Plans to get fitter, lose weight, reduce alcohol consumption and eat more healthily commonly feature as resolutions are made and broken in the New Year. The unexpected insult on our bodies in January is a time when musculoskeletal injuries can occur. A lunge during a game of racket sports, or a misplaced and fatigued limb whilst running can put our largest and only eponymously named tendon at risk of injury.
ISEH consultant Mr Michael Oddy co-chaired the symposium on Achilles Tendon Rupture (ATR) featured in the ISEH Sports Injuries and Sports Orthopaedics conference at The Royal Society of Medicine on the 14 January with several ISEH staff also contributing to this excellent symposium:
"There is epidemiological evidence that the incidence of this sports orthopaedic injury has increased over the last decade. The aetiology of the condition seems to be multi-factorial and the treatment remains an area of controversy and debate. Dr Bhavesh Kumar, Consultant in Sports and Exercise Medicine at the ISEH and co-chair for the session cogently summarised the current theories of intrinsic collagen degeneration, relative tendon avascularity and mechanical risks for ATR whilst alluding to the as yet unanswered metabolic and genetic factors which undoubtedly may be the key to understanding this injury which affects twenty-fold more males than females in approximately 7 per 100000 in the population. Whilst the diagnosis is based on the clinical examination triad of a palpable gap in the tendon, absence of a foot plantar-flexion response with a calf squeeze (Simmonds or Thompson test) and the loss of tension leading to a change in the hanging foot angle, radiology imaging is used to support the diagnosis, and in certain protocols guide treatment after an ATR. Consultant Musculoskeletal Radiologist Dr Kannan Rajesparan described the pros and cons of the imaging modalities which he uses at the ISEH.
Whilst user dependent, ultrasound remains the investigation of choice in the acute ATR to delineate tendon end apposition. Dr Lorenzo Masci, Consultant in Sports and Exercise Medicine at the ISEH outlined his experience managing partial injuries of the Achilles tendon and the important differences in rehabilitation protocols compared to those used for Achilles tendinopathy. The novel imaging modality of Ultrasound Tissue Characterisation (UTC) available at the ISEH may lead to a better understanding of intra-substance tendon change pre-rupture as well as guiding the response to training and safe return to normal function and sport.
Mr Aria Ghassemi, Consultant Trauma and Orthopaedic Surgeon at the ISEH and Mr Derek Park, Consultant Trauma and Orthopaedic Surgeon at Barnet and The Royal Free Hospitals put forward the cases for non-operative and operative treatment of ATR respectively. Contemporary non-operative treatments with functional bracing and supervised or accelerated physical therapy programmes have reported outcomes equivalent to surgery and far better than historical plaster-cast based immobilisation. Avoiding surgery always negates the risks of infection, soft-tissue healing problems and sural nerve injury. Surgical repair, however, still has the advantage of achieving an immediate physical continuity of the tendon and avoids the risk of tendon lengthening during healing and subsequent weakness which can be recalcitrant to training.
As co-chair of the symposium I outlined the clinical effects of a delayed presentation of an ATR and the range of complex surgical strategies which may need to be employed to reconstruct an Achilles tendon - soft-tissue tendon lengthening procedures and tendon transfer surgery. My non-operative and post-surgical rehabilitation techniques after an ATR treated at the ISEH always involves functional bracing with serial reduction of heel wedges, early weight-bearing and early self-directed therapy.
Detailed consultations help patients understand how tendons heal and the need for early, frequent and progressive movements. The presentations precipitated a lively series of questions from the audience which culminated in an astute proposition to the faculty of “Which treatment would you have if you ruptured your own Achilles tendon?” The panel’s response was predictably divided between non-operative and operative treatments which is how treatment for this injury will remain, despite increasing attempts in current research to answer ‘big picture’ questions. How did ‘A Year on Foot at the ISEH’ respond? I would have my ATR repaired surgically...at least, until I change my mind again".
See #Sportsorth for more conference highlights.