Achilles (heel tendon) injury is a common soft tissue injury. The heel tendon is very strong. Violation of the integrity of the Achilles is possible with excessive load that does not correspond to its strength. More often, the disease is diagnosed in males, aged from 30 to 50 years, involved in sports. The disruption of the integrity of the heel tendon is complete, compared to injury to other soft tissues. This pathology is called an Achilles tendon rupture.
In the first place among the causes of occurrence is overstrain of the calf muscle of the leg. This happens when there is a sudden, excessive load on the leg.
An example of such a load is a sharp start in runners or when jumping. This happens when you don't warm up enough. Sometimes an Achilles injury (photo below) occurs against the background of a congenital anomaly, in which case the person is especially susceptible to the occurrence of this pathology.
Due to their structure, women are less susceptible to injury. In older people, injuries occur due to careless walking, when going up or down stairs.
Less commonly, the etiology is a direct blow with a blunt object directly above the heel. Injury from a sharp object may also be the cause.
The concept of trauma is quite broad and includes nosologies that are similar in occurrence and clinical picture, but different in treatment tactics. What is an Achilles injury? It includes the following nosologies:
Depending on the strength of the tissues and the force acting on them, the violation of integrity can be of varying degrees. A bruise is a closed injury to soft tissue, without severely disrupting the integrity of the structure. Stretching is a tear of tissue, with partial preservation of the structure. Rupture is a complete divergence of the structure, with a violation of anatomical continuity.
In the practice of doctors, there is a concept: chronic sprain. This pathology is diagnosed to patients in case of prolonged absence of treatment for an Achilles tendon injury. The clinical picture includes enlargement of the calf muscle on the affected leg.
If more than six months have passed since the torn tissues appeared, excessive arching of the foot is likely to develop.
The signs of an Achilles rupture are quite typical and are similar to ruptures of other soft structures of the body. The symptoms and treatment for both rupture and sprain of the Achilles tendon are almost identical. The first and most important symptom for all types of injuries to the heel ligaments and muscles is local sharp pain when standing on the foot in the projection above the heel bone; injury to the Achilles tendon is also accompanied by pain on palpation. Local tissue swells at the site of injury.
When sprained, it is difficult to flex the foot, there is a violation of the contours of the structures, and there is a small hematoma. A complete tear visually looks like a divergence of tissue, with a hole in the center.
It is impossible to flex the foot, and when the calf muscle is compressed, there is a complete lack of movement. Achilles rupture injury is accompanied by a large hematoma.
An Achilles tendon injury is accompanied by mild or absent symptoms. There may only be a sensation above the heel that the Achilles tendon is pulling.
Diagnosing an Achilles tendon injury and starting treatment is not difficult. The main method for diagnosing injury is anamnestic data obtained from the patient’s mouth.
Typically, when collecting anamnesis, there will be information about sports activities that involve sudden movements of the legs or other excessive stress. There may be a history of injury caused by sharp or blunt objects in the area above the heel bone, such injuries to the Achilles tendon are called sharp or blunt, respectively.
Additional information about the condition of the limb is provided by palpation; if there is severe swelling and hematoma, palpation helps to make a preliminary conclusion about the presence or absence of complete separation.
A mandatory examination is radiography. It allows you to rule out the presence of a broken bone, torn ankle ligaments, or other damage to nearby structures.
An ultrasound examination is required to determine the percentage of separation. Only ultrasound can clearly differentiate between an Achilles tear and rupture.
Magnetic resonance imaging is usually not used as unnecessary. However, if desired, MRI can be performed to obtain a detailed picture of the damaged structures.
With a delayed diagnosis and lack of treatment for Achilles damage, chronic carriage of partially torn structures develops, which will complicate therapy in the future.
Identifying Achilles tendon injuries is not difficult based on a textbook. They must be distinguished from the following ailments:
If someone has sprained their Achilles tendon, what should they do first? First, you need to lay the person down to rest the leg. Then apply ice to the Achilles sprain, avoiding direct contact with the skin. Transport the patient to the emergency room as quickly as possible.
Treatment of an Achilles tendon bruise does not have any special features compared to bruises of other soft tissues. The main postulates in this case are rest and cold for the sore leg. If necessary, you can use painkillers.
If there is a tear or rupture, what to do? The mainstay of therapy is surgery. The essence of the operation is the mechanical comparison of parts torn from each other by applying sutures.
It is mandatory to place the leg in equinus and apply a cast in this position for a period of 2-3 weeks. The leg is then adjusted to a 90 degree position to avoid shortening the leg. The number of weeks in a cast depends on the regenerative properties of the body and the degree of tissue damage.
A necessary stage of treatment after an Achilles tendon injury is rehabilitation. It consists of prescribing physical therapy, the purpose of which is to fully position the person on the foot; it is also necessary to stand on tiptoes after an Achilles injury; these exercises are mandatory. Plus, special shoes are prescribed. Rehabilitation after any Achilles tendon injury is long, but necessary, so you should be patient. The approximate recovery time after an Achilles injury depends on the regenerative abilities of the body and compliance with the necessary exercises.
In the case of a chronic disease, an operation is performed, the purpose of which is to dissect the formed scars that interfere with free movement. Then stitches are applied, and further tactics do not differ from those for recent damage.
Achilles rupture is a serious injury. If correct therapy is carried out and the time frame for recovery of the Achilles tendon injury is observed, the disease will pass without a trace. However, there is a possibility of repeated tearing, since the tissue has a weaker structure and will not withstand enormous loads, such as an intact leg. If recovery from an Achilles tendon injury is not sufficient, the function of the leg will be impaired.
Achilles tendon injuries are quite common. For yourself, be sure to remember the need to see a doctor as soon as possible. A torn Achilles tendon above the heel is a very serious injury and often requires emergency surgery.
Treatment at home for an Achilles tendon injury is not possible. Only during the recovery period should you perform a group of exercises. Only an experienced doctor, knowing the symptoms and what kind of Achilles tendon injury you have, can provide the correct treatment.
Achilles tendon injuries can be open or closed, the latter being less common. Tendon injuries can be partial or complete.
For open wounds, a tendon suture is necessary.
The patient's position on the table is on his stomach, legs extended, place a cushion under the ankle joint so that the toes lightly touch the table.
Anesthesia - local, infiltration anesthesia.
Technique of operation. To apply a suture to the tendon, it is necessary to widen the wound upward and downward. With a partial injury, the ends of the tendon do not separate, but it is necessary to apply sutures to the tendon rupture.
If the tendon is completely cut, its ends may diverge significantly, but in fresh cases it is not difficult to connect the ends. The peripheral end is usually found in place, but the central one can move upward for a considerable distance. To bring the ends of the tendon closer together, it is necessary to plantar flex the foot and bend the limb at the knee joint at an obtuse angle, i.e. place a large cushion under the ankle joint. The tendon can be sutured using a simple mattress stitch.
In order to reduce tension on the tendon tissue and thereby not impair its blood supply, G. F. Sinyakov recommends using silk thread No. 1 using a thin round needle to stitch the tendon 0.5 cm from the end, grabbing it shallowly, then apply another stitch next to it and tighten the thread ; a wrapping seam is obtained around the tendon bundles. Three such sutures are placed on each end of the cut tendon: one on the lateral surface on the right, the second on the left, and the third on the back surface of the Achilles tendon. In order to prevent the ends of the stitched tendon from coming apart in the postoperative period, its central end is fixed to the skin with a silk thread 4-6 cm above the applied sutures.
After suturing the tendon in the above-mentioned position of the limb, a plaster cast is applied to it for a period of three weeks. When the plaster cast is removed, the leg is carefully straightened at the knee joint and the foot is given slight plantar flexion. This position is fixed with a removable plaster splint for another three weeks. During this period, baths, massage and moderate exercises are prescribed. After six weeks, treatment is considered complete.
Closed Achilles tendon injuries are rare and usually appear after injury or after a sharp, sudden plantar flexion of the foot as a result of
rapid contraction of the calf muscles. Patients complain of pain in the calf muscle, they are concerned about leg weakness and impaired support function of the forefoot. Locally, there is swelling and a depression at the site of the tendon rupture.
If there are obvious signs of rupture, surgical intervention should be undertaken, i.e. also apply a primary suture, as with an injury to the Achilles tendon.
Avoiding errors and dangers
1. The main cause of errors leading to gross dysfunction is unclear knowledge of the topographic anatomy of tendons and nerve trunks.
2. Incomplete use of functional treatment in the postoperative period.
Useful and interesting materials:
Injuries to the Achilles tendon, the most powerful and durable tendon in humans, are among the most common injuries in sports. Its ruptures are the third most common and account for 20 to 32% of the total number of injuries to large tendons of the musculoskeletal system.
Most modern authors associate the increase in the number of Achilles tendon ruptures with the development of sports and the increasing involvement of the population in sports. It is indicated that approximately every tenth injury during sports activities occurs due to Achilles tendon ruptures. Most often, Achilles tendon ruptures occur during sports that require strong tension and uncoordinated work of the calf muscle. These are sports such as basketball, volleyball, handball, badminton, tennis, football, gymnastics, and athletics.
Regardless of the mechanism of occurrence, Achilles tendon ruptures always occur as a result of contraction of the triceps surae muscle, the force of which exceeds the strength of the tendon tissue.
The history of this type of injury is quite typical. Most of the ruptures occur during competitions and training, accompanied by significant strain and movement at maximum amplitude. Moreover, most often this happens when taking off for a jump or landing.
The desire to reduce diagnostic errors, as well as to more objective interpretation of clinical data, has led to the introduction of additional research methods for Achilles tendon injuries (MRI, ultrasound).
Depending on the period that has passed since the injury, all ruptures are divided into fresh and old. Although such a division is quite arbitrary, it nevertheless reflects the main patterns occurring in the area of damage over time. The main criteria for this are the formation of granulation tissue and the presence of retraction of the triceps surae muscle, which greatly complicates the approximation of the ends of the damaged tendon. As a rule, this occurs by the end of the second week from the moment of injury. Thus, if no more than two weeks have passed since the Achilles tendon rupture occurred, then it can be considered fresh, and if this period is longer, it can be considered old.
Depending on the etiological factor that led to tendon damage, ruptures are divided into traumatic and pathological.
For fresh ruptures, the application of tendon sutures has become most widespread; there are currently more than 40 methods of application. In cases of significant fiber separation of the ends or degeneration phenomena accompanying a fresh rupture of the tendon, a number of authors suggest, after applying tendon sutures, additional repair is performed with an autoflap from the proximal tendon fragment. Percutaneous submersible suturing has certain advantages over other techniques, which allows you to minimize the possibility of developing complications associated with surgery and at the same time reliably adapt the ends of the torn tendon.
An equally difficult task is the restoration of the tendon in the later stages after its damage. The whole variety of plastic surgeries (more than 80 techniques) proposed for the treatment of chronic Achilles tendon ruptures comes down to the use of various methods of auto- and alloplasty, as well as the use of a variety of xenografts and synthetic materials. The most widely used methods are autoplastic restoration of damaged tendons. Its various modifications are widely used today. In this case, flaps cut from a tendon-muscular stretch of the gastrocnemius muscle or from the ends of the Achilles tendon are most often used as plastic material. Along with this, many authors use the tendons of the plantaris longus, peroneus longus and peroneus brevis muscles as a plastic material to replace the defect. In the case of an elongated scar regenerate with old damage to the Achilles tendon, dissection of the scar in the frontal plane with partial shortening and its suturing in the form of a duplicate is indicated.
Postoperative treatment of Achilles tendon injuries is divided into three periods: a period of immobilization, a period of restoration of motor functions, and a training period.
The main objectives of rehabilitation treatment at this stage should be: improving blood circulation in the area of surgery, preventing the development of muscle atrophy and stiffness of the ankle joint, preventing adhesions, promoting the process of tendon regeneration. Completing these tasks significantly influences the outcome of treatment. Moreover, in each specific case, restorative treatment should be the result of a dynamic analysis of clinical manifestations. In cases of postoperative edema and pastosity of soft tissues, the use of physiotherapeutic methods such as UHF and magnetic therapy is justified. In order to maintain muscle contractility and strength, stimulate blood circulation in them, as well as to optimally restore the motor activity of the limb during the immobilization period in case of Achilles tendon ruptures, myoelectric stimulation has been widely used.
After termination of external fixation of the operated limb, a period of restoration of musculoskeletal function begins. The objectives of treatment at this stage are to increase the range of motion in the ankle joint, to restore the support of the forefoot and roll of the foot, as well as to normalize the condition of the neuromuscular system of the lower leg. For these purposes, therapeutic exercises should be carried out, including exercises with gradually increasing weights for the lower leg muscles and hydrokinesitherapy. Correct walking is practiced until the function of rolling the foot is completely restored. As the support on the fingers normalizes, a transition to special sports exercises occurs. This stage of medical rehabilitation ends with the restoration of the supporting function of the limb and the general working capacity of the athlete and its duration, as a rule, is 2.0 - 3.5 months from the date of surgery.
The main goal of the sports rehabilitation period is the complete restoration of the neuromuscular function of the operated limb, while observing the principle of gradually increasing loads.
The stage of sports training begins on average 5-6 months after the operation. For old injuries, the transition to this stage is possible no earlier than 8-9 months. Moreover, in each specific case, the issue of resuming previous physical activity should be decided individually, taking into account both clinical and functional indicators.
Achilles tendon injury is the most common closed soft tissue injury of the lower leg. Most often, this problem occurs in people aged 30 to 50 years who play sports or lead an active lifestyle. As you know, the Achilles tendon is one of the largest. It lifts the heel when a person walks and lowers the forefoot to the ground.
Without this tendon it is impossible to run, climb stairs or stand on your toes. Among the most common injuries to this part of the human body are Achilles tendon ruptures, partial Achilles tendon ruptures, or Achilles tendon sprains.
The main causes of Achilles tendon injuries are:
Symptoms of an Achilles tendon injury:
It is easier to prevent a disease than to deal with the consequences.
The diagnosis is carried out by an orthopedic surgeon. To diagnose the disease, the following manipulations are used:
Treatment for Achilles tendon rupture involves only surgical intervention. Treatment of fresh Achilles tendon injuries (injury duration is no more than 2 weeks) involves the following steps:
Treatment for an Achilles tendon sprain is suturing followed by immobilization with a plaster cast. After stitching, the plaster cast is worn for about 6 weeks. Full weight bearing on the leg is allowed 8-9 weeks after surgery.
Injuries to the Achilles tendon can cause problems with movement, including the inability to walk. Therefore, with such injuries, you do not need to self-medicate, but should contact specialists.
To prevent damage to the Achilles tendon, doctors recommend taking the following measures:
One of the most common problems among runners is an Achilles tendon injury. Achilles injuries are common among both beginner and elite runners, so it's important to know what to look for during training.
Achilles tendon injury
The Achilles tendon (Achilles, calcaneal tendon) attaches the calf muscle to the heel bone. Thanks to the Achilles, a person can jump, run, and stand on his toes. This tendon is one of the strongest, it can withstand a tensile load of 400 kg, but it is also the most frequently injured.
The most common problems with the Achilles are tendonitis and tendon rupture. Both of these pathologies are quite serious and require qualified medical care.
Achilles tendonitis is an inflammation that manifests itself as pain in the ankle, usually closer to the heel. Sometimes it may be accompanied by local swelling and redness of the skin and increased sensitivity.
Tendinitis can manifest itself as pain when standing on your toes or heels, limited ankle mobility, and pain when starting to walk in the morning.
A ruptured Achilles tendon is a serious injury that requires immediate medical attention and surgery. This is a condition in which a complete or partial separation of the tendon from the heel bone occurs. Symptoms of a rupture include sudden severe pain, swelling, inability to stand on your heels or toes, and sometimes the inability to simply stand on the affected leg.
All problems with the Achilles are based on either biomechanical factors or external factors and neglect of the principles of reasonable dosed loading.
Biomechanical factors causing Achilles injuries:
Unfavorable external factors:
But perhaps the most important cause of injury is ignoring the first symptoms. Often athletes, especially beginners, try not to notice aching pain, explaining it as ordinary fatigue or pain “out of habit.” And even if the Achilles swells and hurts, they are in no hurry to see a doctor, trying to independently apply warming and pain-relieving ointments.
Indeed, the inflammatory process may be accompanied by prolonged, but not severe, discomfort. In this case, the pain is often episodic in nature - it appears with increased loads and disappears with rest.
This is where the greatest danger lies! Against the background of chronic inflammation, the strength of the fibers decreases. Scars form in places of microtears, and soon the elasticity of the fibers noticeably decreases. As a result, after a couple of months, only one sudden movement will be enough for a complete separation to occur.
The most important rule is to never run through pain! This is not the case when overcoming yourself is required, and your heroic efforts will not benefit the body.
In general, it must be remembered that the risk of injury to the Achilles tendon is not a reason to give up running. The main thing to remember is that the key to your sporting success should be a competent approach to training and attentive attitude towards your body.
The strongest and largest tendon in the human body is the Achilles tendon. Due to its location, you can often hear another name for it – the heel tendon (or Achilles tendon).
It can withstand tensile strength of up to 350 kg, and sometimes even more. Moreover, it is this tendon that is most often subject to injury.
The tendons of the soleus and gastrocnemius muscles take part in the formation of the calcaneal tendon.
The gastrocnemius muscle begins on the posterior surface of the epicondyles of the femur. It is there that both of its heads are attached, which unite approximately in the center of the lower leg and gradually turn into a thin tendon called the aponeurosis of the gastrocnemius muscle.
The soleus muscle is located deeper under the gastrocnemius muscle. It begins on the posterior surface of the head and upper third of the fibula. Below it also ends with an aponeurosis, which is thicker and shorter, in contrast to the aponeurosis of the gastrocnemius muscle. These 2 aponeuroses are located directly next to each other, but are connected only in the lower part, forming the calcaneal tendon.
The fusion of the two aponeuroses occurs approximately in the center of the lower leg, with the common aponeurosis located on the inner side of the soleus muscle, where muscle fibers are still present.
It is not entirely correct to consider the confluence of the Achilles tendon as the beginning of the Achilles tendon. Since for different people its location may vary and occur in the upper part of the lower leg or completely at the heel.
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After fusion, the tendons narrow and take on an oval shape in cross section. The fibers of the soleus tendon run along the oblique and are inserted on the medial side. The fibers of the gastrocnemius tendon twist around these fibers and are attached on the lateral side. Each person's fibers are twisted according to an individual principle. There are 3 types of twisting.
This structure gives the heel tendon mechanical strength, elasticity, and the ability to accumulate energy.
The width of the tendon should not exceed 7 mm in cross section and 3 mm in the thinnest places. The length may vary for each person, but the normal length is considered to be 13-17 cm, the average width in different parts of the tendon is from 1 to 7 cm.
This tendon is attached to the tubercle of the heel bone. Between them there is a mucous bursa that reduces friction. In addition, the heel tendon is located in a special channel. It also contains a little liquid, which ensures sliding without friction.
During contraction, the muscles pull the tendon, which ensures flexion of the leg at the ankle joint. This allows a person to stand on his toes, jump and make other movements with his feet.
The Achilles tendon performs a number of very important and unique functions. Namely:
Damage to the Achilles tendon occurs due to inappropriate loads, direct strong blows directly to the tendon, or due to sudden muscle contraction.
Athletes and people leading an active lifestyle are most often susceptible to such damage. The heel tendon can be injured when running, jumping, active walking, etc.
Some causes of heel tendon injury include:
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Biomechanical factors that increase the risk of tendon injury:
Achilles tendon soreness can occur due to injury, damage, and disease. The main ones:
Most people believe that Achilles tendon problems occur suddenly. But it is not so. Almost always, lesions of the heel tendon occur as a result of previously ignored or previously unnoticed minor injuries and damage over a long period of time.
If you do not stop physical activity after the onset of pain, the elastic fibers of the tendon will gradually be replaced by scar tissue and the pain will become constant.
The general name for tendon injuries is tendinopathy.
Symptoms of heel tendinopathy:
If the patient cannot rise to his toes, this most likely indicates a tendon rupture.
Usually, it is enough for a doctor to examine the patient and listen to his complaints to determine the diagnosis, but in some cases, X-rays, ultrasound and MRI may be required.
First of all, you should unload the sore leg. Loads should be minimized and plenty of rest. Physical activity should be resumed gradually after recovery.
Ice can be applied to the injured tendon to relieve pain. If the pain is too severe, you can take non-steroidal anti-inflammatory drugs.
In some cases, a bandage, splint, plaster, or orthoses can be used to ensure joint immobility. Depending on the degree of damage to the tendon, these devices can be worn only during sleep or while awake. In some cases, it is necessary to wear them around the clock. Sometimes the use of crutches may be necessary.
Special massages occupy a special place in the treatment of heel tendon pain.
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For tendon ruptures, surgical interventions are performed. The skin is cut at the site of injury, the ends of the tendon are isolated and sutured. After this, a plaster cast is applied for a month. The cast is then removed to remove the stitches and reapplied for another 1 month.
After this, physical therapy is prescribed. The patient should move with a stick for 2-3 months, until the tendon is completely restored.
As you recover, you need to gradually stretch the heel tendon, as well as train the posterior muscles of the leg. The set of exercises, their number and intensity are selected individually in each case.
Like all other diseases, heel tendon problems are easier to prevent than to treat. To prevent damage it is necessary:
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Diagnosis of Achilles tendon injury is not easy, both in the acute and long-term periods of injury.
In the first days after the rupture, swelling in the area of injury and the lower third of the leg, the preservation of plantar flexion of the foot due to the preserved tendon of the plantaris longus muscle, prepares the novice surgeon for the possibility of partial rupture of the Achilles tendon and the possibility of successful conservative treatment. The focus on conservative treatment is also explained by the fear of surgery, which is often complicated by necrosis of the edges of the skin wound and months-long rejection of the tendon and suture material. This complication, even in the hands of experienced surgeons, occurs in 12-18% of those operated on (S. V. Russkikh, 1998).
It is necessary for all paramedics and surgeons to accept as an axiom that there are no partial ruptures of the Achilles tendon. All of them are complete, and all of them require surgical treatment. A complete rupture and the need for serious hospital treatment are
confirms a simple symptom - the patient cannot rise on his toes, since this requires both healthy Achilles tendons, and one of them is torn.
The patient should be hospitalized, put to bed and the injured limb should be elevated. An easier way to do this is to put a mesh bandage on the leg up to the middle third of the thigh or a regular cotton stocking and hang the foot by the distal part of the stocking to the bed frame, and place a large pillow or Beler splint under the thigh. We also give this position to the foot and lower leg when treating injuries to the ankle joint. After the swelling has completely subsided (4-5 days), the retraction above the site of the Achilles tendon rupture becomes clearly visible. It is especially noticeable if the patient is kneeled on a chair and looks at both Achilles tendons.
All patients have a positive finger sign - you need to run the outer side of the index finger of the right hand from above the calf muscle down the Achilles tendon to the heel tubercle. The finger falls through at the rupture site.
S.I. Dvoinikov (1992) offers two simple techniques. These are the “finger pressure” symptom and the “peripheral tendon fragment movement” symptom.
The first symptom is defined as follows: the surgeon uses his finger to forcefully press on the site of the supposed rupture, while the patient loses the ability to actively flex and extend the foot on the side of the injury.
The second symptom is that the surgeon uses the finger of his left hand to press on the area of the suspected tendon rupture, and with his right hand he makes a passive movement of the patient’s foot. Under the skin in the subcalcaneal area there is a clearly defined moving distal end of the damaged Achilles tendon, the movements of which can also be determined by palpation.
Diagnosis of stale and old ruptures is more difficult, when the regenerate that appears at the site of the rupture conceals digital symptoms. But by this time, atrophy of the subcutaneous muscle is already noticeable to the eye, which is documented by measuring the circumference of the lower leg in the upper and middle third. As before, the patient cannot stand on the toe of the injured leg; as before, when running the index finger along the back surface of the shin from the calf to the heel, a “failure” is determined at the site of the rupture.
The patient must definitely be operated on, since over time, atrophy of the calf muscle will increase, and then other muscles of the leg, lameness and dissatisfaction with the patient’s quality of life will increase due to the obvious functional limitation of the injured limb.
It should be immediately noted that suturing a damaged Achilles tendon is a very delicate operation, and it should be performed in a specialized orthopedic and trauma center or in a local hospital by a highly trained surgeon who knows how to perform this operation reliably.
Firstly, the operation cannot be performed under local anesthesia; pain relief must be complete - this is either anesthesia, or spinal, or epidural anesthesia.
In order for the surgeon to operate comfortably, the patient must lie on his stomach, the heel must “look” straight up.
I do not like to perform operations under a tourniquet if there is electrocoagulation. If it is not there, then you need to put a tourniquet on the upper third of the leg, but remove it before stitching the wound and stop the bleeding well.
Before surgery, the foot should be thoroughly washed several times with warm water and a soft washcloth and soap. She washes herself for the last time the evening before surgery and wraps herself in a sterile sheet. If there is a need to shave the hair on the back of the leg, this should be done in the morning, an hour before surgery. In the evening, on the eve of the operation, you should not shave your hair, since inflammation of possible cuts (scratches) of the skin will cause possible suppuration of the wound.
The approach should in no way be in the midline over the tendon. After suturing its ends in the position of plantar flexion, it is difficult to bring the edge of the skin wound together without tension. This is even more difficult to do if a tendon repair is performed.
I have been enjoying the external approach for many years - I start the incision from the midline of the back surface of the leg 12-13 cm above the rupture site, smoothly go to the lateral side and then down vertically through a point located in the middle of the distance between the posterior edge of the lateral malleolus and the Achilles tendon , to the level of the upper edge of the heel tubercle, then I wrap the incision horizontally onto the heel tubercle (Fig. 15.1). Care must be taken not to damage the n.suralis. The paratenon is incised along the midline. Torn ends of the tendon are easily located and resected sparingly. If the gap is old, then the regenerate is excised. After this, the foot is given maximum plantar flexion and the freshened ends of the tendon are sewn together.
For fresh ruptures, any tendon suture can be used - Rozova, Casanova, Sipeo, U-shaped. The Kessler seam modified by S.V. Russky (1998) is rational (Fig. 15.1, b). This suture differs from the Tkachenko suture in that the knotting of the thread occurs at two levels above the area of tendon tissue disintegration. After tying the Kessler suture, additional adapting U-shaped sutures made of thin nylon are applied.
Since the pathologically altered tendon usually ruptures, it is advisable to perform plastic surgery in case of fresh injuries. This is absolutely necessary for old tears. I prefer a simple technique of plastic surgery according to Chernavsky - a flap 5-6 cm long is cut out from the upper end of the tendon, base down, and transferred to the lower end of the tendon. With maximum tension, the flap is sutured with thin nylon to both ends of the damaged tendon.
To strengthen the suture and improve tendon gliding in people involved in professional sports (physical education teachers, athletes, circus performers), in addition to the tendon suture and plastic surgery, I take a strip of my own fascia from the outer surface of the thigh 3 cm wide, 10-12 cm long and wrap it with fascial tape like a spiral stitched tendon. The fascia tape is sutured to both ends of the tendon, and between each other with thin continuous sutures. After this, with minimal plantar flexion of the feet, the paratenon, subcutaneous tissue and skin are sutured with continuous sutures. Plantar flexion of the foot 25-30° is fixed with a plaster splint applied from the patella to the toes along the anterior surface of the foot and lower leg. There is no need to fix the knee joint. After the sutures are removed (not earlier than 12-13 days), the foot is brought to the average physiological position (10° plantar flexion) and fixed with a blind plaster cast from the head of the metatarsal bones to the knee joint. A heel is placed under the arch of the foot and walking with weight is allowed. 6 weeks after the operation, the plaster cast is removed, walking with a stick is allowed, and physical therapy is prescribed. Full weight bearing is possible 8-9 weeks after surgery.
It is difficult to treat old ruptures when several months have passed after the injury and there is regenerate up to 10 cm or more between the ends of the damaged tendon. Care for such patients should be provided in a specialized plastic surgery department.
During the operation, the scar regenerate is excised completely, and myotenodesis of the upper end of the tendon and the gastrocnemius muscle is performed so that it can be stretched by bringing the ends of the tendon closer together. The remaining defect is eliminated by autoplasty with one or two flaps on “pedicles” obtained from opposite sides of the tendon. Then the lateral surfaces of the tendon are corrugated
at the sites where the transplant was taken. The suture area must be unloaded using the tendon of the long plantaris muscle or part of the longitudinally cut tendon of the longus peroneus muscle. This improves the course of regeneration processes in the damaged Achilles tendon.
I highly recommend covering the entire area with your own fascia (3*12 cm), like a spiral, taken from the anterior outer surface of the thigh. The fascia spiral is sutured to the tendon and between the turns with thin nylon sutures.
Biceps brachii injuries account for more than half of subcutaneous tendon and muscle ruptures. According to the literature, of all injuries to the biceps muscle, 82.6-96% of cases occur in damage to the long head, 6-7% - in the general belly of the muscle, 3-9% - in the distal tendon.
Damage to the biceps muscle is more common in men engaged in physical labor, when there is long-term trauma to this muscle through overexertion (“traumatic disease” of the tendon according to S.I. Dvoinikov, 1992).
A rupture of the long head tendon is noted by patients with sharp pain in the projection of the injury. The patient notices an unusual shape of the muscle when bending the arm at the elbow joint. This deformity is clearly visible if you ask the patient to tense the biceps muscle with the elbow joint bent to a right angle. The muscles on the side of the injury are shortened and pulled towards the middle of the shoulder and stand out under the skin with a noticeable bump.
The patient should be asked to slowly move both arms to the sides. In this case, some lag of the damaged upper limb is detected. With active resistance to the abduction of the patient's arms, a decrease in the strength of the limb on the side of the injury can be noted; the patient feels the appearance of sharp pain in the injured shoulder muscle.
Surgery to restore continuity of the long head of the biceps brachii muscle can be performed by a surgeon and traumatologist at a local hospital.
The damaged tendon, in a state of tension of the biceps muscle, is fixed to a new attachment site - it is sutured to the humerus in the area of the tibiofibular groove or to the coracoid process of the scapula.
If the tendon has ruptured closer to the muscle belly and its distal end is too short, the tendon is lengthened using a fascial flap taken from the gastrocnemius fascia of the thigh or a conservative fascial allograft. The degeneratively changed proximal end of the tendon is cut off at the level of the intertubercular groove and removed.
Plastic surgery of a long tendon and suturing it to the usual place of attachment (tuberositas supraglenoidalis) is too traumatic and does not always give good results. It is more expedient to suture the end of the torn tendon to the upper part of the intertubercular groove.
If the short (internal) head of the biceps muscle is damaged, it is sutured or plastically restored using fascia.
After the operation, the arm is fixed with a wedge-shaped pillow and a scarf, bent to 60° at the elbow joint, for 3 weeks. Massage, therapeutic exercises and thermal procedures complete the treatment. If a tendon or fascial preserved allograft is used during surgery, then active movements are allowed after 5-6 weeks.