0:00

Now let's talk a little bit about

0:02

further tendon pathology.

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Tendinosis, of course, represents degeneration

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and typically, although not invariably, it appears

0:12

as an enlarged tendon with little areas of gray within it.

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The gray may be small punctate regions,

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they may be more globular regions.

0:23

The tears have been described into three types.

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I don't typically use type one, type two

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or type three nomenclature,

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but as originally described, not just in the Achilles tendon

0:36

as shown here, but in other tendons about the ankle

0:40

and foot, and even in other anatomic sites, a type one

0:45

is a partial tendon tear with tendon hypertrophy.

0:50

Okay, perhaps we could argue

0:52

that here more about that in a moment.

0:55

A type two is a partial tendon tear with attenuation.

0:59

A type three is a complete tendon tear.

1:03

So the problem is clearly how to differentiate

1:07

tendonosis alone from low grade tearing,

1:12

and it can be difficult, the brighter the gray,

1:16

particularly if it approaches fluid signal intensity.

1:21

We generally shift our terminology from tendinosis

1:25

to tendon tear.

1:27

But in a case like this, this is borderline,

1:30

and I'm certain some persons would call this

1:33

simply tendonosis.

1:35

Others would say that is a partial tear.

1:39

Let me show you a few examples. Two cases displayed here.

1:43

This is tendonosis involving the distal portion of the

1:47

Achilles tendon with perhaps a little bit

1:50

of retro calcan bursitis.

1:53

Re, this is normal fluid

1:55

and a posterior recess of the subtalar joint commonplace,

1:59

where you see that an enlarged tendon

2:02

with a little bit here of slight bright gray signal,

2:07

perhaps an early partial tear,

2:09

and in this case tendinosis with enlargement

2:13

of a long segment of the Achilles tendon with bright gray,

2:18

almost brighter like fluid.

2:20

All right. Okay.

2:22

That's to me I would read as a partial tear associated

2:25

with Achilles power tendonitis.

2:31

Complete tears of the Achilles tendon occur typically,

2:34

most commonly in middle aged person.

2:37

We see them in the weekend, warriors

2:39

who come out on the weekend,

2:40

and as I kind of alluded

2:42

to an earlier discussion in this course,

2:46

that if you have a problem on one side here, a

2:49

complete tear, I would be surprised in fact

2:53

that the opposite side,

2:54

the Achilles tendon would be normal. I would expect

2:58

In most persons you would see

3:01

tendinosis in the opposite ankle,

3:03

and in six to 26% of persons,

3:07

you eventually will get herring.

3:09

On the opposite side.

3:11

Here you can see the typical location of the tear, five

3:15

to eight centimeters above the level

3:17

of the calcan attachment, perhaps related to

3:22

vulnerable vascularity of the tendon in that region.

3:26

We would describe the location of the tear, the gap.

3:29

We would also describe the quality of the ends

3:32

of the tendons in our description.

3:35

Another example here of a complete tear

3:37

of the Achilles tendon with a large tendonous gap.

3:42

You can appreciate at this level the enlarged tendon

3:46

above the tear tendon knot retracted, of course,

3:50

and at this particular level, no tendon is seen

3:55

in some cases of tendon tears, not just about the ankle,

3:59

and not just with the Achilles tendon pieces

4:02

of bone sometimes, and oph fights are pulled away.

4:07

Uh, I think these are picked up more often on

4:09

ultrasonography than on other imaging methods,

4:13

but certainly should always look

4:15

for these little vols pieces of bone,

4:18

as in this particular case.

4:20

Now, how do you treat problems of the Achilles tendon?

4:25

You have two general choices you can operate

4:29

or you can treat them conservatively.

4:32

The advantages of operation or improve functional outcome

4:35

and decrease re-rupture rate.

4:39

That disadvantages the invasive nature.

4:42

And of course, they're more expensive.

4:45

Non-operative treatment.

4:47

The advantages, the absence of these complications,

4:51

the disadvantages, at least statistically,

4:54

perhaps the patients won't be satisfied.

4:57

There is a slightly higher likelihood of re rupture

5:01

and the rehabilitation period is longer.

5:04

Alright, general comments about operative versus

5:07

conservative, and in some cases of chronic tearing

5:12

of the the Achilles tendon.

5:15

One of the things that might be used to augment

5:17

or any repair would be the nearby flexor lysis, long

5:22

as tendon shown here, which has been surgically moved

5:27

to reinforce the tear of the

5:31

distal Achilles tendon.