PROBLEMS AND SOLUTIONS: ACHILLES TENDON/THROWER’S ELBOW
From Kaiser Permanente’s 2006 Dale Daniel, MD, Orthopedic Symposium
| TREATING ACHILLES TENDON CONDITIONS: TENDINITIS, BURSITIS, AND PUMP BUMP —
Shepard Hurwitz, MD, Professor of Orthopaedic Surgery, University of Virginia School of Medicine,
Charlottesville
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| How to approach evidence: for busy surgeon looking for quick answer; frequently seen problem—many possible
answers; best use of time spent researching or attending meeting; rare problem—go directly to expert opinion
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| Achilles tendon problems: multifocal—in tendon; at insertion; part of bone deformity (“pump bump” or Haglund
deformity); or painful area in back of heel that defies exact diagnosis; >100,000 annually in
North America; what we are treating—mix of acute, acute on chronic, and chronic conditions of uncertain
etiology and prevalence
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 | Tendinitis: acute and reversible; etiologies—“overuse” (microinjury); systemic (eg, drugs); adhesions (prior
trauma); metabolic (eg, gout); induced by fluoroquinolones
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| Tendinopathies: irreversible changes in tendon and surrounding tissues; characterized by proliferation,
degeneration, and adhesions; noninsertional (above calcaneus)
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| Enthesopathy: at juncture of tendon and bone; etiologies—local (presumed cumulative microtrauma); systemic
(arthritis); metabolic (corticosteroids; renal failure)
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| Calcaneal (Haglund) deformity: developmental; acquired (“pump bump”; associated with bursitis and
enthesopathy); avulsion (underlying osteopathy, eg, diabetes, renal failure)
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| Diagnosis: plain x-rays useful for detecting pathology, eg, spike on back of calcaneus, osteophyte formation
in insertion, soft tissue outline of Achilles tendon in anteroposterior (AP) dimension
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| Haglund deformity: bump; enlarged bursa; tendon thickening; physical inspection (pinch to feel convergence
of bone, tendon, and bursa)
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| Bursitis: local irritation; systemic (erosive; seronegative arthritis); mechanical etiology (tendon thickening;
calcaneal enlargement)
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| Achilles tendinitis: apparent with inspection (tender; warm; limp); plain x-ray; ultrasonography; magnetic
resonance imaging (MRI; gold standard; expense justified in planning surgery)
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| Enthesopathy: symptoms at bone-tendon junction; dorsiflexion stretching painful
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| Treatments and evidence of benefit: reviewed by Cochrane database; rest (0); immobilization (+/-); nonsteroidal
anti-inflammatory drugs (+); physical therapy (+/-; if no response, stop; dorsiflexion stretching rarely
effective); corticosteroid injection (+); laser (-); shock wave therapy (-; ineffective for tendinitis and
plantar fasciitis); surgery (+; last resort)
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| New technique for therapeutic injections: speaker developing alternative to palpation and insertion of needle;
guided injections by radiologists to insert medication in space around tendon, eliminating risk of injecting
tendon; diagnostic injection (lidocaine); therapeutic injection (lidocaine/triamcinolone); indications
(bursitis; tendon problems); MRI prior to injection in 62% of patients (pathologic changes in all)
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| Overall results: 524 patients; complications in 14 patients; no infection or rupture; >50% improved for ≥6
mo; over 1 yr, average of 2.2 injections
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| Surgery: 1-yr results—bursal incision, 2 patients; tendon repair, 23 patients; both, 24 patients; Foot Function
Index (FFI) average 0.2% (significant improvement); considerations—approach consistent with informal
guidelines that surgery indicated when nonoperative measures fail; tendon tear debrided, sewn with running
suture (knots on outside); secondary repair with tendon graft or transfer
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| Surgical issues: speaker prefers prone position; axial incision on lateral side; for augmentation, local fascia,
tendon graft, allograft, and xenograft (mucosal membrane from sheep and goat approved); no recommendation
on technique
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| Results (1995-2005): 49 patients; 2 complications; no ruptures or detachments; limited to wound problems
requiring casting and debridement; improvement in FFI ≈0.3%
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| Rehabilitation: conflicting recommendations make decisions difficult; valuable approach—block dorsiflexion;
early active plantar flexion; decreases symptoms of tight ankle and weak muscle
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| Current surgical treatment: for Achilles tendon, bursal, and insertion problems; reported complications—infection
and dehiscence (6%-8%); deep infection (<2%); rupture or detachment (≈1% seems acceptable, but
should be near 0% if not ruptured); pain (8%-11%); other information—surgical and nonsurgical therapies
not compared in Cochrane reviews; to access Evidence Based Medicine website, type “EBM” into web
browser or go to cebm.net (Center For Evidence Based Medicine website); type “Database of Abstracts
of Reviews of Effects” (DARE) into your browser to directly access DARE; now lacking—levels I, II, and
III evidence for effective treatment; “we have to fill in that void; otherwise, we’re going to have guidelines
forced down our throats that are highly unproductive and very dissatisfying”
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| Summary: corticosteroid injections and NSAIDs seem most effective treatment preoperatively; avoid physical
therapy; no compelling reasons to wait for surgery; level IV evidence shows surgery offers way to
reduce pain and dysfunction; surgery indicated when patient and surgeon agree on need for procedure to
relieve symptoms
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| Questions and answers: tendon rupture after steroid injection—no hard data; speaker’s prejudice that injection
within tendon only accelerates natural history of disease; stretching exercises increase risk of rupture; effect
of tight triceps mechanism—high forefoot take-off pressures; functional shortening of triceps unit; increased
incidence of plantar fasciitis, retrocalcaneal bursitis, tendon rupture, and Achilles tendon trouble;
stretching exercises may help; central calcification and surgical approach—disease thought to start centrally,
creating need to core out central one third of tendon; approach not decisive; speaker prefers lateral approach
for better access; “central approach” puts skin at risk; more on “pump bump” surgery—remove
enough bone to improve appearance of deformity to naked eye; remove bursa; thin enlarged tendon (may
need to reattach); immobilize in neutral with splint; begin fracture boot at ≈2 wk, when stitches removed;
in noncompliant patient, eliminate unprotected weight bearing with short-leg walking cast; after 4 wk,
dorsiflexion-blocking splint with cast boot
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| DIAGNOSING AND MANAGING ELBOW INJURIES IN THE THROWING ATHLETE: RECONSTRUCTING
THE UCL—Michael F. Schafer, MD, Professor and Chair, Department of Orthopaedic Surgery,
Feinberg School of Medicine, Northwestern University, Chicago
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| Ulnar collateral ligament (UCL): comprised of 3 bundles (anterior; posterior; transverse); anterior and posterior
bundles work reciprocally; in elbow extension, anterior bundle tight and posterior bundle lax; in elbow
flexion, anterior lax and posterior tight; flexor-pronator mass poorly studied
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| Biomechanics of baseball pitching: phases—wind-up; early cocking; late cocking; acceleration; follow-through;
resulting stress—during late cocking to acceleration, stress focused on shoulder and medial aspect of elbow;
medial shear force of 300 newtons (N) and peak angular velocity repeated during each pitch, leading to repetitive
motion injury over time; ultimately results in “valgus overload,” which can eventually lead to degenerative
changes in posteromedial structures (spur formation on capitellum and olecranon)
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| UCL injury: occurs in high-energy throwers; present in football, gymnastics, and wrestling; repair may be
unnecessary
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| Evaluation of injured patient: context of injuries—baseball now almost year-round sport, without break necessary
to reduce risk of damage; injuries increasing in high school students; determine—duration of symptoms;
location of pain (typically in medial aspect of elbow); ulnar nerve symptoms (numbness and tingling
in fourth and fifth digits); pitching velocity (steady decrease); valgus stress test—pronate hand with elbow
flexed ≈30°; unlocks radiocapitellar joint; MRI—with contrast to image leakage of dye into soft tissues
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| Muscle-splitting technique: David Altcheck developed procedure to avoid problems with original Jobe technique;
incision begins at center of anterior surface of medial epicondyle of humerus; incision straight,
“maybe lazy C”; split goes directly through flexor muscle mass, separated by raphe, which guides incision
down to actual ligament structure
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| Advantages: splitting muscle eliminates need to expose ulnar nerve (unless symptoms present); 1 humeral
tunnel (2-tunnel Jobe technique associated with risk of pulling off medial epicondyle of humerus
after return to throwing); final tensioning of ligament easier with docking procedure in muscle-splitting
technique
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| Points on procedure: safe zone—posterior area of flexor-pronator wad (semicircular structure on anterior elbow);
behind ulnar nerve; avoid sharp retractor; removing posteromedial osteophyte—reach around to locate
osteophyte and burr it down; only time retracting ulnar nerve necessary; ulnar tunnel—leave bridge of bone
between anterior and posterior drill holes, near sublime tubercle; must remove osteophyte before drilling
tunnel; identifying isometric point—put double-loop suture through tunnel; pull tight and straight up, and
pump elbow up and down to locate point; tendon harvest—palmaris tendon from opposite arm (retains tendon
in throwing arm; avoids risk of complications from infection at harvest site on throwing arm); fiber
wire from Krakow stitch through tendon; second tunnel drilled in humerus; if enough graft length remaining,
used to create “3-strand repair”
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| Keys to success: treatment of olecranon osteophytes causing posterior impingement (only reason for preoperative
arthroscopy; avoid routine arthroscopy [distorts tissue]); muscle splitting protects flexor-pronator
wad; avoids ulnar nerve; secure grafts in tunnels
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| Postoperative therapy: need to convince parents of importance and duration; throwing program delayed until
week 16 to 18 (before beginning, focus on regaining extension, completing total conditioning program,
including back, core, and legs); throwers not ready to return to competition before 9 mo
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| Results: ≥2 yr follow-up; 11 professional, 8 collegiate players; 2- and 3-strand results identical so far; ulnar
nerve transposed in 2; osteophyte removed arthroscopically in 2; 18 returned to play at previous or
higher level; became competitive after 15 mo
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| Questions and answers: when shoulder problems develop during rehabilitation—not caused by rehabilitation;
same forces transmitted to shoulder and elbow; shoulder problems may have been previously masked by
decreasing velocity; judging tendon graft length—measure tunnel; mark length of tunnel on tendon; if length
misjudged, fiber wire knot can be untied; if tendon too long, excess tendon used for 3-strand repair
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Educational Objectives
| The goal of this program is to educate orthopaedists about treating Achilles tendon problems and diagnosing
and managing ulnar collateral ligament (UCL) injuries in throwing athletes. After hearing and assimilating
this program, the surgeon will be better able to:
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| 1. Describe the etiology and characteristic features of Achilles tendon problems, including tendinitis,
tendinopathy, enthesopathy, and calcaneal deformity.
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| 2. Diagnose common Achilles tendon problems.
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| 3. Weigh the effectiveness of guided corticosteroid injections and surgery as therapies to relieve Achilles
tendon and bursal symptoms.
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| 4. Evaluate elbow injuries in throwing athletes.
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| 5. Perform the muscle-splitting procedure for UCL reconstruction.
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Suggested Reading
Aoki M et al: Strain on the ulnar nerve at the elbow and wrist during throwing motion. J Bone Joint Surg Am
87:2508, 2005; Chen AL et al: Imaging of the elbow in the overhead throwing athlete. Am J Sports Med
31:466, 2003; Chen FS et al: Shoulder and elbow injuries in the skeletally immature athlete. J Am Acad Orthop
Surg 13:172, 2005; Costa ML et al: Shock wave therapy for chronic Achilles tendon pain: a randomized
placebo-controlled trial. Clin Orthop Relat Res 440:199, 2005; Fredberg U et al: Ultrasonography as a tool for
diagnosis, guidance of local steroid injection and, together with pressure algometry, monitoring of the
treatment of athletes with chronic jumper's knee and Achilles tendinitis: a randomized, double-blind, placebo-controlled
study. Scand J Rheumatol33:94, 2004; Gill SS et al: Fluoroscopically guided low-volume peritendinous
corticosteroid injection for Achilles tendinopathy. A safety study. J Bone Joint Surg Am 86-A:802,
2004; Hutchinson MR et al: Biomechanics and development of the elbow in the young throwing athlete. Clin
Sports Med 23:531, 2004; Jobe FW et al: Reconstruction of the ulnar collateral ligament in athletes. J Bone
Joint Surg Am 68:1158, 1986; Jost B et al: MRI findings in throwing shoulders: abnormalities in professional
handball players. Clin Orthop Relat Res:130, 2005; McLauchlan GJ et al: Interventions for treating acute and
chronic Achilles tendinitis. Cochrane Database Syst Rev:CD000232, 2001; Ouellette H et al: Imaging of the
overhead throwing athlete. Semin Musculoskelet Radiol 9:316, 2005; Sabick MB et al: Biomechanics of the
shoulder in youth baseball pitchers: implications for the development of proximal humeral epiphysiolysis
and humeral retrotorsion. Am J Sports Med 33:1716, 2005; Epub 2005 Aug 10. Sammarco GJ et al: Operative
management of Haglund's deformity in the nonathlete: a retrospective study. Foot Ankle Int 19:724, 1998;
Tasto JP et al: Microtenotomy using a radiofrequency probe to treat lateral epicondylitis. Arthroscopy
21:851, 2005; Thompson WH et al: Ulnar collateral ligament reconstruction in athletes: muscle-splitting approach
without transposition of the ulnar nerve. J Shoulder Elbow Surg 10:152, 2001; Yu C et al: Achilles tendinopathy
after treatment with fluoroquinolone. Australas Radiol 49:407, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any
significant financial relationship with the manufacturer or provider of any commercial product or service
discussed. For this issue, the faculty reported nothing to disclose.
Drs. Hurwitz and Schafer were recorded at the 2006 Dale Daniel, MD, Orthopedic Symposium, sponsored by
Kaiser Permanente of Southern California, January 13-14, 2006, in Palm Desert, California. The Audio-
Digest Foundation thanks the speakers and the sponsor for their cooperation in the production of this program.
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