Ankle Fracture

Background

For many primary care physicians, ankle injuries are the most common sports-related injury seen in their practice. Of those patients evaluated for ankle injuries, only approximately 15% have a clinically significant fracture. Therefore, familiarity with a thorough ligamentous examination and the Ottawa ankle rules is essential for proper management.

Successful primary care management of an ankle fracture begins with differentiation of a stable injury versus an unstable injury. The bones and ligaments of the ankle form a ring around the ankle mortise; thus, for instability to occur, ligamentous injury or fracture must include both the medial and lateral sides of the ring. The ring involves the structures that surround the talus, which are composed of the tibial plafond, the medial and lateral malleoli, the deltoid ligament complex, anterior talofibular ligament, calcaneofibular ligament, posterior talofibular ligament, and the anterior and posterior tibiofibular ligaments.

Generally, isolated nondisplaced distal fibular or distal tibial fractures are stable when no ligamentous instability is present on the opposite side of the ring. Careful evaluation of the ankle for medial and lateral swelling and ecchymosis should be routine, and their presence should increase clinical consideration of an unstable injury.

Frequency

United States

The ankle joint is the most commonly injured joint in sports. Approximately 70% of basketball players have sprained an ankle, and the likelihood of reinjury is as high as 80%. Lateral ankle sprains account for 90% of all ankle injuries, while an ankle fracture occurs only approximately 15% of the time.

Functional Anatomy

The distal tibia, distal fibula, and talus bones make up the ankle joint. These 3 bones are bound together by the joint capsule and surrounding ligaments. The anatomic relationship of the tibial plafond (joint surface of the distal tibia) to the talus is important for ankle stability. Because the anterior portion of the talus is more broadly shaped, dorsiflexion increases bone surface contact, thus improving stability. This relationship causes decreased stability during plantarflexion, accounting for the vulnerability to ligamentous injuries when the foot is plantarflexed.

Sport Specific Biomechanics

Forces acting on the ankle lead to typical fracture or ligamentous patterns. Determining the position of the ankle during injury can assist in assessing for ligament stability. Although simple unidirectional forces can be involved in an ankle injury, multidirectional forces are usually involved, making diagnosis a challenge.

Medial complex injuries typically occur from eversion and abduction forces. The medial complex consists of the medial malleolus, the medial facet of the talus, and the superficial and deep components of the deltoid ligament. Eversion of the ankle causes injury to the superficial deltoid ligaments and, if sufficient, the deep deltoid ligament. Avulsion of the distal medial malleolus tends to occur in young and old patients because the ligamentous strength may be greater than the strength of the bone in these individuals. With continuation of these forces, impaction of the distal lateral malleolus occurs, resulting either in rupture of the syndesmosis or in transverse fracture of the distal fibula.

Most unstable ankle fractures are the result of excessive external rotation of the talus with respect to the tibia. If the foot is supinated at the time of external rotation, an oblique fracture of the fibula ensues. If the foot is pronated at the time of external rotation, a mid- or high-fibular fracture results.

The lateral complex consists of the distal fibula, the lateral facet of the talus, and the lateral collateral ligaments of the ankle and subtalar joints. Lateral malleolus injury (most common type of fracture involving the ankle) typically occurs with supination external rotation forces. The inversion force first strains the lateral ligament complex or avulses (transverse fracture) the lateral malleolus. With continuation of this force, the talus impacts the medial malleolus, causing an oblique fracture of the distal tibia. Inversion ligamentous injuries of the ankle are the most commonly observed soft tissue trauma in sports.

Posterior malleolus injury typically occurs with a supination-external rotation or a pronation-external rotation injury and represents avulsion of the posterior tibiofibular ligament from the posterior distal tibia.

Treatment

Acute Phase

Rehabilitation Program

Physical Therapy

As always, acute management involves analgesics for pain, immobilization, and patient comfort. Use either a well-padded posterior splint or a stirrup splint to keep the patient from bearing weight on the ankle until definitive treatment is instituted in 3-4 days. Small avulsion Danis-Weber type A fractures without medial-sided injury can be symptomatically treated with a walking cast or stirrup brace and ambulation as tolerated. The patient should apply ice to the injured area over a compressive dressing for 20 minutes every 2-3 hours for the first 24 hours and every 4-6 hours thereafter until casting. Keeping the limb elevated above the level of the heart also significantly reduces swelling.

Medical Issues/Complications

Isolated lateral malleolus fractures are the most common fracture involving the ankle. Most inversion injuries result in an isolated sprain of the anterior talofibular ligament. However, a small avulsion fracture can occasionally be seen near the distal portion of the lateral malleolus. Barely visible osseous chip fractures do not alter the routine active management of grade 1 and 2 ankle sprains.

• Most primary care physicians can treat isolated nondisplaced Danis-Weber type A fractures.

• More experienced providers can treat stable, nondisplaced fractures of the malleoli with posterior malleolus involvement of less than 25% of the articular surface.

• Bimalleolar or trimalleolar injuries are always unstable and are treated with open reduction and internal fixation. All displaced medial malleolar fractures are openly reduced and fixed to restore normal ankle congruency and deltoid integrity.

Consultations

Referral to an orthopedist is advisable for all displaced fractures because minor changes involving the joint mortise can cause chronic pain and early osteoarthritis. Patients with possible unstable injury (Danis-Weber classification types B or C) or those with bimalleolar fractures should be referred to an orthopedist. In the presence of medial malleolar tenderness and more than 5 mm of medial clear space on the mortise view, make a presumptive diagnosis of deltoid ligament rupture if a displaced fibular fracture is present. Treat these injuries as a bimalleolar fracture, and refer patients with this injury for treatment by an orthopedist.

Referral is also indicated for all trimalleolar fractures, which involve fracture to both the medial and lateral malleoli, along with a fracture to the posterior lip of the tibial plafond. This fracture is usually secondary to an avulsion of the posterior tibiofibular ligament at its insertion site. Fractures that show no radiographic evidence of healing after 8 weeks are best evaluated for adjunctive measures.

Recovery Phase

Rehabilitation Program

Physical Therapy

After the acute phase, cast immobilization can be accomplished with either a short leg walking cast or walking cast fracture boot in a reliable patient with a stable fracture.

Medical Issues/Complications

The ankle should be put in a cast in a neutral position to avoid shortening of the Achilles tendon. Generally, 4-6 weeks of immobilization is required for healing. Cast boots are generally preferred after swelling dissipates so that intermittent motion can commence. If the fracture site is not tender, gradual ankle rehabilitation can begin because clinical healing is present. If no evidence of fracture healing is present, an additional 2-4 weeks of immobilization may be required.

Consultations

If no evidence of fracture healing is present by 8 weeks, referral to an orthopedist is mandatory.

Maintenance Phase

Rehabilitation Program

Physical Therapy

After completing the immobilization period, the patient should begin ankle rehabilitation. Range of motion and strength returns quickly in young patients, and referral to a physical therapist may not be necessary. Patients motivated to complete rehabilitation at home can perform calf stretching and strengthening exercises, along with range-of-motion activities. Instruct patients to pay particular attention to the attainment of dorsiflexion. Older patients with premorbid conditions often require formal physical therapy to successfully regain strength and range of motion.

Acromioclavicular Joint Injury

Background

Acromioclavicular (AC) joint injuries are common and often seen after bicycle wrecks, contact sports, and car accidents. The AC joint is located at the top of the shoulder where the acromion process and the clavicle meet to form a joint. Several ligaments surround this joint and depending on the severity of the injury, a person may tear one or all of the ligaments. Torn ligaments lead to AC joint sprains and separations. The distal clavicle and acromion process can also be fractured. Injury to the AC joint may injure the cartilage within the joint and can later cause arthritis of the AC joint. This article discusses the anatomy of the joint, the diagnosis of this condition, and the different treatment options.

Frequency

United States

Injuries to the AC joint are the most common reason that athletes seek medical attention following an acute shoulder injury. Glenohumeral dislocations are the second most common injuries seen. Men in their second through fourth decades of life have the greatest frequency of AC joint injuries. These injuries are most often incomplete tears of the ligaments.

Functional Anatomy

The AC joint is made up of 2 bones (the clavicle and the acromion), 4 ligaments, and a meniscus inside the joint.

• The AC joint is surrounded by a thin joint capsule and 4 small ligaments. These ligaments mostly give joint stability to anterior and posterior translation. They provide the horizontal stability to the joint.

• Another set of ligaments also provides vertical stability to the AC joint. These ligaments are called the coracoclavicular (CC) ligaments. The CC ligaments are found medial to the AC joint and go from the coracoid process on the scapula to the clavicle.

• Different injuries result in different tears of the 2 CC ligaments (the conoid and the trapezoid). Torn AC joint ligaments and/or torn CC ligaments are seen in AC joint sprains. The meniscus that lies in the joint may also be injured during sprains or fractures around the AC joint.

Sport Specific Biomechanics

When a person falls onto their shoulder, the force pushes the tip of the shoulder down. The clavicle is usually kept in its anatomic position while the shoulder is driven down, which injures the different ligaments or causes a fracture. When the ligaments are injured they are either sprained or, in more severe cases, torn.

AC joint sprains have been classified according to their severity. In a type I sprain, a mild force applied to these ligaments does not tear them. The injury simply results in a sprain, which hurts, but the shoulder does not show any gross evidence of an AC joint dislocation. Type II sprains are seen when a heavier force is applied to the shoulder, disrupting the AC ligaments but leaving the CC ligaments intact. When these injuries occur, the lateral clavicle becomes a little more prominent. In type III sprains, the force completely disrupts the AC and CC ligaments. This leads to complete separation of the clavicle and obvious changes in appearance. The lateral clavicle is very prominent. A few more types of AC joint sprains have been classified, but types I - III are the most common.

Treatment

Acute Phase

Rehabilitation Program

Physical Therapy

Acromioclavicular (AC) joint injuries are painful and the patient often lacks full range of motion after the injury. Physical therapy plays a role in the treatment of these patients. The author routinely starts therapy within the first couple of weeks in AC joint sprains. For fractures, wait until evidence of healing is apparent either clinically or on radiograph before starting formal therapy. Therapy for degenerative joint disease of the AC joint has not been proven successful.

Surgical Intervention

AC joint sprains do well with conservative management. Type I and II injuries never necessitate surgical care to reconstruct the injured ligaments. These injuries may need further care if the AC joint gets arthritic from the injury. Surgical intervention may be an option in type III AC joint sprains, but only after the patient has failed a good trial of conservative treatment with physical therapy and medication. The procedure for these patients is reconstruction of the torn coracoclavicular (CC) ligaments with either local tissue or an allograft. In the past, surgeons have used screws, sutures, suture-tape, synthetic grafts, and K-wires to try to repair the defect. These have all fallen out of favor and the criterion standard is to reconstruct the torn ligaments as mentioned above.

Postoperative CC ligament reconstruction. The clavicle is back to its normal position. The anchor in the clavicle keeps the allograft tendon from coming off of the clavicle. Also note the distal clavicle has been excised because it had traumatic arthritis from the injury.

Fractures in and around the AC joint are mostly treated conservatively in a sling. The few times surgery needs to be considered is for a moderate amount of displacement of the fracture fragments. Surgery is indicated for open fractures, neurovascular injury, and for those in which the skin is compromised and may rupture from the pressure of the prominent bone.

Injuries that lead to arthritis of the AC joint are also treated with conservative measures first. Anti-inflammatory medication and intra-articular steroid injections work well for degenerative changes in the AC joint. In patients who failed conservative therapy, excision of the distal clavicle can be performed with a minimally invasive arthroscopic procedure.

Consultations

If the athlete has sustained concomitant rib fractures with shortness of breath, good quality chest radiographs are indicated. A consult from a pulmonary physician or cardiovascular chest surgeon may be necessary.

Medication

Initial treatment of degenerative arthritis of the acromioclavicular (AC) joint may include the use of nonsteroidal anti-inflammatory drugs (NSAIDs) along with occasional corticosteroid injections.

Drug Category: NSAIDs

Have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclo-oxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.

Drug Name	Ibuprofen (Motrin, Ibuprin, Advil)
Description	DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult Dose	200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric Dose	6 months to 12 years: 4-10 mg/kg/dose PO tid/qid >12 years: Administer as in adults
Contraindications	Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy

Drug Name	Ketoprofen (Oruvail, Actron, Orudis)
Description	For relief of mild to moderate pain and inflammation. Small dosages initially are indicated in small and elderly patients and in those with renal or liver disease. Doses exceeding 75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe patient for response.
Adult Dose	25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric Dose	3 months to 12 years: 0.1-1 mg/kg PO q6-8h >12 years: Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy

Drug Name	Naproxen (Naprelan, Anaprox, Naprosyn)
Description	For relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of cyclo-oxygenase, which results in a decrease of prostaglandin synthesis.
Adult Dose	500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric Dose	<2>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Contraindications	Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of the drug

Drug Name	Indomethacin (Indocin, Indochron ER)
Description	Rapidly absorbed. Metabolism occurs in liver by demethylation, deacetylation, and glucuronide conjugation. Inhibits prostaglandin synthesis.
Adult Dose	25-50 mg PO bid/tid 75 mg SR PO bid; not to exceed 200 mg/d
Pediatric Dose	1-2 mg/kg/d divided PO bid/qid; not to exceed 4 mg/kg/d or 150-200 mg/d
Contraindications	Documented hypersensitivity; GI bleeding or renal insufficiency
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Category D in third trimester of pregnancy; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; reversible leukopenia may occur; discontinue if persistent leukopenia, granulocytopenia, or thrombocytopenia occurs

Drug Name	Diclofenac (Voltaren, Cataflam)
Description	Inhibits prostaglandin synthesis by decreasing activity of enzyme cyclo-oxygenase, which in turn decreases formation of prostaglandin precursors.
Adult Dose	Persistent night pain or morning stiffness: Up to 100 mg hs may help to relieve pain; not to exceed total daily dose of 200 mg
Pediatric Dose	>12 years: Administer as in adults <12>
Contraindications	Documented hypersensitivity; do not administer into CNS; do not give to patients with peptic ulcer disease, recent GI bleeding or perforation, or renal insufficiency; do not administer to those at high risk of bleeding
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Category D in third trimester of pregnancy; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low white blood cell counts occur rarely and usually return to normal in ongoing therapy; discontinuation of therapy may be necessary if persistent leukopenia, granulocytopenia, or thrombocytopenia occurs

Drug Name	Sulindac (Clinoril)
Description	Decreases activity of cyclo-oxygenase and in turn inhibits prostaglandin synthesis. Results in a decreased formation of inflammatory mediators.
Adult Dose	150-200 mg PO bid or 300-400 qd; not to exceed 400 mg/d
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; patients in whom aspirin, iodides, or other NSAIDS induce hypersensitivity; gastrointestinal (GI) bleed; renal insufficiency
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Category D in third trimester of pregnancy; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in preexisting renal disease or compromised renal perfusion; low white blood cell counts occur rarely and usually return to normal in ongoing therapy; discontinuation of therapy may be necessary if persistent leukopenia, granulocytopenia, or thrombocytopenia occurs; caution in persons with anticoagulation defects or in those receiving anticoagulant therapy

Drug Category: Corticosteroids

Have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.

Drug Name	Hydrocortisone (Solu-Cortef, Hydrocortone phosphate)
Description	Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
Adult Dose	Small joints: 10-25 mg intralesional Large joints: 25 mg intralesional
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; viral, fungal, or tubercular skin infections
Interactions	Corticosteroid clearance may decrease with estrogens; may increase digitalis toxicity secondary to hypokalemia
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in hyperthyroidism, osteoporosis, peptic ulcer, cirrhosis, nonspecific ulcerative colitis, diabetes, and myasthenia gravis

Drug Name	Triamcinolone (Aristospan Intra-Articular, Aristocort Forte, Kenaject-40)
Description	For inflammatory dermatosis responsive to steroids. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.
Adult Dose	2-20 mg intra-articularly q3-4wk
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; fungal, viral, and bacterial skin infections
Interactions	Coadministration with barbiturates, phenytoin, and rifampin decreases effects of triamcinolone
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Multiple complications (eg, severe infections, hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression) may occur; abrupt discontinuation of glucocorticoids may cause adrenal crisis

Achilles Tendonitis

Background

The Achilles tendon, named after the seemingly indestructible mythologic Greek warrior, is the largest and strongest tendon in the human body. Achilles tendonitis was the term originally used to describe the spectrum of tendon injuries, ranging from inflammation to tendon rupture. Recently, a histopathologically determined nomenclature has evolved to classify this range of tendon inflammation and degeneration into 3 stages: (1) peritenonitis, (2) peritenonitis with tendinosis, and (3) tendinosis.

Partial or full tendon ruptures may result from end-stage peritenonitis. Causes of tendon ruptures are associated with overuse and host susceptibility with both extrinsic and intrinsic factors playing a role. Athletes who are poorly conditioned, overtrained, or insufficiently prepared are at the highest risk for this disease process. Repetitive stresses to the tendon, such as prolonged jumping or running, result in chronic pain and tightness along the tendon. Tendonitis usually develops insidiously after sudden changes in activity or training level, use of inappropriate footwear, or training on poor running surfaces, especially if high risk factors are present (eg, age, cavus feet, tibia vara, heel and forefoot varus deformities).

Frequency

United States

True incidence of Achilles tendonitis is unknown, although there is a reported incidence of 6.5-18% in runners.

Functional Anatomy

The Achilles tendon (tendo calcaneus) is formed from the tendinous contributions of the gastrocnemius and soleus muscles, coalescing approximately 15 cm proximal to its insertion. Along its course in the posterior aspect of the leg, the tendon spirals 30-150° until inserting into the calcaneal tuberosity. The tendon's ability to glide is facilitated by the presence of a thin paratenon sheath, which is composed of both a visceral layer and parietal layer, rather than simply a true synovial sheath. The tendon's blood supply arises from the osseous insertion, the musculotendinous junction, and multiple infiltrating mesotenon vessels, which cross the layers of the anterior paratenon.

Various injection and nuclear medicine studies have demonstrated a paucity of mesotenon and intratendinous vessels 2-6 cm proximal to the heel insertion known as the watershed area. Due to the relative lack of blood supply in the watershed area, this area of the tendon is less resilient to repetitive microtrauma and has a higher tendency for irritation, degeneration, and possible rupture.

Sport Specific Biomechanics

The entire gastrocnemius/soleus musculotendinous unit spans the knee joint, tibiotalar (ankle) joint, and talocalcaneal (subtalar) joint. Contracture of this complex flexes the knee, plantar flexes the ankle, and supinates the subtalar joint. During running, forces equaling 10 times the body weight have been measured within the tendon.

Treatment

Acute Phase

Rehabilitation Program

Physical Therapy

Peritenonitis

Recommend rest and limitation of activities determined by the severity and duration of pain. Ice compresses can be used for relief of acute pain and inflammation following activities. Recommend nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce pain and inflammation. Suggest a heel lift of 1-2 cm on a temporary basis for comfort. Heel lifts on a prolonged basis may result in tendon shortening.

Instruct the patient in stretching, training modification/re-evaluation, and muscle strengthening. Stretching exercises are believed to be the key modality in treatment as they provide better flexibility to the ankle. Stretching of the posterior gastroc-soleus complex should always be slow and deliberate. Each stretch should last for 20-30 seconds, with multiple repetitions in a set.

Three possible methods of stretching the gastroc-soleus complex include 1) incline board, 2) wall leans, and 3) "foot on chair" stretching. An incline board is a fabricated ramp of 15-18° that allows the patient to gradually stretch the heel cord complex. A much simpler method is to have the patient stand and face a wall, while leaning with his knees extended and his heels planted on the ground. The "foot on chair" method requires the athlete to place his foot flat on a chair, and gradually bring his knee forward as far as possible without losing heel contact with the chair. Use orthotics to treat overpronation or heel cups to provide extra support and cushion to the tendon. Return to activities is gradual.

Tendinosis

Tendinosis alone usually is asymptomatic and is noticeable only with palpation of a nodule or fullness along the tendon. Tendinosis becomes symptomatic when coexistent peritenonitis is present and the patient complains of activity-related pain or swelling. Treatment is first conservative with methods similar to simple peritenonitis. Six to eight weeks of activity modification, orthotics (walking boot with a heel lift), anti-inflammatory analgesics, and physical therapy should be prescribed prior to any operative treatment or orthopedic referral.

Certain modalities have been used in physical therapy programs. Therapeutic ultrasound provides silent mechanical vibrations of high frequency that penetrate superficial tissue in order to generate deep heat. Ultrasound has been shown in some studies to increase the rate of collagen synthesis and the breaking strength of the tendon. Ultrasound's effectiveness as an anti-inflammatory technique remains unproven. Both phonophoresis and iontophoresis deliver topically applied anti-inflammatory medications transdermally with the aid of mechanical ultrasound energy or an electrical field gradient, respectively. Typically, because the anti-inflammatory substance is a steroid (known to weaken tendinous tissue), we do not recommend its use.

Medical Issues/Complications

Steroid injections into and around the tendon are not advised because they have been shown to weaken the tendon.

Surgical Intervention

Operative treatment is indicated in athletes with peritonitis and/or tendinosis after a comprehensive conservative treatment program has failed and who are unwilling to modify or stop their activity. Although there are no absolute indications, relative contraindications include noncompliant patients, active infection site, and patients with potential wound healing problems (eg, diabetes mellitus, peripheral vascular disease, smokers).

Lysis of adhesions through release of the Achilles tendon from the inflamed paratenon is the mainstay procedure for unrelieved peritonitis. Release is performed on the dorsal, medial, and lateral aspects of the tendon. Circumferential dissection to include the anterior sheath may jeopardize the vascular supply to the tendon and cause excessive scarring. This surgery is followed immediately with passive range of motion (PROM) and progressive weight bearing and strengthening for 2-3 weeks. When ambulating without pain, the patient may begin closed chain activities, such as biking or stair climbing. Running may begin at 6-10 weeks after surgery. Participation in competitive sports can start after 3-6 months.

For people with tendinosis, failure of nonoperative treatment often requires excision or splitting of the paratenon, debridement, and repair of the degenerated tendon with side-to-side repair. Following the operation, a period of protected weight bearing, ROM, and strengthening is advised until return to full activities is achieved.

Other Treatment

Operative brisement (ie, injection of dilute anesthetic into the paratenon sheath under ultrasound guidance to break up adhesions) may be useful in patients with peritenonitis or tendinosis with peritenonitis.

Recovery Phase

Rehabilitation Program

Physical Therapy

See Physical Therapy above.

Medical Issues/Complications

Tendonitis may go onto rupture. Steroid injections, especially multiple injections, may weaken the tendon leading to tendon rupture.

Maintenance Phase

Rehabilitation Program

Physical Therapy

Achilles tendonitis is best prevented, treated, and maintained by preserving good ROM in the heel cord complex. Such motion can be gained with the use of an incline board, wall leans, or the "foot on chair" stretching exercises as described. Moist heat or compresses prior to workouts and at night are beneficial. Cold modalities should be used following strenuous activities to provide pain relief and anti-inflammatory effects.

Medication

No medical therapy of choice exists. Most patients are treated symptomatically with acetaminophen or NSAIDs as determined by the patient's medical condition and physician's preferences.

Drug Category: Analgesics/antipyretics

Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties, which are beneficial for patients who have sustained trauma or have sustained injuries.

Drug Name	Acetaminophen (Tylenol, Feverall, Tempra)
Description	DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.
Adult Dose	650 mg PO q4h prn
Pediatric Dose	10-15 mg/kg PO q4h prn
Contraindications	Documented hypersensitivity
Interactions	Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Hepatotoxicity possible in patients with chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; APAP is contained in many OTC products and combined use with these products may result in cumulative APAP doses exceeding recommended maximum dose

Drug Category: Nonsteroidal anti-inflammatory drugs (NSAIDs)

Have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but may inhibit cyclo-oxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.

Drug Name	Ibuprofen (Motrin, Advil)
Description	DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult Dose	200-600 mg PO q8h prn
Pediatric Dose	10 mg/kg PO q6-8h prn
Contraindications	Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	D - Unsafe in pregnancy
Precautions	Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

Achilles Tendon Rupture

Background

Ruptures of the Achilles tendon most commonly occur spontaneously in healthy, young, active individuals who are aged 30-50 years and have no antecedent history of calf or heel pain. Unlike tears or ruptures at the musculotendinous junction of the Achilles tendon (tennis leg), Achilles tendon ruptures are located within the tendon substance itself, approximately 1-2 inches proximal to its insertion into the calcaneus. Poor conditioning, advanced age, and overexertion are risk factors for this injury. However, the common precipitating event is a sudden eccentric force applied to a dorsiflexed foot. Ruptures of the Achilles tendon also may occur as the result of direct trauma or as the end result following Achilles peritenonitis with or without tendinosis.

Achilles tendon pathology, other than rupture, can be classified into a spectrum of injuries including peritenonitis, tendinosis, and peritenonitis with tendinosis. Patients with peritenonitis experience localized burning pain along the tendon during or following activities; as the disease progresses, onset of pain may occur earlier during activities, with decreased activity level, or even at rest. Tendinosis usually is comprised of an asymptomatic, noninflammatory, degenerative disease process (mucoid degeneration); patients with tendinosis may complain of a sensation of fullness or a nodule in the back of the leg. Peritenonitis with tendinosis is comprised of activity-related pain, diffuse swelling of the tendon sheath, and presence of nodules. Treatment of these entities is not discussed in this article.

Frequency

United States

The true prevalence of Achilles tendon rupture is unknown, although it occurs more commonly in men who are in their third to fifth decade of life and who participate in recreational activities.

Functional Anatomy

The Achilles tendon, coined after the mythologic Greek god, is the largest and strongest tendon in the human body. The Achilles tendon is formed from the tendinous contributions of the gastrocnemius and soleus muscles coalescing approximately 15 cm proximal to its insertion. Along its course in the posterior aspect of the leg, the tendon spirals 30-150° until it inserts into the calcaneal tuberosity. The gliding ability of the Achilles tendon is aided by a thin sheath of paratenon rather than a true synovial sheath. The sheath of paratenon is composed of a visceral layer and a parietal layer.

The blood supply of the Achilles tendon arises from its osseous insertion, its musculotendinous junction, and multiple infiltrating mesosternal vessels, which cross the layers of the anterior paratenon. Various injection and nuclear medicine studies have demonstrated a paucity of mesosternal and intratendinous vessels 2-6 cm proximal to the heel insertion (ie, the watershed area). Due to the relative lack of blood supply in this area, the tendon is less resilient to repetitive microtrauma and has a higher tendency for irritation, degeneration, and rupture.

Sport Specific Biomechanics

The entire gastrocnemius-soleus musculotendinous unit spans the knee, tibiotalar (ankle), and talocalcaneal (subtalar) joints. Contracture of this complex flexes the knee, plantar flexes the ankle, and supinates the subtalar joint. The function of the gastrocnemius-soleus musculotendinous unit is necessary in running, jumping, toe standing, and stair-climbing activities because it forcefully plantar flexes the ankle. During running, forces 10 times the body weight have been measured within the tendon substance.

Treatment

Acute Phase

Rehabilitation Program

Physical Therapy

An individual who ruptures his or her Achilles tendon should seek prompt medical treatment. Physical therapy generally is not indicated in the acute phase of treatment, but it later becomes a crucial part of rehabilitation once adequate healing of the tendon has occurred. The course of treatment (nonoperative vs operative) is determined on a patient-by-patient basis. Typically, both nonoperative and operative treatment options are offered to patients, with particular emphasis on the benefits and risks of each procedure. The recommendations provided in this section regarding operative versus nonoperative treatment are guidelines only and must be personalized to each patient’s needs and condition.

Surgical Intervention

The goal of the orthopedic surgeon is to restore tendon continuity and length to allow the patient to regain his or her functional and desired activity level.

• In general, the author recommends operative intervention for younger, healthier, more active individuals who desire a reliable treatment method. Individuals participating in high school, college, semiprofessional, or professional sports are strongly encouraged to have surgery to decrease the chance of rerupture.
  

• Acute ruptures, large partial ruptures, and reruptures are indications for surgical repair. On the other hand, patients who are more elderly and/or more inactive and those who have systemic illnesses or poor skin integrity are not optimal candidates for operative treatment and are better served with nonoperative treatment.
  

• Numerous operative procedures are available to repair the Achilles tendon. Open and closed (percutaneous) procedures are described. These procedures usually involve primary end-to-end tendon repair with or without fascial or tendon reinforcement.
• Open repair
• In an open repair of the Achilles tendon, both medial and lateral longitudinal approaches have been advocated. Medial incisions allow better visualization of the plantaris tendon and avoid injury to the sural nerve. Midline incisions have been used but have had a higher incidence of wound complications and adhesions.
• A tourniquet is first used to provide hemostasis, and the rupture gap is palpated. The medial or lateral longitudinal incision is made through the skin and subcutaneous fat down to the paratenon. The paratenon is divided along the length of the incision to uncover the ruptured ends, which are then irrigated and debrided. By plantar flexing the ankle, the ends are passively reapposed and are secured with heavy nonabsorbable sutures using a modified Kessler, Krackow, or Bunnell technique.
• Care is taken to not overtighten the repair. Overtightening shortens the tendon length and may lead to loss of dorsiflexion.

• If the repair is insecure, it may be reinforced using a pull-out wire or multiple interrupted sutures and/or it may be augmented with a turn-down fascial graft, a weaved plantaris, or, if necessary, a flexor hallucis longus (FHL) or peroneus brevis (PB) tendon transfer.
• The paratenon and skin are then closed.
• Percutaneous repair

• A percutaneous repair of the Achilles tendon uses multiple percutaneous stab incisions on either side of the ruptured ends. Keith needles and nonabsorbable sutures are passed through these stab incisions and are woven through both the proximal and distal tendon ends. The suture ends are then passed through an enlarged medial incision and are tied as the ankle is held in equinus bringing the ends together.

• Postoperatively, a posterior splint or short-leg cast is placed in gravity equinus for 10-14 days to reduce tension on the incision. With each cast change, the ankle is gradually dorsiflexed, with a neutral position being reached at approximately 4 weeks postsurgery. At that time, the patient is allowed to begin weight bearing on the leg. At 6 weeks postsurgery, the cast is discontinued, and the patient is referred to physical therapy.

• Advantages of operative treatment include a lower rerupture rate (0-5%), a higher percentage of patients to return to sports, and a greater return of strength, endurance, and power.
  

• Disadvantages of operative treatment include hospitalization, high operative costs, wound complications (eg, infection, skin slough, sinus formation), adhesions, and possible sural nerve injury (especially through a lateral longitudinal approach).

Other Treatment

Nonoperative treatment usually is indicated for patients who are elderly and/or inactive and for those with systemic illnesses or poor skin integrity. Patients with diabetes, wound healing problems, vascular disease, neuropathies, or serious systemic comorbidities are encouraged to opt for nonoperative treatment because of significant risks of operative treatment (eg, infection, wound breakdown, repair dehiscence, perioperative complications).

• A short-leg cast is applied to the affected leg while the ankle is placed in slight plantar flexion (gravity equinus). By keeping the foot in this position, the tendon ends are theoretically better apposed. Cast immobilization is continued for about 6-10 weeks. Forced dorsiflexion is contraindicated. The ankle gradually may be dorsiflexed to a more neutral position after a period of immobilization (~4-6 wk). This position is sustained with serial casting or adjustable ankle orthotics. Walking in the cast is allowed at this time. Following cast removal, a 2-cm heel lift in the shoe is worn for an additional 2-4 months. During this time, a rehabilitation program is initiated.

• Advantages of nonoperative treatment include no wound complications (eg, skin breakdown, infection, scar formation, neurovascular injury), decreased hospital costs and physician fees, lower morbidity, and no exposure to anesthesia.
  

• Disadvantages of nonoperative treatment include higher incidence of rerupture (up to 40%) and more difficult surgical repair following rerupture. In addition, the tendon edges may heal in an elongated position because of a gap in the unapposed tendon ends resulting in decreased plantar flexion power and endurance.

Recovery Phase

Rehabilitation Program

Physical Therapy

Following cast removal, gentle passive range of motion (PROM) of the ankle and subtalar joints is initiated. After 2 weeks, progressive resistance exercises (PREs) are added to the regimen. This is followed by aggressive gait training exercises at about 10 weeks following injury (nonoperative patients) or surgery (operative patients), leading toward activity specific maneuvers and a return to activities at 4-6 months. The patient's recovery is largely dependent on the quality of the rehabilitation program, his/her motivation and focus, as well as his/her desired postinjury activity level.

Medication

No medical therapy is indicated for this condition. Medication is only prescribed for symptomatic relief of pain. These medications may include acetaminophen, various nonsteroidal anti-inflammatory drugs (NSAIDs), or narcotics, depending on physician preference.

Drug Category: Nonsteroidal anti-inflammatory agents (NSAIDs)

Although most NSAIDs are used primarily for their anti-inflammatory effects, they are effective analgesics and are useful for the relief of mild to moderate pain.

Drug Name	Ibuprofen (Motrin, Advil, Ibuprin)
Description	DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult Dose	200-600 mg PO q8h prn
Pediatric Dose	10 mg/kg PO q6-8h prn
Contraindications	Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

Drug Category: Analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties, which are beneficial for patients who have sustained trauma or injuries.

Drug Name	Acetaminophen (Tylenol, Feverall)
Description	DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.
Adult Dose	650 mg PO q4h prn
Pediatric Dose	10-15 mg/kg PO q4h prn
Contraindications	Documented hypersensitivity; known G-6-PD deficiency
Interactions	Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Hepatotoxicity possible in those with chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; APAP is contained in many OTC products, and combined use with these products may result in cumulative APAP doses exceeding recommended maximum dose

Drug Name	Acetaminophen and codeine (Tylenol #2, Tylenol #3, Tylenol #4)
Description	Indicated for the treatment of mild to moderate pain. The available dosage strengths are as follows: Tylenol #2: 300 mg Tylenol/15 mg codeine Tylenol #3: 300 mg Tylenol/30 mg codeine Tylenol #4: 300 mg Tylenol/60 mg codeine
Adult Dose	1-2 tab of Tylenol #2 or Tylenol #3 PO q4h prn 1 tab of Tylenol #4 PO q4h prn
Pediatric Dose	Tylenol with codeine elixir (120 mg Tylenol + 12 mg codeine)/5 mL Under 3 years: Not established 3-6 years: 5 mL PO tid-qid prn 7-12 years: 10 mL PO tid-qid prn
Contraindications	Documented hypersensitivity
Interactions	Toxicity increases with CNS depressants or tricyclic antidepressants
Pregnancy	D - Unsafe in pregnancy
Precautions	Head injury; increased intracranial pressure; acute abdominal injury; impaired renal, hepatic, thyroid, or adrenocortical function; prostatic hypertrophy or urethral stricture; and asthma (tabs) Caution in patients dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction; may cause dizziness, sedation, nausea, vomiting, constipation, urinary retention, rash, respiratory depression, and/or hepatotoxicity (overdose)