Athletic juries to the Soft Ties ofthe Foot and Ande m Chapter 30 (I surgeons feel that this method of removal and debride- ‘ment of the paratenon devascularizes the area and makes the Achilles tendon even more susceptible to failure, Their ‘eatment method includes longitudinal incisions along the paratenon, which stimulates healing and vascular ingrowth." Additional techniques to supplement the defective tissue involve tendon transfers that augment the native tissue and potentially bring a new vascular network to the area to aid in the healing process. Gh surgical Technique (Video Cp 98) With the paticnt in a prone position under tourniquet control, a longitudinal incision is made parallel but 1 cm medial to the Achilles tendon. It extends from the musculotendinous junction inferiorly along the Achilles tendon, The incision can be curved laterally at the area ofthe insertion for additional exposure 2 The dissection is deepened to the Achilles tendon. A fallthickness flap is created between the Achilles tendon and the subcutaneous tissue to minimize the risk of a skin slough. "The Achilles tendon and paratenon are inspected 3. With Achille tendinitis orparatenonitis, the paratenon is usually found to be hyperemic and thickened with adhesions. The paratenon is dissected and excised. Care is taken not to dissect the Achilles tendon circum ferentially but rather to leave the anterior blood supply intact” 4. The tendon is inspected and palpated for areas of thickening or degeneration, A longitudinal incision is made over the area of degeneration, when present, and this atea is debrided. The tendon is then repaited. ‘The Achilles tendon insertion is inspected, With dor siflexion ofthe ankle, the tendon is inspected to iden. tify any areas of impingement on the superior surface of the calcaneus, The retzocalcaneal bursa is excised. If the bursa is prominent, the posterosuperior angle of the of caleis is removed tansversely in the azea just superior to the insertion of the Achilles tendon at a 45-degree angle to the long axis of the tendon, The area is then smoothed with a rasp and the ankle brought txough a range of motion, Dorsilesion should be checked to ensure impingement no longer cxists Postoperative Care The patient is immobilized in a below-knee splint for 2 ‘weeks. The patient is then transitioned into a walking boot with progression of weight bearing over 2 weeks, ‘Once the boot is weaned, strengthening may commence after motion has been regained. Jogging is permitted 8 to 12 weeks after surgery. Results Kyist et al reported results on 182 patients (201 proce- dures), many of whom were high-level athletes.""” The crural fascia was incised, adhesions resected, and patients started on early range-of-motion activities. Of 201 cases, 36% were noted to have palpable nodules and 14% diffuse tendinosis. The disorder was localized to the upper tendon in 10%, the middle area in 51%, and the lower tendon in 24%, Nodules were thought to develop secondary (o partial Achilles tendon ruptures. Results were good or excellent in 97% of cases. Twenty-six patients developed recurrent disorder, and 20 underwent second surgery and did well, On the other hand, Paddu et al stated that performing a “tenolysis” will “ensure failure” because the surgeon does nothing to revitalize cxculation to the degenerated area,” They recommended multiple longitudinal inc sions in the peritendinous tissue to encourage ingrowth of vascularity. In advanced cases where the tendinosis involves greater than 50% of the Achilles tendon, a FIL. for EDL tendon can be used to augment the repair, Unlike the FHL, a potential problem when using the FDL is that its new course from its muscle belly’ location to the Achilles can eross the tibial nerve creating an inadvertent entrapment. Avhigh level of good and excellent results is generally achieved in the suxgical treatment of noninsertional tendinitis =F ENDOSCOPIC RETROCALCANEAL DECOMPRESSION Given the availability of equipment for arthroscopic pro- cedures and surgeons familiar with these techniques, endoscopic approach to the retrocalcaneal bursa, the insertion of the Achilles, and the posterior superior process ofthe calcaneus is growing in popularity. Through small portals adjacent to the Achilles tendon, the bursa is entered. Using a combination of palpation, endoscopic visualization, and image intensification, shavers and burs are inserted to address the pathology. The advantage of a smaller scar in this vulnerable atea and a less tat matic debridement may prove beneficial in reducing recovery time and patient morbidity.”"” In a systematic review of 15 published studies, Weigerinck et al found that endoseopie decompression and debridement of retrocalcaneal bursitis is superior to open debridement with regard to patient satisfaction and results in fewer complications.""" ACHILLES TENDON RUPTURE Ruplutes of the Achilles tendon have been document since the time of Hippocrates, although Ambroise Paré published the frst description of this entity in 1633.””*"* Although the uue frequency of Achilles tendon sup- tures in the general population is unknown, several reports suggest an incidence of less than 0.296." Goldman et al reported only 38 cases ueated at the Mayo Clinic over 20 years, and it was concluded that rupture of the Achilles tendon was an uncommon if not rare Iesion™6H0 Older studies reported that Achilles tendon ruptures occurred less often (2%) than quadriceps. ruptures (5%)."" This observation was widely quoted in the past. 1621BI #2 it Sports Meine but it has become clear that Achilles tendon ruptures are the most common tendon rupture of the lower extremity." In ecent years there has been better reporting of series of Achilles tendon ruptures. With increased interest in physical conditioning and participation in athletic activi ties by middle-aged and older patients, spontaneous rup- tures of the Achilles tendon are occurring with greater frequency as well." Etiology Achilles tendon ruptures occur in the second through eighth decades of life, although the peak incidence is during the third to fifth decades." ""™""" There is a marked male predominance (male-to-female ratio, 5:1)." A history of direct trauma is uncommon, but dis ruption can occur anywhere along the course ofthe Achil- les tendon." Causes include direct blows tothe posterior ankle, crushing injuries, and lacerations. These injuries ‘can cause a varlable amount of adjacent soft issue injury. Inditeet causes of rupture are the most frequently reported mechanism of injury and likely result from a combination of mechanical stress and intratendinous degeneration.""” Amer and Lindholm proposed the fol- lowing three distinct mechanisms of indirect loading or overloading resulting in tendon failure: a sharp unex: pected dorsiflexion force to the ankle coupled with a strong contraction of the triceps surae (eg, tripping on a curb, unexpectedly stepping into a hole), pushing off the ‘weight-bearing foot with the knee in extension (eg., lunging for a tennis shot), and a strong or violent dorsi- flexion force on a plantar-flexed ankle (cg, jumping from a height).”* All these mechanisms describe variations of a rapid loading process on an alzeady tensed tendon, The Achilles tendon acts as a viscoelastic material with rapid, loading of the muscle-tendon unit, With the modulus of elasticity increasing, the tendon becomes a stiffer suruc- ture and is more prone (o rupture.” Ruptutes are associ- ated with strenuous activity in almost all cases."°* Most often they are associated with athletic endeavors. Hooker reported that most patients had sedentary occupations and occasionally indulged in strenuous physical activ- ity." Most patients are recreational athletes. When the person is not in adequate physical condition, the onset ‘of muscle fatigue can predispose the tendon to rupture Although lacerations or disruptions from external ‘causes can occur anywhere along the length of the tendon, inditect ruptures routinely are localized to an atea 2 10 Gem proximal to the calcaneal insertion. Concomitant factors can predispose apatientto Achilles tendon rupture, including systemic inflammatory arthritis (theumatoid arthritis, gout, systemic lupus erythematosus), endocrine dysfunction (renal failure, hyperthyroidism), infection (philis, bacterial infection), and tumor" It has References 953, 96, 1053, 1068, 1125, 16h 1622 even been suggested that patients with eestain blood types are mote at risk for Achilles tendon rupture." The use of fluoroquinolone antibiotics has been impli. cated in Achilles tendon rupture"! Oral contco- steroids and local injections of corticosteroids have been implicated in several reports. Ljunggvist noted that 50% ‘of patients in his series with Achilles tendon ruptures gave a history of steroid use, while Jacobs reported five rup- tures after local comticosteroid injection. """"" On the other hand, Mahler and Frtschy reviewed 19 reports of Achilles tendon ruptuses and observed that most patients receiving corticosteroids had concomitant systemic inflammatory arthritis. They questioned whether the inglammatory process or pharmacologic therapy was the ‘causative factor in Achilles tendon rupture." The notion that some patients are predisposed to Achilles tendon rupture is supported by familial occur rence and nonsimultaneous bilateral Achilles tendon rup- wares, Numerous cases of nonsimultancous bilateral ruptures have been reported, Jessing and Hansen stated that there is a 25% risk of a contralateral rupture of the Achilles tendon with return to sporting activities similar to the type that led to the initial rupture.” Intinsic degeneration ofthe Achilles tendon has been. proposed as a predisposing factor to rupture" The Achilles tendon is subjected to substantial tension forces uring athletic activities. In a younger patient with a nommal tendon, these forces may be well tolerated. With aging, the tendon may be more vulnerable to injury.” Numerous authors have suggested that rupture occurs cnly in an abnormal tendon, and the combination of intratendinous degeneration and incteased mechanical stress Hikely results in tendon faire." In 75 histo- logic examinations of Achilles tendon biopsies from the site of rupture, 74 cases demonstrated tendinous degen- tration, including mucoid degeneration, tendinous ealci fication, or evidence of microscopic disruption of normal collagen fibers. Histologic specimens were examined {yom rupture sites of patients who had chronic symploms and functional disability before Achilles tendon rupture and found diffuse degenerative changes in the tendon structure that they believed ultimately esulted in tendon failure. A high incidence of fibrinoid and myxomatous degeneration was observed.” McMaster concluded that a normal tendon does not rupture, and that a tendon must undergo considerable damage before it will rupture. Although it has been stated that no relation: ship exists between poor blood supply and frequency of Achilles tendon ruptute, vascular evaluation of cadaver and autopsy specimens demonstrated a decreased nuimber and size of blood vessels in this vulnerable region in several studies.”"""""""© The authors concluded that diminished vascularity can predispose to tendon rupture inthis region. While it has been commented that “normal Achilles tendons can and do rupture," most often predis- posing factors exist" Prodromal symptoms are reported before rupture and evelop in approximately 10% of cases. InsertionalAthletic juries to the Soft Ties ofthe Foot and Ande m Chapter 30 (I ruptures occur 496 to 14% of the time, musculotendinous ruptures account for 14% to 24% of the ruptures, and nearly 75% of the ruptures occur in the tendinous region. 2 to 6 cm proximal to the insertion (Fig. 30-90).""" ‘The most common rupture results in fraying of the tendon fibers, stranding, and a consolidated hematoma that resembles a mop end or horse's mane (Fig. 30-91) History and Physical Examination ‘A middle-aged male patient often gives a history of prior involvement in an athletic activity. Afler a misstep, jump, co push off, patients report the sensation of a snap or an audible pop followed by the onset of acute pain, difficulty walking, and weakened plantar flexion power.” The audible pop can be likened to a rifle shot and the pain characterized as feeling as though the patient was kicked cor struck in the posterior heel region. Patients might com- plain of lack of coordination, and many note swelling and ecchymosis in the ankle region. The left ankle is reported to be involved more often,” "8 1 { “6. Figure 30.90 A, Achilles tendon rupture can occur anywhere along tendan’s course. Ruptures in middle portion ‘occur most often (72%-73%), distal ruptures occur less often (14%4-24%), and proximal ruptures of musculotendinous junction occur least often (6% 148%), Figure 30-91 Example of acute Achilles tendon rupture. A, Rupture demonstrated by excessive right ankle dersifiexion 8, Complete rupture. C, Fellowing debridement of tendon. Note intact plantar tendon, D, Acute rupture with fraying of tendon, 1623BI #2 it Sports Meine Figure 30-92 Techniaue of Thompson test to diagnase ruptured Achilles tendon. A, Patient kneels on chair and. {gastrocnemiussoleus muscle complex is grasped with hand. B, With intact muscle-iendon unit, ankle will plantar flex With ruptured Achilles tendon, foot typically will not plantar flex (positive Thompson sign). C, Clinical demonstration of Thompson test A palpable gap at the rupture site and diminished plantar flexion strength are pathognomonic ofan Achilles tendon rupture ®” Ecchymosis and swelling occur rapidly after injury and can aid in eatly diagnosis; within 24 hours, however, these findings can make diagnosis more !" in an interesting study, a prospective evaluation was per- formed in patients with achillodynia to establish prog- nostic parameters for tisk of nupture.°* No patient with normal sonographic findings went on to develop rupture, whereas 28% of the patients with thickening, circumscribed lesions of echotesture, and chronic pain developed spontaneous rupture. The advantages of ultra sonography include its ease of use, convenience for the patient, low cost, and ability to dynamically determine ‘whether tendon ends are unapposable. Ultrasonography is operator dependent, and lack of clinical experience, Jack of individual familiarity with technique, and lack of experience in interpretation by both orthopaedic sur- sgeons and radiologists are major limitations to its wide- spread use. MAI is also useful for Achilles tendon lesions and is very sensitive for detecting intratendinous lesions, with a positive predictive value of 94%." MRI has also been studied to evaluate postsurgical intemal structure of repaired Achilles tendons.*"” MAI is considered the most comprehensive diagnostic imaging modality for Achilles tendon injuries, IU has advantages in its unparalleled detailing of incomplete ruptures, extent of degeneration, infiltration of the paratenon, and retrocalcaneal patholo- gies. is disadvantages include cost, inconvenience, and relative oversensitivity in identifying areas of inflamma- tory change. Figure 30-93 Clinical examination following Achilles tendon rupture. A, Dimple in posterior skin. B, Obvious eect on dinical exam. C, Comparison with contralateral Lninjure extremity. Conservative Treatment Nonsurgical treatment of Achilles tendon ruptures pre- dominated in the 1800s and 1900s, Starting in the early 1920s, surgical repair gradually increased.” After Nistor’s randomized prospective study claiming essentially no 1625 i chapter 30BI #2 it Sports Meine Figure 30-94 Kager triangle. A, In normal lateral radiograph, a "crisp" Kager triangle is formed in area posterior to lateral malleolus. Border is formed by anterior aspect of Achilles tendon, posterosuperior aspect of calcaneus, and deep flexors of foot. B, After rupture, sharp definition of triangle is obliterated. C, Long complex tear of Achilles tendon. Note fibrotic tendon with wavy orientation land gap 6 to 7 cm above calcaneus, 10 cm long) after extensive debridement, B, Bone block Achilles allograft. C, Allograft sutured into repair with dermal matrix to augment healing expander in four cases to stretch and expand skin around a previous rupture site before initiating the tendon recon. struction procedure.” Although use of synthetic materials and allografts has a place in the armamentarium of procedures used for Uueating severe Achilles tendinosis and chronic ruptures for reruptures, sich approaches should be used with caution owing to introduction ofa foreign body, exposure to a grafthost reaction, and/or the potential for wound healing problems. These are extensive procedures, and it is important to thoroughly advise patients prior to surgery of the risks involved, Platelet Rich jasma (Video Clip 98) © Because of its widespread use and controversial nature, platelet-rich plasma (PRP) for augmentation and supple- mentation of Achilles tendon teatment, either with or without concurrent surgery, wll be discussed briefly. PRP hhas been a popular and common supplementary treat ment for a variety of soft tissue, tendon, and cartilage pathologies across many specialties """"" Although this treatment has been used and studied in a variety of Achil les tendon weatments, more retearch is necessary to clearly define its benefits PRP is a concentrated component of whole blood that is taken from the patient and refined to a highly concen. uated bioactive component. Many methods ate available for refining the whole blood into PRE, resulting in con. centrations and preparations that vary from company to company. Further research will ultimately identify the most ideal concentration and preparation of PRD. PRP contains a variety of cytokines and factors thought to stimulate soft tissue healing by enhancing native responses lo tissue damage. Platelets ate one of the com- ponents that play a critical role in tissue repair. Other growth factors have been found that modulate angiogen- esis within tissue, such as vascular endothelial growth factor (VEGF), fibroblast growth factor (FBCF), epidermal growth factor (EG), and many more, These growth factors are also responsible for increasing collagen pro- duction and altering the inflammatory response.” {A prospective study of PRP in patients who previously failed conservative treatment of Achilles tendinosis showed promising beneficial outcomes in that patient population." Clinical and radiologic outcomes were ‘measured in the patient population and showed continu: fous improvements in clinical scores throughout follow. up and together with improved radiologic findings. A. placebo-controlled study showed improved results in PRP ‘weatment groups when compared to placebo groups for Uweatment of chronic Achilles tendinopathy.”” Many studies have shown that PRP assists in the treat ment of tendinitis and tendinosis within the Achilles tendon, but few studies exist analyzing the benefit of adjunctive treatment with PRP following surgical repairs of ruptured Achilles tendons, Even though this method of PRP use remains unclear, many surgeons use PRP prep- arations after surgical repair with hopes of aiding in the healing process and speeding recovery time." ""* Conclusion Delay in diagnosis of an Achilles tendon rupture can occur because of retained ankle plantar flexion power Plantar flexion power augmented by FIIL, FDI, and pos terior tibial tendon function can allow a patient to walk without obvious disability. The gap present at the rupture site can rapidly fill with hematoma, and within 48 hours a defect may be difficult to palpate." The accuracy of a patient’s history and the persistence of complaints may 1641BI #2 it Sports Meine be the most helpful factors in facilitating the diagnosis at the initial evaluation. Minimal symptoms of pain can prevent a patient from even secking medical evaluation, In time, complaints of weakness with gait, inability 10 ascend or descend stairs, an antalgic gai, and an inability to rise on the toes of the affected limb may necessitate a ‘medical evaluation, ‘Treatment decisions depend on the time elapsed since the rupture, the magnitude of the disability, the desire of the patient for improved function, and risk factors associ ated with surgery. Bracing and nonsurgical treatment may bbe an acceptable alternative for a patient when weighed against the surgical risks and the potential necessity of a free tissue wansfer should a severe wound problem develop. Gillespie and George reported on 16 patients and con- cluded that after delayed reconstruction of Achilles tendon ruptures, patients did not do as well as those with primary repairs." In a report of 11 patients who underwent late reconstruction for Achilles tendon rupture, Boyden et al found that those with delayed surgery had successful dlinical results comparable to those who had early repair” Similar findings have been reported by others with a varieyy of treatment methods." In genezal, patients can expect reasonably good function following delayed surgical reconstruction for neglected, late, or chronic rupture of the Achilles tendon, aT Sprains involving the ligaments of the intertarsal and larsometatarsal joints are potentially serious injuries that commonly occur in sports. More commonly, these joints aze affected in waumatic circumstances such as motor vehicle accidents with subsequent fractures and/or dislo- cations of these bones and joints. The more severe forms ‘ofinjury to the midfoot are covered thoroughly in Chapter 435 and ate not discusted here. That is not to say that such, severe injuries cannot occur in sports, but the treatment is clearly outlined in the trauma section, and there is no need for duplication. On the other hand, the lesser grades of injury with purely ligamentous disruptions or small avulsions are becoming more recognized in athletes. ‘When present, they can become a persistent source of difficulty if not treated appropriately. Furthermore, the ‘methods of treatment, whether by open reduction or per ‘cutaneous, intemal fixation or primary fusion, and fixing ‘with screws versus endobuttons versus bridge plates, are the subject of much current debate, INCIDENCE Te overall incidence of injuries to the midfoot is uncleat, but they seem to be recognized more frequently now, 1642 particularly in sports participants. A study looking at intercollegiate football players found an incidence of 42% annually, with the majority occurring in offensive inemen (29.28).""" In our own intemal retrospective review of foot and ankle injuries among Rice University intercol- legiate athletes from 1971 through 1985, midfoot sprains constituted 12.7% of all foot injuries that required ‘weatment."" In examining the literature on Lisfranc injuries over the past 40 years, only five articles specifically address these injuries in the sports setting "7"! The review of these papers written over a 12-year period from 1990 ‘until 2002 gives insight into the inconsistencies in teat rent recommendations for athletes. Among, $3 injuries, '39 were treated nonoperatively and 14 underwent surgery, Diastasis measured on weight-bearing radiographs was 0 to 2.3 mm in the nonoperative group and 2.8 to 5 mm in the surgical group. Of those treated without surgery, 92% returned to play at an average of 3 months afier injury: Those treated surgically all returned to play at an average of 4.6 months. Results were 77% good to excel- lent in the nonoperative patients and 100% good to excel lent in the surgical patients. This was far from a valid meta-analysis, owing to the multiple variables between studies, but the information is valuable to consider for those treating athletes who have different standards in ‘what treatment and result they find acceptable for their return to play Moving proximally, recognition of injury to the inter- tarsal and transverse tarsal joint is increasing." * Mid. tarsal joint injuries occur rarely and are usually associated with significant adjacent fractures or fracture-dislocations. ‘A study of this injury from the Netherlands reviewed a G-year experience at one institution and found nine patients, five of whom were injured as a sprain or sports injury.””” Four of seven patients (57.196) continued to have pain and limitations in daily activities on follow-up, which averaged 31.3 months. This points to the need for recognition of this injury eatly with appropriate teat ‘ment and counseling of the patie MECHANISMS OF INJURY The mechanism of injury in these sports-related cases typically differs from what is seen in the more common, traumatic injuries seen in motor vehicle accidents ot falls from heights. Sports injuries in general are more low ‘energy injuries in contrast to the high-energy injuries seen, in motor vehicle accidents. Its for that reason that many lof these sports injuries fall into the category of subtle diastasis from purely ligamentous injuries or injuries with, small avulsion fractures. That is not to say sports injuries ‘cannot produce more severe injury patterns. Clearly this ‘ean be the case in car racing and equestrian or wind: sailing participation, but such cases also occur in football, which moze commonly produces the subtle variety of the Lisfranc injury (Fig, 30-112A-F), Midfoot injuries typically ‘occur from direct or indirect mechanisms, Direct injuries