Foot and Ankle cases 33
A 57-year-old female presents with an 8-month history of pain at the Achilles tendon insertion. She reports a burning pain that is worse with activity. She is only able to wear backless shoes. On physical examination, she has point tenderness at the insertion of the Achilles tendon. She has a positive Silfverskiold sign, with ankle dorsiflexion to 0 degrees with the knee extended that increases to 10 degrees with the knee flexed to 90 degrees. A radiograph is shown in Figure 5–64.
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Figure 5–64 Lateral radiograph of the ankle showing calcification at the insertion of the Achilles tendon.
The most appropriate initial management of Achilles tendinopathy includes:
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Cortisone injection
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A nonweight-bearing cast for 4 weeks
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Surgical debridement
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Eccentric calf stretching and physical therapy
Discussion
The correct answer is (D). Eccentric calf stretching (application of load during
muscle lengthening) has been shown to decrease pain and shorten the time to return to sport. Insertional Achilles tendinopathy does not respond as well to eccentric calf stretching as noninsertional tendinopathy but should still be considered as a first-line treatment. A nonweight-bearing cast may help improve symptoms but will result in calf atrophy and poor organization of the collagen repair. Cortisone should be avoided around the Achilles tendon; case reports of Achilles tendon rupture following corticosteroid injections exist. Surgical debridement should be used to treat refractory cases of tendinosis.
Acute tendinitis has been associated with which class of medication?
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Aminoglycosides
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Fluoroquinolones
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β-Lactam antibiotics
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Lincosamides
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Macrolides
Discussion
The correct answer is (B). Fluoroquinolone antibiotics have been linked to Achilles tendinitis and Achilles tendon rupture. Ciprofloxacin is the most commonly implicated fluoroquinolone and has been associated with a 4.1-fold increase in risk of Achilles rupture. Median onset of tendinitis is 6 days (85% of cases within first month) after starting the ciprofloxacin and symptoms typically precede tendon rupture by up to 2 weeks. While other tendons can be involved, the Achilles is most commonly affected (90% of cases). Aminoglycosides, such as gentamycin, have been associated with renal toxicity and hearing loss. β-Lactam antibiotics, such as penicillin, may be associated with GI symptoms or a rash. Lincosamides, such as clindamycin, may be associated with pseudomembranous colitis. Macrolides, such as erythromycin, may be associated with GI symptoms.
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Figure 5–65 A T2 sagittal MRI showing insertional thickening of the Achilles tendon and >50% involvement of the tendon.
What is the best surgical treatment option for this patient?
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Multiple percutaneous longitudinal tenotomies
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Excision of Haglund deformity
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Achilles tendon debridement, excision of the Haglund deformity, and flexor hallucis longus (FHL) tendon transfer
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Calcaneal osteotomy
Discussion
The correct answer is (C). Excision of the Haglund deformity alone will not address the tendinopathy; the degenerative portion of the tendon should be debrided. Tendon transfer to supplement Achilles debridement should be considered when >50% of the tendon is involved and in older patients (>55 years). A recent study evaluating FHL tendon transfer showed more improvement in functional outcomes in patients older than 50 years compared with patients younger than 50 years. Multiple percutaneous longitudinal tenotomies can be used as a minimally invasive treatment option for noninsertional Achilles tendinopathy. A calcaneal osteotomy may be used to address hindfoot malalignment but does not address tendon pathology.
Objectives: Did you learn...?
Importance of eccentric stretching and strengthening for Achilles tendinopathy?
Describe the relationship between fluoroquinolone antibiotics and Achilles tendon pathology?