Tendon Problems around the Ankle

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• Tendon Problems around the Ankle
• Nicola Maffulli

Centre for Sports and Exercise Medicine
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Tendons around the ankle
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Tendon problems

Human studies
Cell models
Animal models
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Plenty to say, so little time

• Achilles tendinopathy
• Aetiology
• New paradigms
• Peroneal tendons

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• Achilles tendinopathy
• Aetiology

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Increased demands on tendon
Adequate repair (adaptation)?
Inadequate repair (inadequate collagen and matrix
production)?
Predisposition to further injury
Tenocyte disruption
Further alteration in collagen and matrix
production
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HYPERTROPHY
TRAINING
Poor blood supply
Increased matrix synthesis
Hyperthermia Free radicals Hypoxia
microdamage
CELL DAMAGE
Ineffective repair
Poor blood supply
Inability to repair damage
EXTRACELLULAR FAILED HEALING RESPONSE
Mechanical loading
RUPTURE
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Tendinopathy Do we get the right picture?
Onset of symptoms
Surgery
Unknown factors
Histology Biochemistry Molecular biology

• Risk Factors
• Injury?
• Overuse?
• Metabolic disorder?

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TENDINOPATHIES

• Difficult to manage
• Management
• often anecdotal
• rarely evidence-based
• often emotional
• dubiously effective

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We do not know where the pain originates from!

• Therefore, we do not know why and how any
  therapeutic modality, including surgery, works

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Hurdles to optimal management of tendinopathies

• No validated conservative management protocols

• relative rest
• physical therapy
• NSAIDs
• deep frictions
• hyperthermia
• HOT
• fibrolysis
• eccentric loading

• laser treatment
• ozone
• injections
• steroid
• heparin
• aprotinin
• others
• ESWT
• topical glyceryl trinitrate

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Eccentric heel drops dont always work!

• Murali K. Sayana
• Nicola Maffulli
• J Sci Med Sport 2007

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Eccentric heel drops dont always work!

• Nicola Maffulli
• Murali K. Sayana
• Gayle Walley
• Umile Giuseppe Longo
• Vincenzo Denaro
• Disab Rehabil 2008

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Polarization sensitive optical coherence
tomography evaluation of intratendinous changes
in ruptured and tendinopathic Achilles tendons

• PO Bagnaninchi, Y Yang, M Bonesi, GD Maffulli, C
  Phelan, I Meglinski, A El Haj, N Maffulli

Department of Trauma and Orthopaedic
Surgery Keele University School of Medicine
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L Ohberg, H Alfredson Ultrasound guided
sclerosis of neovessels in painful chronic
Achilles tendinosis pilot study of a new
treatment. Br J Sports Med 2002 3 173-175
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Paradigm change

• Tendinopathy FHR
• Neovascularity and neoinnervation
• Deleterious neo-innervation
• Not necessary to excise the lesion

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Think out of the box

• Tendinopathy FHR
• Neovascularity and neoinnervation
• Deleterious neo-innervation
• Not necessary to excise the lesion

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High volume injections at interface between
Kagers triangle and Achilles tendon
Skin
Achilles tendon
Neovessels
Needle
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High volume injections at interface between
Kagers triangle and Achilles tendon
Skin
Achilles tendon
Neovessels no more
Fluid
Needle
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Surgical management of tendinopathies

• No validated surgical protocols

• needling
• coblation
• percutaneous (ultrasound guided) tenotomy
• arthroscopic debridement (tendoscopy)?
• percutaneous paratenon stripping
• percutaneous Achilles tendon-Kagers triangle
  stripping
• open tenotomy and paratenon stripping
• tendon grafting

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Minimally Invasive Achilles Tendon Stripping
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Minimally Invasive Achilles Tendon Stripping
Skin
Achilles tendon
Suture thread
Neovessels
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Minimally Invasive Achilles Tendon Stripping
Skin
Achilles tendon
Suture thread
Neovessels
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Minimally Invasive Achilles Tendon Stripping
Skin
Achilles tendon
Suture thread
Neovessels
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Minimally Invasive Achilles Tendon Stripping
Skin
Achilles tendon
Suture thread
Neovessels no more!
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Minimally Invasive Achilles Tendon Stripping
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The best treatment?

• Outcomes are difficult to compare between studies
• Inverse relation between rigour of trial and
  claimed results
• Randomised control trials are lacking

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Outcome of Surgery

• Scores were generally low concerning the type of
  study, subject selection process, and outcome
  measures
• We found a negative correlation between reported
  success rate and overall methods scores (r 5
  20.53, P , 0.01), and a positive correlation
  between year of publication and overall methods
  score (r 5 0.70, P , 0.01)

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Coleman Methodology Score versus reported success
rate (r0.53 P0.01)
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Peroneal Tendons Subluxation
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PERONAL RETINACULOPLASTYWITH ANCHORS

• General or spinal anaesthesia
• Patient supine with sandbag under ipsilateral
  buttock
• Tourniquet (250 mmHg) to thigh and exsanguination
  of leg

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PERONAL RETINACULOPLASTYWITH ANCHORS
Exposure and sectioning of the common peroneal
tendon sheath
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PERONAL RETINACULOPLASTYWITH ANCHORS

• Superior peronal retinaculum thin and deficient
  anteriorly
• Tendons identified and protected
• Lateral aspect of lateral malleolus exposed

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PERONAL RETINACULOPLASTYWITH ANCHORS
Lateral malleolus roughened up
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PERONAL RETINACULOPLASTYWITH ANCHORS
3 to 4 anchors inserted along posterior border of
distal fibula
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PERONAL RETINACULOPLASTYWITH ANCHORS
SPR reconstructed vest over pants
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PERONAL RETINACULOPLASTYWITH ANCHORS

• BK walking cast applied, ankle in neutral and
  slight eversion
• Weight bearing allowed first day post-op

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PERONAL RETINACULOPLASTYWITH ANCHORS

• Cast removed 4 weeks after the procedure
• Sport allowed 3 to 4 months post-op

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If you wish to know more.....
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2008-2009 busy time!also for my fellows
Guest Editor
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• Centre for Sports and Exercise Medicine
• IBSc in SEM
• MSc in SEM

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• Centre for Sports and Exercise Medicine
• Annual Scientific Meeting
• 10-11 September 2009

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If you just cannot wait

• Gateway Surgical Centre, NUH
• Sportscare UK, LIH

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Thank you
Thank you
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n.maffulli_at_qmul.ac.uk