Foot and Ankle Cases

Question 1

What is achilles tendonitis?

Answer 1

• Inflammation of achilles tendon
• Usually in those who take part in high energy activities and chronically overload the tendon eg running and jumping
• Can lead to rupture

Question 2

What makes up the achilles tendon?

Answer 2

• Gastrocnemius
• Soleus
• Plantaris
• All insert onto calcaneus and plantarflex foot

Question 3

Pathophys of achilles tendonitis and rupture

Answer 3

• Repetitive action of tendon = micrtears
• = localised inflammtion
• Tendon thickens, becomes fibrotic and loses elasticity
• Rupture occuers when sudden force applied across tendon eg sudden jump or rapid change direction when running

Question 4

RF for achilles tendon rupture

Answer 4

• Unfit individual
• Sudden increse in exercise frequency
• Poor footwear
• Male
• Obesity
• Fluoroquinolone use eg ciprofloxacin

Question 5

Tendonitis features

Answer 5

• Gradual onset pain and stiffness in posterior ankle
• Worse with movement
• Improved with physiotherapy or heat application
• Tenderness over tendon on palpation - worst 2-6cm above insertion

Question 6

Rupture clinical presentation

Answer 6

• Sudden onset severe pain in posterior calf
• Audible popping
• Feeling that something ‘went’
• OE - loss of power of ankle plantarflexion

Question 7

Specific clinical indicators for tendon rupture

Answer 7

• Thompsons test
• Palpable ‘step’ in achilles tendon

Question 8

Differentials for ankle pain presentation

Answer 8

• Ankle sprain
• Calcaneal fracture
• Tibial fracture
• OA
• For rupture - ankle # or sprain

Question 9

Invetsigations for tendon rupture/tendonitis

Answer 9

• Clinical diagnosis usually
• If unsure, can USS scan tendon - differentiate complete and partial tears

Question 10

Management tendonitis

Answer 10

• Supportive
• Stop precipitating exercise
• Ice
• NSAIDs
• If chronic - rehab and physiotherapy eg slow controlled movements against resistance

Question 11

Management tendon rupture - initial - within last 2 weeks

Answer 11

• Analegsia
• Immobilise - splinted in plaster in full equinus
• = ankle and toes maximally pointed
• Some now using weight bearing orthosis (moonboot) with large heel insert instead of plaster - puts foot in same position but can weight bear

Question 12

How long is ankle kept in full equinus for in plaster/moonboot?

Answer 12

• For 2 weeks
• Then semi-equinus for 4 weeks
• Then neutral position for 4 weeks

Question 13

How

How do tendons heal?

Answer 13

• Extrinsic - fibroblasts and inflammatory cells migrate from surrounding tissues and help heal
• Intrinsic - these cells migrate from tendon itself and epitenon surrounding tendon

Epitenon - tissue surrounding tendon

Question 14

When do you have surgery for ruptured achilles tendon?

Answer 14

• Delayed presentations - >2 weeks
• Re-rupture

= Need surgical fixation with end to end tendon repair

Question 15

Ankle OA presentation

Answer 15

• Gradual onset pain
• Associated swelling
• Reduced mobility