Although Achilles ruptures are not commonly seen in Primary care a missed diagnosis has significant implications. What causes Achilles rupture? The factors leading to rupture of achilles can be divided into two categories: a) Intrinsic factors- This tendon bears high loads. It is estimated that up to 10 times body weight goes across this tendon when running. In addition it spans three joint (knee, ankle and subtalar joints). There is a zone of relative avascularity, 2-6 cm proximal to its insertion. Most of the Achilles tendon ruptures occour in this region. )
Extrinsic factors- These include mechanical factors (over pronation), yperthermia (sudden exposure to increased temperatures, classical example being lack of warm up prior to running or sports), medication (steroids and flouroquinolones) and iatrogenic (steroid injection). (Fig 10. 2) What is the incidence of Achilles ruptures? This affects 0. 2% of population. The incidence is rising with the increase in the number of people who are trying to keep fit. The male to female ratio is 5:1. There are two peaks in terms of age. The first involves age group of 30-50 years and is primarily due to Sports related activities.
The second peak is after 50 years and involves non sporting population and females. The incidence of contralateral rupture is 26%. Why is this injury missed? Unfortunately, the diagnosis of Achilles rupture could be delayed. This however could lead to litigation. There are several reasons for a missed diagnosis. Achilles rupture is usually not associated with significant pain. The patient might not therefore present immediately. Sometimes the patient self diagnoses this as an ankle sprain. I have seen cases where the initial injury happened when the patient was abroad and presented after sometime to their GP.
Diagnosing this injury after a while can be challenging due to swelling and hematoma, which can mask the ap. Most common cause of this injury to be missed is due to the fact that the diagnosis of Achilles rupture has not crossed the mind of the examiner. Sometimes the diagnosis might have been considered but as the patient was able to move foot up and down the diagnosis of ruptured Achilles was excluded. Remember that the patient would be able to plantar flex the foot in presence of Achilles rupture as the other plantar flexors (tibialis posterior, flexor digitorum and flexor halluces longus) are functioning.
How to diagnose Achilles rupture? It is important to consider the diagnosis of Achilles rupture hen examining a patient with calf or ankle injury. Alarm bells should ring regarding possible Achilles rupture if a patient tells you that it felt as if he/she was kicked in the calf. Examination: A gap can be palpable at the site of rupture (usually 2-6 cm proximal to insertion). However, this becomes difficult with a delayed presentation. The most reliable clinical test is calf squeeze test (also known as Simmonds or Thompson’s test). This test has sensitivity of 0. 96 and specificity of 0. 3.
The second test to aid the diagnosis is single heel raise test. If there is plantar flexion on calf squeeze and patient is able o perform single heel raise, Achilles rupture is highly unlikely. (Fig 10. 3) The other clinical finding seen in cases of an Achilles rupture is excessive dorsiflexion of the ankle on the ruptured side. What are the treatment options for Achilles rupture? Historically this injury was treated by either open surgery or non-surgically in plaster cast. Those who would favor surgery would quote high re rupture rate (13%) with the non-surgical treatment.
On the other hand, wound-healing complications (5%) were reported with open surgical repair. In the last few years non-surgical, weight bearing functional mobilisation has ained momentum. There are many studies, which have shown good outcomes and low re rupture rate with this treatment (Ref 1). I have been treating most of these injuries with Vacoped boot since 2009. In my experience with nonsurgical, weight bearing functional mobilisation for 8 weeks in Vacoped boot the re rupture rate of Achilles tendon is 2-3%. (Fig 10. 4) A case for surgery can be made for high demand patients who are engaged in sporting activities.
Minimum invasive repair avoids the risks of open surgery and results in quicker rehabilitation. Take home message: Consider the diagnosis of Achilles rupture n lower leg, calf or ankle injuries. “It felt that somebody kicked me in calf” should ring an alarm bell. Calf squeeze and single heel raise tests are most important clinical diagnostic tests. Achilles Tendinopathy Introduction Traditionally, Achilles tendon pain has been referred as Achilles tendonitis. However, studies have shown absence of inflammatory mediators in tendon biopsies of chronic Achilles tendinosis.
Interestingly, the concentrations of glutamate which is a potent mediator of pain have been found in higher concentrations in these cases (Ref 2). The term Achilles tendonitis has therefore been replaced by Achilles tendinosis pathological) or Achilles tendinopathy (Clinical). The Achilles tendon is the conjoined tendon of two muscles (Gastrocnemius and Soleus). It is the largest and strongest tendon and crosses three joints: knee, ankle, and subtalar joints. It can withstand forces up to 10 times body weight specially during impact activities.
There is a watershed area from 2-6 cm above the insertion of Achilles with relatively sparse blood supply. Most Achilles tendon problems (pain or rupture) are seen in this zone. What are the two types of Achilles Tendinopathy? The classification is based on the location of swelling and enderness- Mid-substance (Non insertional) Tendinopathy: The swelling is seen about 5-6 cm proximal to the insertion of the Achilles tendon. (Fig 10. 5) It is twice as common as insertional Achilles tendinopathy. It is common in runners with incidence as high as 25% in athletes.
The other predisposing factors are: genetic, hypertension, hypercholesterolemia and diabetes. Insertional Tendinopathy: The tenderness and swelling is localised at the insertion of Achilles tendon. It might be associated with calcification of tendon (enthesopathy) or an enlarged and prominent heel bone (Haglund’s deformity) which is also referred as pump bump. Fig 10. 6) What is the clinical presentation? The presenting symptoms are: pain, swelling and stiffness. In the initial stages, morning stiffness is common and pain is triggered off with activities and relieved by rest.
The pain might become constant with chronic problem. What is the management of Achilles Tendinopathy? The duration of symptoms is inversely proportional to the success of treatment. The following are the treatment measures: Eccentric stretching of the Achilles tendon: This is the mainstay of treatment. Modification of activities and use of insoles (medial arch support) if there is excessive pronation. Shock wave therapy (ESWT): This treatment modality has become quite popular recently. It is a non invasive intervention.
It is an outpatient procedure and involves application of shock wave therapy at the area of tenderness. Each treatment cycle takes about 5 minutes. It is done at weekly interval and usually about 3-6 sessions are recommended. It is a low risk procedure. It acts by stimulating body’s healing response. The success rate of this treatment is in the order of 60-80%. Ultrasound guided dry needling and saline infiltration: The success rate of this procedure is 60%. Surgery: Non-insertional tendinopathy: The overlying layer (paratenon) is stripped from the underlying tendon. The damaged tendon is excised.
The tears are repaired. Tendon transfer using Flexor Hallucis Longus (FHL) tendon might be required If the extent of involvement of damaged tendon is greater than 50%. Insertional tendinopathy: Heel bone prominence which is in contact with Achilles and is causing irritation and inflammation of the tendon is excised. The Achilles tendon is re attached to calcaneum with help of bone anchor sutures. If there is undue tightness of Gastrocnemius muscle then some surgeons believe that eleasing the tight fascia of this muscle can be beneficial. Post operatively a plaster/boot is applied for 2-6 weeks depending on the surgery.
The overall recovery can take up to six months. The success rate of surgery is 80-90%. Take home message: Do not inject Achilles tendon with steroid as this can lead to rupture. Non surgical treatment is successful for majority. Surgical treatment can be considered if symptom do not improve with conventional treatment. Ankle arthritis What causes it? Unlike the hip and knee, which are prone to develop primary osteoarthritis, the ankle develops arthritis usually because of a raumatic event. In 70% patients with ankle arthritis there is a history of trauma (ankle fracture or a significant ankle sprain).
The second most common cause of ankle arthritis is Rheumatoid arthritis. How to diagnose it? The most common location of pain is anterior which gets worse by walking uphill. Pain caused by going downhill suggests problem at the back of ankle usually due to posterior impingement. Pain caused by walking on uneven grounds is indicative of subtalar joint problems. In late stages of ankle arthritis, the movements (dorsiflexion & plantar flexion) are restricted. X-rays are required to confirm the clinical diagnosis. What is the treatment? 1) Non-surgical measures must be considered before surgery.
These include: Oral and topical anti-inflammatory medication, ankle brace, activity modification, weight loss, use of stick in contralateral hand and lace up boots. 2)Steroid injections are useful in mild to moderate arthritis. This can be done in the clinic setting and is fairly straightforward to administer. Anteromedial approach is safe. The placement of needle is in the soft area between the tendon of Tibialis anterior (TA) and Medial Malleolus (MM) at the level of ankle joint. Fig 10. 7) 3)The role of intra articular hyaluronic acid in treatment of ankle arthritis is controversial. )
Arthroscopic Ankle Debridement: For mild to moderate arthritis particularly in young patients, keyhole surgery has a role. This is useful in early arthritis. It does not help in severe arthritis. In one series, 70% good or excellent results were achieved with arthroscopic treatment of synovitis, loose bodies, osteochondral defect or osteophytes, compared with only 12% in patients with significant arthritis. ) Distal Tibial (Supramalleolar) osteotomy: This operation has gained increasing popularity for the treatment of early and mid stage arthritis in young patients.
Correction of varus or valgus deformities can improve pain and function and delay ankle fusion or replacement. 6) Ankle fusion: Most of the ankle fusions can be now performed by keyhole surgery, which avoids the morbidity and complications of the open surgery. (Fig 10. 8) 7) Ankle Replacement: Ankle replacement has gained popularity in the last 15 years. The advantages of this surgery include: preserved movements, less stress on other joints and improved gait. The current third generation implants have resulted in improved outcome.
The survivorship of one make of ankle replacements (Hintegra) has been reported to be 84% at 10 years for a group of 684 patients (Ref 3). The ideal candidate for ankle replacement surgery is a low demand patient with preserved movements and deformity less than 10 degrees. (Fig 10. 9) Take home message: Ankle arthritis is usually post traumatic. Ankle fusion is the gold standard treatment for end ritis. Though ankle replacement is not as successful as hip and knee replacement, the results are improving and can lead to a good outcome in carefully selected patients.
Bunion (Hallux Valgus) Introduction A bunion is a swelling of the first metatarsophalangeal joint and is derived from the Latin for turnip (bunio). Hallux valgus on the other hand describes the deformity normally associated with bunions. What causes it? The most common cause is genetic. Hypermobility and pes planus (flat feet) are contributing factors. High heels and narrow, pointed shoes increase the rate of progression. Hallux valgus is also commonly seen in Rheumatoid arthritis patients. How does it present? The presentation could be due to pain localised around bunion.
On the other hand, in quite a few cases the bunion might not be painful but the hallux valgus deformity could lead to secondary problems such as pain around second toe MTP joint due to synovitis, claw toe or hammer toe deformity affecting lesser toes, Morton’s Neuroma and metatarsalgia. I have seen stress fractures of lesser metatarsals due to increased pressure as a result of inefficient first ray. What is the Non Operative treatment? Orthoses have not shown to reduce bunion symptoms though a medial arch support can help bunions with flatfeet.
Bunion guards and toe spreaders do not provide long-term relief. For those patients who are not suitable for surgery, accommodative shoes made of soft leather with extra wide and deep toe box can be useful. What is the surgical treatment? Excision of bunion on its own does not address the underlying deformity thereby leading to recurrence. Bunionenctony is combined with soft tissue release, metatarsal osteotomy (Scarf or Chevron) and Phalangeal (Akin) osteotomies. (Fig 10. 10) What is the post-operative recovery? For the first six weeks the osteotomies need to be protected.
In the past patients were treated in plaster cast following bunion surgery. With modern techniques a plaster cast is not required and patients can mobilise in special heel weight bearing shoe usually for six weeks. Patients can start driving a manual transmission car after six weeks. Most patients recover by three months after surgery. Some swelling after foot surgery can last for up to 12 months. (Fig 10. 11) Take home message: Non surgical measures are not effective for hallux valgus treatment. An asymptomatic bunion with significant hallux valgus can cause problems related to lesser toes.
