A key opinion leader in the field of orthopedics discusses how he or she would manage and treat a difficult case presentation.

BLOG: A 56-year-old physician with right Achilles pain

In this case, we have a 56-year-old otherwise healthy physician with right Achilles pain. He reports that he landed awkwardly approximately 8 months ago and has persistent pain and weakness. Upon examination, an intact Achilles tendon with a palpable nodule 3 cm proximal to the insertion was found. He had notable abnormality in his gait and weakness with plantarflexion.

After review of his MRI, it appeared that he had an intra-substance partial tear of the Achilles with some degenerative changes. The Achilles is contiguous, but there are some substantial changes in the region of thickening and he has reported pain.

Kathryn O'Connor

 

Treatment plan

Prior to any surgical intervention, I would be certain that the patient had exhausted nonoperative options including immobilization in either a cast or a boot; bracing, such as a molded ankle-foot orthosis; anti-inflammatories and physical therapy. Some physicians would consider injections, such as platelet-rich plasma, steroids or sclerosing agents, although these have not been completely borne out in studies. After 8 months of symptoms with no improvement following nonoperative care, surgical intervention is a reasonable option.

Surgically, I would lean toward a debridement and possible augmentation with either a V-Y or a flexor hallucis longus (FHL) transfer. The decision would be made intraoperatively and based on the quality of the tendon remaining after debridement and any residual gap if aggressive debridement was necessary. Recent evidence suggests that augmentation with FHL provides additional strength, although there is no difference in functional outcomes. With this in mind, I may reserve the FHL for cases of complications or revisions, or high-level athletes who need to optimize power.

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A 56-year-old physician landed awkwardly on the right ankle 8 months ago and has a calcaneus gait, positive Thompson test and palpable nodule approximately 3 cm proximal to the Achilles insertion. MRI images are shown below. What would you recommend?

Kathryn O'Connor, MD

 

In this case where there is a large area of pathology, an extensive debridement may be required and result in a gap. For this, I would expect the need for a V-Y advancement. I generally would approach this prone, using a midline incision to give me the option for all possible procedures. Of note, there is substantially less literature on the surgical management of mid-substance Achilles pathology than there is on insertional pathology, so much of the decision-making is based on insertional literature.

References:

Gross CE, et al. Foot Ankle Int. 2013;doi:10.1177/1071100713475353.

Hunt KJ, et al. Foot Ankle Int. 2015;doi:10.1177/1071100715586182.

Wagner E, et al. Technique and results of Achilles tendon detachment and reconstruction for insertional Achilles tendinosis. Foot Ankle Int. 2006;27(9):677-684.

Kathryn O’Connor, MD, is a fellowship-trained foot and ankle surgeon practicing at the University of Pennsylvania. She completed residency at the Mt. Sinai School of Medicine in New York City and fellowship training at Washington University in St. Louis.

Disclosure: O’Connor reports no relevant financial disclosures.