Medico-Legal Aspects of Achilles Tendon Disorders

16 Pages·2007·0.17 MB·English

26
Medico-Legal Aspects of Achilles
Tendon Disorders
W.J. Ribbans and Ramanathan Natarajan
Introduction • Help health-care professionals seek the evidence
they require and provide signposts to the back-
Achilles tendon disorders present to a range of ground work that underpins their management
health-care professionals, including primary care of these disorders.
physicians, physiotherapists, triage nursing staff, • Provide objective information upon which
emergency care physicians, rheumatologists, and patients can arrive at informed consent relating
orthopedic surgeons. to treatment and outcome.
Recent epidemiological studies have demon-
strated a signifi cant increase in the prevalence of
Achilles tendon pathology,1,2 with some authors Acute Ruptures of the Achilles Tendon
reporting a 400% increase in the incidence of
Achilles tendon ruptures in their personal prac-
Acute ruptures of the Achilles tendon present fre-
tice over 20 years.
quently and with increasing regularity as general
Tendon pathology accounts for between one-
participation in recreational sports increases. The
third and one-half of all sports-related injuries
history and examination usually lead to a clear
with the Achilles tendon most commonly
diagnosis on clinical grounds alone. Considering
involved.1,3–5 To a large extent, this can be explained
the frequency with which the condition presents,
by the increasing numbers of people in their fourth
the management of such injuries remains contro-
decade and beyond who continue to enjoy aerobic
versial with a surprising paucity of “gold stan-
exercise as a means of promoting cardiovascular
dard” randomized prospective studies.
fi tness—the “weekend warrior” syndrome. Achil-
les problems are the third most common site of
injuries in runners in the United States, account- How Often Do Acute Achilles Tendon
ing for 11% of all injuries and generating approxi-
Ruptures Get Missed?
mately 825,000 injuries every year.
Other chapters in this book describe the pathol- Acute Achilles tendon ruptures may present to a
ogy and management strategies for specifi c forms variety of health-care professionals with signifi -
of Achilles pathology. This chapter brings together cantly different levels of clinical experience. Fre-
some of the more controversial issues related to quently the patient does not appreciate the
assessment and management. Where possible, it signifi cance of the injury sustained.
presents the evidence, or lack of it, for selecting Overall, the diagnosis is missed in up to 25% of
particular pathways, and presents facts on out- patients on initial assessment.6,7 However, in the
comes that patients frequently ask. older age group, the delay is frequently greater
While duplicating some of the information due to a combination of reduced patient
found elsewhere in this book, this chapter will: awareness and lowered clinical suspicion. In
252
26. Medico-Legal Aspects of Achilles Tendon Disorders 253
Nestorson’s series,8 36% of the over-65-year age Ultrasound
group were not diagnosed for at least one week.
The accuracy of ultrasound examination of the
Achilles following rupture is still at least partially
Medico-Legal Implications
dependent on the experience of the radiologist.10
• A careful history and examination should be In experienced hands, ultrasound is very accu-
taken and recorded in all patients with an rate at diagnosing a full-thickness tear as a com-
account of sudden pain, snap, or pop in the calf. plete gap between the retracted torn ends and
The fi ndings on conducting the following tests posterior acoustic shadowing. The gap between
should be recorded: the torn ends can be measured and act as a guide
• Palpable gap to decision making on surgical or conservative
• Calf squeeze test (Simmonds, Thompson and management. Because of its dynamic nature,
Doherty) ultrasound can determine whether torn ends will
• Knee fl exion test appose and if so the ankle position required to
• Tiptoe test (may be too painful) fully appose the torn ends.
• Have a heightened suspicion in an elderly There is some controversy over the usefulness
patient with a history of a snap or pop in the of ultrasonography in postoperative follow-up,11–
calf. This group forms a second peak for rup- 13 although it has been advocated for patients
tures, albeit smaller than for the younger sports- treated conservatively.14
man or -woman. Ultrasound can offer unique advantages when
• After a few days, an initial palpable gap may be trying to distinguish between full- and partial-
obscured by hematoma and early granulation thickness tears. There is always a caveat, as a
tissue. plantaris tendon may manifest itself as an intact
• If there are any doubts as to the presence of an medial part of the Achilles tendon itself.
acute rupture or whether it is total or partial, Distinction between a partial- and full-
you should either seek more experienced advice thickness tear could be made with 92% accuracy
or arrange for objective information in the form in Hartgerink et al.’s paper15 with a sensitivity
of either real-time high-resolution ultrasonog- of 100% and specifi city of 83%.
raphy or an MRI scan. Ultrasonographically detectable tendon abnor-
malities persist long after the tendon has success-
fully healed and the patient has returned to normal
How Accurate Is Imaging of a Suspected activities of daily living.
Acute Achilles Tendon Injury?
MRI
The diagnosis of an acute rupture of the Achilles
MRI is increasingly used to image the Achilles
should remain a clinical diagnosis based on a
tendon for chronic tendinopathy. The same
sound history and examination. There are,
imaging modality can be used to evaluate acute
however, occasions when additional imaging may
injuries.
be helpful.
MRI will accurately locate and determine the
size of the gap following acute injury. Compared
Conventional Radiography
with ultrasound, it is less easily adaptable as a
Plain radiographs of the hindfoot and distal leg dynamic tool in determining the ability to close
contribute little in the diagnosis of acute Achilles the gap between torn ends in different ankle
ruptures. Occasionally, a lateral radiograph, espe- positions.
cially after a couple of days, may show loss of the It can be helpful in distinguishing between
usually sharp interface between the anterior partial and complete tears. However, in patients
border of the tendon and the pre-Achilles fat pad with longstanding severe tendinopathy, distinc-
(Kager’s triangle) due to swelling or hemorrhage. tion between a partial tear and tendinopathy is
However, chronic tendinopathy may give a similar not always possible. Marked tendon enlargement
appearance.9 and signifi cant alteration in signal intensity from
254 W.J. Ribbans and R. Natarajan
within the tendon should be considered to be a age, occupation, level of activity, and medical
partial tear unless proven otherwise.16 history. Other factors such as the surgeon’s own
experience and facilities for rehabilitation need
Medico-Legal Implications to be taken into account.
Imaging may be useful in certain cases of sus-
pected or proven acute Achilles tendon ruptures: What Are the Likely Complications after an
Acute Rupture of the Achilles Tendon?
• To determine whether the tear is a partial or
complete rupture
Numerous studies tackle this subject. Kirkley20
• In cases of delayed presentation, when the gap
performed a quantitative review of the literature
may have fi lled with hematoma and granulation
(Table 26.1) Others authors have produced simi-
tissue, to confi rm diagnosis
larly useful review publications on complications
• To determine whether the gap between torn
and re-rupture rates (Tables 26.2 and 26.3).
ends closes as the ankle plantarfl exes
These studies combine many authors’ experi-
• To monitor progress toward healing—
ence using both conservative and several forms of
especially if nonoperative treatment has been
surgical techniques on a large number of patients.
instituted
• Occasionally, to monitor satisfactory healing
later in the rehabilitation process, especially for TABLE 26.1. Summary of Complications from the Management of
elite/professional athletes prior to return to Acute Achilles Tendon Ruptures
sports Statistical
Significance
However, the limitations of ultrasound and MRI
Using Unpaired
should be appreciated and the primacy of history Complications Nonoperative Operative t-Test
and clinical examination acknowledged.
Major Complications
Death 0 0
Conservative or Surgical Management for Pulmonary embolus 1 0
Deep vein thrombosis 4 1
Acute Rupture of the Achilles Tendon?
Pneumonia 0 2
Skin slough 0 6
When counseling a patient diagnosed with an Sinus formation 0 3
acute rupture of the Achilles tendon, a signifi cant Fistula formation 0 0
proportion of the time will be spent discussing the Tendon lengthening 2 0
Second operation 0 9
merits of conservative versus surgical manage-
ment, and the potential ensuing complications of Total 7/248 21/701
each management modality. Percentage 2.8% 3.0% p = 0.296
The debate over conservative versus surgical
Moderate Complications
repair of acute ruptures continues to rage and is
Delayed healing 0 18
hampered by the lack of a number of prospective Granuloma formation 0 11
randomized “gold standard” studies. Cetti,17 Infection 0 4
Nistor,18 and Möller19 are the three studies that Sural nerve injury 1 42
have attempted to prospectively examine these Total 1/248 76/701
issues. Percentage 0.4% 10.84% p = 0.0296
Minor Complications
Medico-Legal Implications
Adhesions 2 99
• Patients need to be informed that there are no Total 2/248 99/571
absolutes in decision making for management Percentage 0.8% 17.3% p = 0.0003
of acute ruptures of the Achilles tendon.
Re-rupture Rate 29/248 21/742
• Each patient needs to be individually assessed,
Percentage 11.69% 2.83% p = 0.001
and a fi nal decision on management made
according to elements such as the individual’s Adapted from Kirkley et al.20
26. Medico-Legal Aspects of Achilles Tendon Disorders 255
TABLE 26.2. Review Articles Comparing the Complications Following Surgical and Nonsurgical Treatment of Acute Achilles Tendon
Ruptures
Number of Number of Tendon Nonsurgical Surgical Nonsurgical Surgical
Authors Articles Reviewed Ruptures Complication Rate Complication Rate Re-rupture Rate Re-rupture Rate
Wills et al.21 20 1003 2/20 (10%) 155/777 (19.9%) 40/226 (17.7%) 12/177 (1.5%)
Cetti et al.17 66 4597 24/514 (4.7%) 425/4083 (10.4%) 69/514 (13.4%) 58/4083 (1.4%)
Kirkley et al.20 19 990 10/248 (4%) 196/742 (26.4%) 29/248 (11.7) 21/742 (2.8%)
Popovic et al.22 16 5046 27/569 (4.7%) 492/4477 (11.0%) 76/569 (13.3%) 69/4477 (1.5%)
Wong et al.23 125 5056 59/645 (9.4%) 976/4411 (22.1%) 63/645 (9.8%) 103/4411 (2.3%)
Bhandari et al.24 6 248 0/210 (0.0%)* 10/221 (4.7%) 29/233 (12.4%) 7/225 (3.1%)
Kocher et al.25 32 1893 12/365 (3.3%) 306/1487 (20.6%) 29/347 (8.4%) 32/1437 (2.2%)
Khan et al.26 4 356 5/183 (2.7%) 59/173 (34.1%) 23/183 (12.6%) 6/173 (3.5%)
*Bhandari’s paper limited to infections for complications.
Adapted from Movin et al.32
It is likely that different reviews will have used a • Patients should be aware of the increased risks
similar cohort of papers upon which to base their of wound breakdown and infection following
fi ndings. This makes it diffi cult to summate the surgery to this area. Sural nerve injury at 6%
fi ndings and produce average complication and incidence19 should be specifi cally mentioned.
re-rupture rates. Similarly, the criteria for count- • Overall, complication rates following conserva-
ing complications will vary widely between tive treatment are on average about 3–5%. Con-
studies. However, the fi ndings from these numer- versely, the overall complication rates for all
ous authors provide a useful resource upon which types of surgical procedures combined is about
to base patient counseling. four to fi ve times greater at about 12–25%. This
excludes re-rupture rates, which will be dealt
Medico-Legal Implications with separately.
• A discussion regarding potential complications
following an acute Achilles tendon rupture How Likely Is Re-rupture of the
should form a central part of the patient coun-
Achilles Tendon?
seling process and help the patient and surgeon
arrive at an informed decision over manage- Kirkley’s20 literature review reported an overall
ment strategy. re-rupture rate of 11.69% (29/248) in nonopera-
• Patients should be left in no doubt that the tively managed patients compared with a re-
rupture of the most powerful musculotendinous rupture rate of 2.83% (21/742) in those managed
unit in the body is not a benign injury. Signifi - surgically (Table 26.1).
cant complications may ensue, and some degree In Table 26.2, the re-rupture rate following sur-
of long-term disability is possible. gical repair ranges from 1.4% to 3.5% in the papers
• Patients should be informed that any man- quoted. Conversely, the re-rupture rate in nonop-
agement strategy has hazards or potential eratively managed patients ranged from 8.4% to
complications. 17.7% from the same set of authors.
TABLE 26.3. Summary of Complication Rates from Wong et al.’s Review with Respect to Management Techniques23
Minor Wound Major Wound Minor General Major General Re-rupture
Management Techniques Complications Complications Complications Complications Rate
Conservative (n = 645) 0.5% 0% 8.5% 0.6% 9.8%
Percutaneous + Immobilization (n = 247) 4.9% 0% 8.5% 0.8% 3.6%
Percutaneous + Early Mobilization (n = 122) 6.6% 3.3% 14.8% 0.8% 6.6%
Open + Immobilization (n = 3718) 12.3% 2.3% 12.3% 2.3% 2.2%
Open + Early Mobilization (n = 283) 4.9% 0.4% 5.3% 0.4% 1.4%
External Fixation (K-wire fixation) (n = 41) 7.3% 0% 7.3% 0% 0%
256 W.J. Ribbans and R. Natarajan
However, in some of these series, patients sys- • Co-morbidity
temically unsuitable for surgery may have been • Level of pre-rupture activity
offered conservative treatment only. Their under- • Age of patient
lying medical health (e.g., obesity, vascular • Type of occupation and pre-injury recreational
disease, steroid medication) may increase their activities
risk of re-rupture as well as making them unsuit- • Method and timing of initial treatment
able for surgery in the fi rst instance. Also, 80% of • Rehabilitation regime
re-ruptures occur within the fi rst 3 months.2 • Absence of complications
Medico-Legal Implications Despite changes in initial management, changing
views on early weight-bearing status, and more
• All patients with acute Achilles ruptures should
proactive functional rehabilitation, the very fact
be counseled about the possibility of
of sustaining a rupture of the Achilles constitutes
re-rupture.
a potential signifi cant long-term disability for the
• Overall the risk of re-rupture is about four times
patient.
higher in patients managed conservatively.
In 1986, Haggmark28 reviewed the dynamic calf
Historically, patients managed surgically have muscle status following rupture. At 3–5 years,
about a 1 : 33 chance of re-rupturing compared those treated surgically were functioning signifi -
with about a 1 : 8 chance for those managed cantly better than those treated conservatively.
conservatively. More recent studies have indicated that, despite
instituting more modern management strategies,
• It is probable that modern methods of manage-
some degree of residual weakness, muscle atrophy,
ment—both surgical and conservative—will
and plantarfl exion defi cits can persist in the long-
reduce re-rupture rates as techniques of repair,
term.19,29,30 Möller19 found a gradual improvement
protection, and rehabilitation develop.
in triceps surae strength and endurance during
• The most dangerous time for re-rupture is
the fi rst year post-injury.
within the fi rst 3 months following injury.
A trend toward gradual, continuing improve-
ment during the course of the fi rst 12 months
What Is the Risk of Rupture on the
post-injury mirrors the serial ultrasound changes
Contralateral Side Following Initial
noted during the same period. Healing is noted
Acute Rupture? within the fi rst 6–8 weeks, and the tendon reaches
its maximum width (15–20 mm) after 3 months.
The reported risk of sustaining a rupture on
As remodeling progresses, the tendon gradually
the opposite side following an initial acute rupture
thins over several years. In the long-term, the
is 6%.27
tendon is approximately double (12 mm) normal
width.31
Medico-Legal Implications
A return to pre-injury occupation is dependent
The risk is at a suffi ciently high level to suggest to a great extent on the type of work performed.
that, as part of the counseling process for patients A sedentary form of occupation is associated
following treatment for an acute rupture, the pos- often with a return to employment within one
sibility of a rupture of the other Achilles should month if the patient is motivated and the employer
be discussed and advice given regarding warning suffi ciently understanding. Kirkley et al.20 found
signs. that, in over 500 operated patients, the average
time to return to work was 1.95 months compared
How Complete Is the Recovery Following an with 2.3 months for those managed conserva-
tively. This difference did not reach statistical sig-
Achilles Tendon Rupture?
nifi cance (p = 0.611). However, in heavy manual
The degree of recovery following an Achilles occupations, periods absent from work are likely
tendon rupture depends on a number of factors, to exceed 3–4 months.32 For the latter, health and
including: safety issues at the workplace often govern the
26. Medico-Legal Aspects of Achilles Tendon Disorders 257
willingness of the employer to allow the patient to The patients usually present with calf atrophy,
return to work. plantarfl exion weakness, limp, and an inability to
An overt limp should disappear by 3 months, increase activity (e.g., to run, play sports, or stand
but ballistic activities such as running and jumping on single-stance tiptoe). However, in some
will usually be undertaken after six months.19 patients, their disability may be more subtle.
A return to pre-rupture formal recreational There may have been some connective tissue
activities is by no means guaranteed. Many regeneration between the tendon ends and the
patients declined to return, despite being able to, plantaris tendon may have hypertrophied. There-
for fear of further injury (30% at one year), while fore, the gap will not be so apparent and the
15% were unable to return at one year, leaving just patient may be able to perform activities such
over one-half (54%) returning to their pre-rupture as single-stance tiptoe—although usually not
recreational activities at 12 months.19 Of 545 repetitively.
patients managed surgically, 73.39% returned to
sports compared with 69.48% for the 200 patients
managed conservatively. This difference did not Do All Patients with Chronic Ruptures
reach statistical signifi cance (p = 0.581).20 of the Achilles Tendon Require
Operative Repair?
Medico-Legal Implications
There is no doubt that all patients with chronic
The patient should be warned that following
Achilles tendon ruptures need appraising of their
rupture:
management options (i.e., surgical or conserva-
• The Achilles tendon will remain permanently tive regimes).
thickened—approximately double the healthy Prospective, randomized trials of surgical and
contralateral tendon. conservative treatment are not available, are prob-
• The thickening will reduce gradually over the ably unethical, and are likely to cause diffi culty
course of the fi rst year, in concert with improve- with matching patients on account of varying
ment of strength and endurance of the triceps medical co-morbidity in many of the patients pre-
surae. senting in this group.
• Despite modern rehabilitation techniques, some Many orthopedic surgeons with an interest in
degree of permanent calf wasting and weakness trauma and foot and ankle disorders will have
may persist, and be associated with some degree encountered elderly patients with delayed
of ankle stiffness and loss of proprioception. Achilles ruptures, who appear to be performing
• 70–84% of patients will be able to return to the adequately for their required level of
same level of recreational activities within the functioning.
year, but less than two-thirds of those able will The largest series on outcome following conser-
choose to do so. vative management of chronic ruptures was pub-
• Return to work is largely determined by the pre- lished over 50 years ago by Christiansen.33 In a
accident employment. Employed patients series of 51 patients, 18 patients (35%) were
should liase at an early stage with their employ- treated conservatively for a variety of reasons.
ees over any relevant health and safety issues Satisfactory results were obtained in 75% of surgi-
governing a return to work. cally treated patients and 56% of the conservative
group. A satisfactory result was judged by normal
gait, return to work, and slight or no discomfort.
Considering that some of the patients managed
Chronic Ruptures of the
conservatively were “preselected” as surgery may
Achilles Tendon
have been contraindicated because of nonortho-
pedic considerations, the results are surprisingly
Chronic ruptures of the Achilles tendon occur similar. In addition, improvement in function in
through either initial misdiagnosis or late presen- the nonsurgical group could continue for several
tation on behalf of the patient. years following diagnosis.
258 W.J. Ribbans and R. Natarajan
The late presentation of patients is often due to the tendon of fl exor hallucis longus (FHL), fl exor
an underlying sedentary or infi rm state. The digitorum longus (FDL), peroneal, or plantaris).
patients are frequently elderly with little under- Patients need to be aware that the surgical plan
standing of the signifi cance of the injury, which will be fi nalized only once the tendon has been
may have seemed relatively trivial. exposed, the diseased stump ends “freshened,”
Among those conditions that might preclude the surgical bed inspected, and the fi nal gap pro-
surgical intervention would be: duced measured.
No adjacent transferred tendon can ever be as
• Peripheral vascular disease strong as the Achilles it is augmenting. Calf
• Chronic infection strength and endurance will always be defi cient.
• Systemic disease (e.g., diabetes mellitus, rheu- Loss of the transferred tendon from its normal
matoid arthritis) point of insertion may cause disability, particu-
• Morbid obesity larly for the peroneus brevis, with some loss of
• Advanced age eversion strength, and with loss of hallucal fl exion
• Pre-senile dementia or dementia strength with FHL tendon transfer.
• Sedentary or bed-bound existence
• Inability to comply with the postoperative Medico-Legal Implications
regime
• Chronic Achilles ruptures are rare. Conse-
quently, reported series of particular surgeons’
Surgeons should carefully evaluate the patient
experiences are often small.
for all of these conditions before recommending
• Presenting patients may be elderly with signifi -
operative intervention. Conservative options in
cant co-morbidity. In such circumstances,
the form of ankle-foot orthoses (AFO), physio-
strenuous efforts should be made to determine
therapy, and pain relief can be employed to
the viability of the soft tissues and their ability
improve comfort and function.
to heal.
• Not all patients need surgical intervention, with
continuing improvement in function likely to
What Should Patients Be Told Prior
occur over several years.
to Surgery for Chronic Achilles
• Patients should be made aware of the potential
Tendon Ruptures?
for complications following surgery, which will
exceed those of acute repair (i.e., in excess of
Surgical intervention for chronic Achilles tendon
20%).
ruptures involves increased and additional risks
• Surgeons undertaking such surgery should be
compared with primary repair.
fully aware of and experienced in different tech-
All of the complications outlined following
niques for repair and reconstruction. Options
acute Achilles ruptures managed surgically still
need to be kept open until the damaged area is
stand. However, the incision is likely to be
exposed and prepared. This is not surgery for
considerably longer, the procedure more demand-
the inexperienced operator.
ing, and the surgical time prolonged. Such patients
are likely to be older than those presenting with
acute ruptures, and the risks of delayed wound
Chronic Achilles Tendinopathy
healing, wound dehiscence, and infection are all
greater.
There are certain risks attached to each of the Attempts to ameliorate the disabling symptoms
potential surgical solutions (e.g., autogenous arising from various forms of Achilles tendinopa-
versus allograft versus synthetic repairs). In addi- thy have led to many different surgical, mechani-
tion, if an autogenous repair is employed, there cal, and chemical modalities trialed with variable
are differences between different forms of gap effi cacy. In some instances, the management may
bridging (e.g., direct repair, V-Y advancement, endanger the health of the tendon and surround-
and functional augmentation, for example, using ing soft tissues.
26. Medico-Legal Aspects of Achilles Tendon Disorders 259
What Should a Patient Be Told about the les tendinopathy. As in many aspects of medicine
Prognosis of Chronic Achilles Tendinopathy? and surgery where a condition has many potential
remedies, it usually refl ects an uncertainty of
Longitudinal epidemiological studies on the long- correct management. There is little reliable scien-
term outcome in patients with chronic Achilles tifi c evidence to support the many management
tendinopathy are sparse. Paavola et al.34 reported strategies.
the long-term outcome after eight years of When considering the varying options, both
follow-up: the health-care professional and patient should
consider the likely effi cacy and potential
• 84% had returned to full levels of exercise, with
side-effects.
94% of the total group pain-free or experiencing
The various nonsurgical options described
only mild pain on strenuous exercise.
include:
• A delay in commencing conservative treatment
for up to six months did not adversely affect
• Rest
treatment outcomes.
• Physiotherapy, including heat, ultrasound, deep
• 29% of patients failed to respond to conserva-
frictions, ultrasound
tive management, and required surgery.
• NSAIDs
• Despite an overall good outcome in terms of
• Orthotics
comfort and return to sports, there still remain
• Eccentric stretches
clear differences in the affected side in terms of
• Cold packs
clinical assessment and ultrasound examination.
• Laser management
• 41% of the group developed contralateral symp-
• Topical ointments (e.g., glyceryl trinitrate)
toms in the previously asymptomatic other
• Injections:
Achilles during the study period.
• Steroid
Patients should be made aware that a degree of • Heparin
responsibility for ensuring a good outcome is • Aprotinin
dependent on them. Many presenting patients
The various surgical options described include:
have developed problems as a result of training
errors and high-impact exercise that they are • Needling
reluctant to change, and frequently return to ill- • Coblation
advised running schedules before the problem is • Percutaneous (ultrasound-guided) tenotomy
fully rectifi ed. • Arthroscopic debridement (tendoscopy)
• Percutaneous paratenon stripping
Medico-Legal Implications • Open tenotomy and paratenon stripping
• Open tendon debridement
• Most patients will make a good recovery.
• Tendon grafting
• However, patients need to be fully involved in
• Tendon reconstruction
the rehabilitation process and aware that early
return to sports can signifi cantly affect
Medico-Legal Implications
outcome.
• Surgical intervention following a failure of con- • Management protocols vary from unit to unit.
servative management is required in about 3 out • There is no unanimity over the most effective
of 10 patients. strategy.
• The development of management strategies has
usually arisen as a result of local empirical expe-
What Should Patients Be Told about the
rience and available resources.
Management Options for Chronic
• Patients should be appraised of the potential
Achilles Tendinopathy? side-effects of any proposed management.
The scientifi c literature is replete with papers on Much controversy surrounds the use of steroid
different management options for chronic Achil- injections, nonsteroidal anti-infl ammatory
260 W.J. Ribbans and R. Natarajan
medication, and the type and timing of any surgi- Olix43 warned of the danger of rupture following
cal intervention. peritendinous injections to the Achilles. Speed37
could detect no signifi cant difference in results
compared with a placebo injection.
Do Corticosteroid Injections for Achilles Other authors have confi rmed that, if steroid
Tendinopathy Increase the Risk of injections are to be placed in the peritendinous
space, the injection should be carefully under-
Subsequent Achilles Tendon Rupture?
taken by experienced physicians using low
The use of corticosteroid injections in the man- volumes of injectable material.3,41,44 It would
agement of soft-tissue injuries is widespread. Cor- appear that if the injection is to be administered
ticosteroids have been injected peri- or in the peritendinous space, it should be done in
intratendinously for many decades, particularly the early stages of the history and using short-
by rheumatologists.35 Already in 1976, Clancy36 acting corticosteroids.4,40,42
reported on the safe use of intratendinous Achil- Local steroid injections have been reported
les injections for the management of early tendi- experimentally by McWhorter45 as having damag-
nopathy in athletes. However, the study was ing effects at both the cellular and matrix level.
confi ned to 5 runners. More recently, orthopedic Collagen synthesis by fi broblasts appears to be
surgeons have tended to be more circumspect inhibited. A recent basic science article46 demon-
with regard to the use of corticosteroid injections strated that a direct steroid injection in the Achil-
in this area—specifi cally within the tendon itself. les tendon of a rabbit diminished its strength,
Debate continues over its use in terms of both increasing the risk of rupture in the following
effi cacy and potential complications. weeks.
Published data have failed to accurately estab- Conversely, two recent articles suggest that
lish the exact risk of rupture following injection4,37 intratendinous injections are safe and effi ca-
or its likely effi cacy on the underlying pathol- cious.47,48 While Koenig’s study47 reports a decrease
ogy.37–40 Partial Achilles ruptures have been in the ultrasonographic features suggestive of
reported after steroid injections. infl ammation, the study was small (6 tendons in
One problem in reviewing the literature on this 5 patients) and the injections administered in the
subject is that patients would not receive a steroid acute phases of a tendinopathy.
injection unless they had underlying Achilles Patients contemplating undergoing a cortico-
pathology with an inherently increased risk of steroid injection into the soft tissues should be
rupture. Possibly, one of the adverse effects of counseled regarding possible local complications,
corticosteroids is to mask the pain and pathology, including infection, subcutaneous fat atrophy
allowing the patient to return to activity on an (Fig. 26.1), skin pigmentation changes, and risk of
incompletely healed tendon, precipitating a delayed wound healing if the area subsequently
rupture.41 undergoes surgery.
Another issue relating to intratendinous steroid
injections is that any randomized double-blind
Medico-Legal Implications
prospective study in humans is unlikely to receive
ethical approval given the understandable con- • The evidence for the benefi t of local corticoste-
cerns of physicians and surgeons based on empir- roids by injection to manage Achilles tendinop-
ical experience. athy is unproven. Peritendinous injections
Gill et al.40 reported the safety of peritendinous undertaken by experienced medical practitio-
steroid injections for chronic Achilles tendinopa- ners using low injectable volumes preferably
thy when carefully undertaken using low volumes under imaging control in the early stages of the
under fl uoroscopic control. In this large retro- condition may be benefi cial.
spective study of 83 patients, 3.6% felt that their • Local steroids have been reported to increase
condition deteriorated, and 27.7% unchanged fol- the risk of spontaneous tendon rupture. Animal
lowing injection. Similar guidelines had been studies attest to the deleterious effect on the
reported by Fredberg.42 However, Unverferth and tendon of intratendinous injections. Human
26. Medico-Legal Aspects of Achilles Tendon Disorders 261
FIGURE 26.1. Subcutaneous fat atrophy around the Achilles tendon following repeated steroid injections.
studies reporting benefi cial effects of direct methacin and naproxen inhibited cell proliferation
tendon injections have not been without criti- and glycosaminoglycan synthesis in the tendon,
cisms, and at the moment there does not seem suggesting that they should be avoided in clinical
to be any strong support for such a management situations where relief is required from pain and
regimen. swelling after tendon trauma. Conversely, no such
• Patients undergoing corticosteroid injections effects could be ascribed to diclofenac or
have an increased risk of wound healing prob- aceclofenac.
lems in the area of the Achilles tendon, and However, the evidence from drug trials and
should be appraised of such risks. Previous local histological examination of pathological tissue
steroid injections to the area can have a deleteri- does not support their use in the more chronic
ous effect on the skin and subcutaneous tissues, situation.
increasing subsequent surgical wound healing Åström and Westlin53 undertook a randomized
risks. study on the effect of piroxicam in the manage-
ment of Achilles paratendinopathy and could not
detect a positive effect.
Does the Use of NSAIDs Affect Achilles
Histological specimens of Achilles tendon have
Tendon Healing? failed to demonstrate an infl ammatory cell infi l-
tration in patients with chronic tendinopathies.54
Nonsteroidal anti-infl ammatory drugs (NSAIDs)
Li55 reported that NSAIDs may exert a detri-
are widely used in soft-tissue disorders. Many dif-
mental effect on the tendon by increasing the
ferent drugs exist within this category and their
levels of leukotriene B4 within the structure and
use is not without potential side-effects, such as
enhance the likelihood of a tendinopathy. Alme-
gastrointestinal disturbances and renal damage.
kinders56 suggested that the effect of NSAIDs may
What is the evidence that they are helpful in the
be negative in the proliferative phase of healing by
management of Achilles disorders, and is there
their inhibition of DNA synthesis, while acting in
any evidence that their use might be potentially
a more positive fashion later as the tissue matures
harmful?
and remodels by stimulating protein synthesis.
Physicians have frequently used nonsteroidal
anti-infl ammatory drugs (NSAIDs) in Achilles
Medico-Legal Implications
tendinopathy, especially in the clinically acute
phases.49–51 • In the acute phases of Achilles tendinopathy, a
Various forms of NSAIDs acted in a less-than- short course of NSAIDs may help relieve
uniform manner when evaluated by Riley.52 Indo- symptoms.