Achilles tendonitis , what it is and treatment of the condition.
Achilles tendon disorders are among the more common maladies seen by sports medicine physicians. Understanding the anatomy and biomechanics of the Achilles tendon and contiguous structures is essential to the diagnosis and treatment of Achilles tendon overuse injuries. Posterior heel pain is multifactorial and includes paratenonitis, tendinosis, tendinosis with partial rupture, insertional tendinitis, retrocalcaneal bursitis, and subcutaneous tendo-Achillis bursitis. Each of these entities is distinct, but they often occur in combination. Although most cases of this disorder are successfully treated nonoperatively, a small subgroup of recalcitrant cases may benefit from surgical intervention. Complete ruptures in active, athletic persons should be treated operatively in most cases and result in predictably good outcomes. There may be some cases that escape early recognition and require a reconstructive procedure to salvage a potentially severe functional deficit
Next, we look at treatments
The ankle is the site of many dace and athletic-related injuries. There a number of options relating tp which treatment strategies are most effective for various conditions. This series of articles cites several treatments and helpful articles which may be able to shed some light on the ongoing controversy regarding the best treatment options , from conservative to operative management, for the treatment of Achilles tendonitis. Achilles tendinitis is a frequentl problem fir dancers. Most specialists now prefer to separate these into “insertional” and “noninsertional” Achilles tendinitis. This is because it allows nonoperative and operative treatment to be looked at as problem specific and systematic
For further information beyond this I would suggest looking at The American College of Sports Medicine, .http://www.acsm.org/ where you can subscribe and buy more detailed articles on this and other subjects.
1; Operative versus nonoperative treatment of Achilles tendon rupture
A prospective randomized study and review of the literature
One hundred eleven patients with acute rupture of the Achilles tendon were included in a prospective trial and randomly assigned to groups for operative (56 patients) or nonoperative (55 patients) treatment.
All of the patients were followed with clinic evaluations at 4 months and 1 year after the rupture. The major complications in the operative treatment group were three reruptures and two deep infections as com pared with seven reruptures, one second rerupture, and one extreme residual lengthening of the tendon in the nonoperative group. There were fewer minor complications in the nonoperative group than in the opera tive group.
The operatively treated patients had a significantly higher rate of resuming sports activities at the same level, a lesser degree of calf atrophy, better ankle movement, and fewer complaints 1 year after the accident.
The conclusion we reached through this randomized prospective study is that operative treatment of ruptured Achilles tendons is preferable, but nonoperative treatment is an acceptable alternative
René Cetti, MD Steen-Erik Christensen, MD Rolf Ejsted, MD Niels Melchior Jensen, MD Uffe Jorgensen, MD, PhD
2; Achilles tendon disorders in runners--a review.
Smart GW, Taunton JE, Clement DB.
The Achilles tendon and the classification, aetiology, diagnosis, treatment, and management of Achilles tendon disorders in runners are reviewed. Due to the presence of a paratenon sheath, the classification of Achilles tendon disease should be revised. Several etiological mechanisms have been proposed in Achilles tendon disease. The authors recognize: faulty foot biomechanics; poor lower leg flexibility; poorly designed athletic footwear; training surfaces; training intensity; overuse through excessive mileage; inactivity; local steroid injections; rheumatic conditions; and indirect violence. An accurate, thorough differential diagnosis is essential when the athlete presents with an Achilles tendon disorder. Except in total rupture and in extensive partial rupture, the authors do not recommend cast immobilization in the treatment of Achilles tendon disease. When the athlete presents with total rupture of the Achilles tendon, the authors believe that surgical repair is the treatment method of choice. Rehabilitation programs to follow successful treatment of Achilles tendon disease are also presented.
3; Non-Surgical Treatment of Tendo Achillis Rupture
Tendon step tretches
We have analyzed the results in sixty-six cases of Achilles tendon injury which were treated by a simple non-surgical method. A gravity equinus walking boot cast was applied for eight weeks. The patient then used a 2.5 centimetre heel elevation for four weeks. Resistance exercises were used to build up the triceps surae. The frequent complications in other series of operative repair were discussed. The virtues of this method are that the hazards of anaesthesia and open surgery are avoided. The complications of infection, skin slough, and scar formation do not occur, and the patient is spared the expense of hospitalization. Early return to work is a distinct economic advantage. The functional results are as entirely satisfactory as those from operative repair; the cosmetic appearance is much better.9Abtract from a bigger report from the Journal and Bone & Joint Surgery)
Robert B.Lea; Lyman Smith.
4; Achilles Tendonitis: Are Corticosteroid Injections Useful or Harmful?
The use of local corticosteroid injections for the treatment of Achilles tendonitis is controversial. Some authors advocate their use based on efficacy in accelerating the healing process of Achilles tendonitis; others feel the associated side effects should preclude their use altogether. The purpose of this study was to comprehensively review and critically appraise the available literature in order to examine the evidence concerning this clinical dilemma.
Data sources: MEDLINE was searched using MeSH and textwords for English- and French-language articles related to Achilles tendonitis and corticosteroids published since 1966. Additional references were reviewed from the bibliographies of the retrieved articles. The total number of articles reviewed was 145.
Study selection: All clinical study designs were included as well as related animal studies using experimental and quasi-experimental designs.
Data extraction and synthesis: In reviewing the literature, particular attention was paid to the relative strengths of the different study designs. From these data, the factors associated with effectiveness and safety of injected corticosteroids were examined.
Main results: The only rigorous studies (one randomized controlled trial, one cohort study) showed no benefit of corticosteroids over placebo. In animal studies, corticosteroid injections decrease adhesion formation, temporarily weaken the tendon if given intratendinously, but have no effect on tendon strength if injected into the paratenon. The overall incidence of side effects with locally injected corticosteroids is ~1%. Most side effects are temporary, but skin atrophy and depigmentation can be permanent. Although there are many case reports of Achilles tendon rupture following local corticosteroid injection, there are no published rigorous studies that evaluate the risk of rupture with or without corticosteroid injection.
Conclusions: There are insufficient published data to determine the comparative risks and benefits of corticosteroid injections in Achilles tendonitis. The decreased tendon strength with intratendinous injections in animal studies suggests that rupture may be a potential complication for several weeks following injection.
(C) Lippincott-Raven Publishers. Shrier, Ian M.D., Ph.D.; Matheson, Gordon O. M.D., Ph.D.; Kohl, Harold W. III Ph.D.
5; Aftercare treatmnet
A retrospective review was performed of the results of operative treatment of stenosing tenosynovitis of the flexor hallucis longus tendon or posterior impingement syndrome, or both, in thirty-seven dancers (forty-one operations). The average duration of follow-up was seven years (range, two to thirteen years). The results were assessed with use of a questionnaire for all patients, and a clinical evaluation was performed for twenty-one patients (twenty-two ankles). Twenty-six operations were performed for tendinitis and posterior impingement; nine, for isolated tendinitis; and six, for isolated posterior impingement syndrome. A medial incision was used in thirty-three procedures; a lateral incision, in six; an anterior and a medial incision, in one; and a lateral and a medial incision, in one. Thirty ankles had a good or excellent result; six, a fair result; and four, a poor result. (The result of the second procedure on an ankle that was operated on twice was not included.) The result was good or excellent for twenty-eight of the thirty-four ankles in professional dancers, compared with only two of the six ankles in amateur dancers.
Pain in the Posterior Aspect of the Ankle in Dancers. Differential Diagnosis and Operative Treatment
WILLIAM G. HAMILTON, M.D.; MARK J. GEPPERT, M.D.; FRANCESCA M. THOMPSON, M.D., NEW YORK, N.Y.
6; Flexor Hallucis Longus Tendon Injury in Dancers and Nondancers
G. James Sammarco, M.D., Paul S. Cooper, M.D.†
Thirty-one cases of flexor hallucis longus injuries in 26 patients were treated over a 16-year period (1977–1993). Groups were divided into dance-related injuries (group I) and other causes (group II). The two groups were compared with regard to age, activity, duration of symptoms, operative findings, histopathology, and postoperative time to resumption of full activities. Twenty-seven cases required surgery for unsuccessful nonoperative treatment. In group I, 71% of patients had a partial longitudinal tear of the flexor hallucis longus compared with 30% in group II. Another common finding was isolated tenosynovitis (21% in group I and 53% in group II). Eight cases had magnetic resonance imaging (MRI) evaluations before surgery. Clinical correlation was found to be an important factor in interpreting the MRI. Dancers tended to have symptoms for a longer period of time before seeking treatment than did nondancers. Follow-up was 19.2 months for dancers and 25 months for nondancers. Surgical correction of tenosynovitis, pseudocyst, and tendon tear yielded good or excellent results in 14 of 15 dancers and 9 of 11 nondancers. Surgical treatment of tendon tears and other pathologic tendon conditions gave consistently good results in patients with refractory flexor hallucis longus disease.
Functional postoperative treatment of Achilles tendon repair
Thomas R. Carter, MD, Peter J. Fowler, MD, FRCS C, Cathy Blokker, MD
Craig Coussins Articles
Achilles Tendon Disorders in Athletes
Anthony A. Schepsis, MD*, Hugh Jones, MD and Andrew L. Haas, MD