- Stretching: eccentric and concentric
Surgical treatment options for Achilles tendinitis
- Tendoscopy
- Release of adhesions
- Debridement of pathologic tissue
- Exostectomy
- Remove retrocalcaneal bursa
- FHL tendon transfer
Where do Achilles tendon ruptures tend to occur
- In the watershed area approximately 2-6 cm proximal to insertion of calcaneus
Etiology of Achilles tendon rupture
- Same as those causing AITC
- Trauma
- System: hyperlipidemia, gout, RA, CKD
Exam findings to diagnose Achilles tendon ruptures
- Mattle’s test: pt prone with knee bent
- Simmond’s test: pt prone
- Thompson squeeze test: patient prone, knee bent and squeeze calf
- Hatchet strike defect
- Palpable dell
- Unable to PF
Radiographic findings for Achilles tendon ruptures
Toygar’s angle: should be less than 150
Arner’s sign: insertion of achilles curves away from calcaneus
-Kager’s triangle will be ill defined
What classification system is used for Achilles tendon tears
Kuwada classification system
- 1: Partial tear (most common)
- 2: Complete tear <3cm: Krackow, Bunnel, Kessler stitch
- 3: Tear is 3-6cm displaced : Autograft, graft jacket
- 4: Tear >6cm displaced: V-Y gastroc recession, Strayer
What protocal claims that conservative treatment does the job
Willits protocol states that accelerated functional rehab and nonoperative treatment just as effective as surgical
What are the surgical suture patterns for Achilles repair
- Krackow: giftbox suture (suture tied away from rupture site
- Bunnel: criss cross stitch to prevent shearing of suture through tendon
- Kessler
What are some adjunctive procedures for delayed presentation of achilles rupture(9)
- V-Y gastroc lengthning
- Silfverskiod
- Lindholm
- Bugg and boyd
- Bosworth
- FHL transfer
- Graft Jacket
- Pegasus
- Lynn
Describe the V-Y lengthening
Especially useful for gaps 3-5cm
Describe silfverskoid procedure
1 strip of gastroc aponeurosis
Describe the Lindholm procedure
multiple strips of gastroc aponeurosis used
Describe the Bugg and Boyd procedure
fascia lata strips join ruptured tendon
Describe the Bosworth procedure
Strip of gastroc tendon freed proximaly and flapped distally
Describe the FHL transfer
Most common procedure, used in conjunction with gastroc lengthening
Stronger than the FDL with a lower muscle belly and has better vascularity
Describe the Graft Jacket procedure
Used for large gaps of >10cm
Describe the Pegasus procedure
Use equine pericardium
Describe the Lynn procedure
use plantaris for augmentation
Keck and Kelly: Duvries osteotomy
Transverse resection through medial or lateral incision
Keck and Kelly: Fowler and Phillip
Transverse resection through posterior heel with a Mercedes incision
Keck and Kelly: Miller and Vogel
Keck and Kelly with bumpectomy and ORIF
