import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, ComparisonTable, Timeline, TimelineItem, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, MedicalImage, Tabs, Tab } from '@/components/mdx' {/* SECTION 1: ONE-PAGER SUMMARY */} {/* SECTION 2: EXAM WARNING */} **Tendinopathy is a failed healing response**, not tendinitis. Histology shows collagen disorganization, neovascularization, NO inflammatory cells. This explains why NSAIDs have limited long-term benefit. **Mid-substance zone (2-4cm proximal)** has poorest blood supply - watershed between musculotendinous junction and calcaneal insertion. This explains 75% of tendinopathy occurs here. **Alfredson protocol works** by promoting collagen remodeling and reducing neovascularization. Must be done through pain (controlled discomfort). Straight knee (gastrocnemius) and bent knee (soleus) variants. **VISA-A questionnaire (0-100)** is validated outcome measure. Less than 60 = severe dysfunction. Use to monitor treatment response and guide surgery decision. Score improvement more important than absolute value. {/* SECTION 2.5: QUICK DECISION GUIDE */} {/* SECTION 3: MNEMONICS */} {/* SECTION 4: OVERVIEW */} **Achilles tendinopathy** is a degenerative condition resulting from failed healing response to repetitive mechanical loading. It represents a spectrum of pathology from paratenonitis to intratendinous degeneration. **Key terminology:** - **Tendinopathy**: Umbrella term for tendon pathology - **Tendinosis**: Degenerative changes (histological term) - **Paratenonitis**: Inflammation of paratenon without tendon involvement - **Tendinitis**: Acute inflammatory process (rare in chronic Achilles pain) **Tendinopathy, not tendinitis.** The chronic Achilles condition is a **degenerative** process with failed healing, NOT an inflammatory process. Histology shows collagen disorganization, hypercellularity, neovascularization, and NO inflammatory cells. This is why anti-inflammatories have limited long-term benefit. **Epidemiology:** - **Running athletes**: 11% lifetime incidence - **General population**: 2-3% prevalence - **Gender**: Equal distribution (slight male predominance in sports) - **Age peak**: 30-50 years (degeneration begins earlier than symptoms) - **Location**: 75% mid-substance, 25% insertional **Risk factors:** - **Age**: Degeneration increases with age - **Biomechanics**: Overpronation, pes planus, cavus foot - **Muscle imbalance**: Gastrocnemius tightness, weak plantarflexors - **Systemic disease**: Diabetes, inflammatory arthropathy, hyperlipidemia - **Previous injury**: Prior Achilles pathology - **Training errors**: Sudden increase in volume or intensity - **Footwear**: Inadequate support, worn shoes - **Surface**: Hard surfaces, hills, uneven terrain - **Medications**: **Fluoroquinolones** (3-4× rupture risk) - **Corticosteroid injection**: Weakens tendon (avoid) **Fluoroquinolones increase Achilles rupture risk 3-4 fold.** Avoid in athletes and active individuals. If prescribed for infection, counsel about tendon risk and consider alternative antibiotics. Risk persists for months after cessation. {/* SECTION 5: ANATOMY */} **Achilles tendon structure:** - **Largest and strongest** tendon in the body - **Gastrocnemius + soleus** convergence (triceps surae) - **15cm length** from musculotendinous junction to calcaneal insertion - **Spiral configuration**: Gastrocnemius rotates laterally, soleus medially - **No true synovial sheath**: Surrounded by paratenon (thin membrane) **Blood supply (explains watershed zone):** The **mid-substance zone (2-4cm proximal to insertion)** is a watershed area with the **poorest blood supply**. This is where 75% of Achilles tendinopathy occurs. The zone relies on segmental blood supply from both proximal and distal sources, making it vulnerable to ischemia and degeneration. **Biomechanics:** - **Peak force**: 6-8× body weight during running - **Plantarflexion**: Primary function (walking, running, jumping) - **Energy storage**: Elastic recoil during gait cycle - **Gastrocnemius**: Knee extended activities (running, jumping) - **Soleus**: Knee flexed activities (walking, standing) **Paratenon structure:** - **Thin gliding membrane** around tendon - **Allows 1.5cm excursion** during dorsiflexion - **Contains blood vessels** that supply tendon - **Paratenonitis**: Can occur independently of tendon pathology **Retrocalcaneal bursitis** is inflammation of the bursa between Achilles and calcaneus. Often coexists with insertional tendinopathy but is a separate entity. Squeeze test (medial/lateral compression at insertion) differentiates from tendon tenderness. {/* SECTION 6: CLASSIFICATION */} ### Classification by Location **Mid-substance tendinopathy** responds better to eccentric loading (80% success) and rarely needs surgery. **Insertional tendinopathy** is more challenging - often associated with Haglund's deformity, responds less well to physiotherapy, and more commonly requires surgical intervention. ### Histopathological Classification **Normal tendon:** - Parallel collagen fibers (Type I collagen) - Sparse tenocytes between fibers - Minimal vascularity **Tendinopathy changes:** - **Collagen disorganization**: Loss of parallel structure - **Hypercellularity**: Increased tenocytes and chondrocyte-like cells - **Neovascularization**: Ingrowth of new vessels with nerves - **Matrix changes**: Increased proteoglycans (mucoid degeneration) - **NO inflammation**: Absence of inflammatory cells (hence NOT tendinitis) Tendinopathy represents a **failed healing response** rather than inflammation. The body attempts to repair microtrauma but produces disorganized collagen. This is why the condition is chronic and why anti-inflammatories have limited benefit. **Grading (not used clinically but exam-relevant):** ### Clinical Staging (Cook & Purdam Model) **Acute overload** response. Tendon thickening without collagen disruption. Short-term adaptation gone wrong. **Reversible** with load management. - Diffuse tendon swelling - Sudden increase in load - Responds to rest **Failed adaptation.** Collagen breakdown exceeds synthesis. Neovascularization and nerve ingrowth begin. **Partially reversible** with appropriate rehabilitation. - Persistent symptoms - Structural changes on imaging - Requires eccentric loading **Chronic degeneration.** Areas of cell death, extensive collagen disruption. **Irreversible** structural changes. May require surgical debridement. - Long duration (months to years) - Focal thickening or nodules - Poor response to conservative treatment The **continuum model** explains why some patients respond to load management (reactive) while others need eccentric loading (disrepair) or surgery (degenerative). Understanding the stage guides treatment - you cannot "exercise away" stage 3 disease. {/* SECTION 7: CLINICAL ASSESSMENT */} **History - key questions:** - **Onset**: Gradual (overload) vs sudden (reactive) - **Location**: Mid-substance (2-4cm proximal) vs insertional - **Pattern**: Worse with activity start, improves with warm-up - **Morning stiffness**: First steps painful (classic feature) - **Duration**: Weeks (reactive) vs months (degenerative) - **Sport/activity level**: What activities aggravate - **Training changes**: Recent increase in volume or intensity - **Footwear**: Type of shoes, recent changes - **Surface**: Hard surfaces, hills, terrain - **Impact on ADLs**: Stairs, walking, standing **Physical examination:** The **painful arc sign** differentiates tendinopathy from paratenonitis. As the ankle moves through dorsiflexion and plantarflexion, the tender area **moves with the tendon** (tendinopathy) rather than remaining stationary (paratenonitis). This is because the pathology is within the tendon substance. **Assessment of biomechanics:** - **Gait analysis**: Overpronation, foot position - **Ankle dorsiflexion**: Gastrocnemius tightness (knee extended) - **Foot posture**: Pes planus, cavus foot - **Footwear examination**: Wear pattern, support **VISA-A questionnaire (outcome measure):** **Victorian Institute of Sports Assessment - Achilles (VISA-A)** is a validated 10-question tool scoring 0-100. Higher score = better function. **Interpretation:** - **80-100**: Mild symptoms - **60-79**: Moderate dysfunction - **Less than 60**: Severe dysfunction - **Under 40**: Consider surgery if failed conservative treatment Use to monitor treatment response and guide intervention decisions. {/* SECTION 8: INVESTIGATIONS */} **Achilles tendinopathy is primarily a clinical diagnosis.** History and examination are usually sufficient. Imaging confirms diagnosis and excludes differential diagnoses. **Dynamic imaging, operator-dependent** Findings in tendinopathy: - Tendon thickening (more than 6mm AP diameter) - Hypoechoic areas (tendinosis) - Loss of fibrillar pattern - Neovascularization on Doppler - Focal nodules - Can assess paratenon **Advantages**: Dynamic, guided injection, cost-effective **Gold standard for soft tissue detail** T1: Normal tendon is low signal (black) T2/STIR: Tendinopathy shows increased signal Findings: - Fusiform thickening - Intrasubstance signal change - Peritendinous edema - Bone edema (insertional) - Haglund's deformity assessment **Use if**: Unclear diagnosis, pre-operative planning, exclude rupture **Not for tendon assessment** but useful for: - Haglund's deformity (lateral view) - Calcaneal spurs - Retrocalcaneal bursitis (soft tissue swelling) - Exclude other pathology **Power Doppler ultrasound** can detect neovascularization (new blood vessel ingrowth with nerves) in chronic tendinopathy. This correlates with pain severity and guides interventions targeting neovessels (e.g., sclerosing injections). Absence of neovascularity suggests reactive rather than degenerative pathology. **Differential diagnosis to exclude:** - **Achilles rupture**: Complete or partial tear (Thompson test, imaging) - **Retrocalcaneal bursitis**: Bursa inflammation (squeeze test positive) - **Haglund's deformity**: Bony prominence (visible/palpable, radiographs) - **Sever's disease**: Calcaneal apophysitis in children (age 8-14) - **Referred pain**: S1 radiculopathy, peripheral neuropathy - **Systemic**: Inflammatory arthropathy (seronegative spondyloarthropathy) {/* SECTION 9: MANAGEMENT */} ### Conservative Management - 6-12 Months **Success rate: 70-85% with appropriate treatment** **Goal**: Reduce pain and inflammation - Relative rest (reduce aggravating activities, not complete rest) - Ice application (15 minutes post-activity) - Heel lift 1-1.5cm (reduces Achilles load) - NSAIDs (short-term for pain, limited long-term benefit) - Address footwear and biomechanics **Avoid**: Complete immobilization, corticosteroid injection **Gold standard treatment** **Alfredson Protocol:** - 3 sets of 15 repetitions - Twice daily (morning and evening) - Two variants: Knee straight (gastrocnemius), knee bent (soleus) - Eccentric only: Good leg lifts, affected leg lowers - Off step edge for full dorsiflexion excursion - **Through pain**: Continue even if painful during exercise - Progress load: Add backpack weight when painless - **Duration**: 12 weeks minimum The **Alfredson eccentric protocol** works by: 1. **Collagen remodeling** - promotes organized collagen synthesis 2. **Neovessel disruption** - mechanical elongation disrupts pathological vessels 3. **Tendon loading** - optimizes healing response Must be done **through controlled discomfort** - pain suppression is not the goal. 80% success rate at 12 weeks. **Return to activity** - Gradual return to sport (10% weekly increase) - Heavy slow resistance training - Plyometric exercises (when pain-free) - Maintain eccentric exercises 3× weekly - Monitor VISA-A score progression **Evidence-based additions:** - **Shockwave therapy**: Extracorporeal shockwave (ESWT) - moderate evidence - **PRP injection**: Platelet-rich plasma - emerging evidence - **GTN patches**: Glyceryl trinitrate 1.25mg - may enhance collagen synthesis - **Sclerosing injection**: Target neovessels (polidocanol) - limited evidence - **Orthotics**: Address biomechanics if overpronation **NEVER inject corticosteroid into the Achilles tendon.** High risk of tendon rupture (weakens collagen structure). Peritendinous injection for paratenonitis is controversial but if used, must be away from tendon substance and patient counseled about rupture risk. ### Surgery - After 6-12 Months Failed Conservative **Indications:** - Failed comprehensive conservative treatment (minimum 6 months) - VISA-A score under 40-50 despite treatment - Significant functional limitation - Patient willing to accept surgical risks and rehab **FHL Transfer Technique (Workhorse Procedure):** - Prone position - Thigh tourniquet - Careful padding (avoid pressure on face/eyes) - Bump under ankle for exposure - Medial incision from medial malleolus to calcaneus - Identify FHL (deep to FDL) - Alternative: Posteromedial approach to Achilles - Longitudinal tenotomy of Achilles - Excise all degenerate tissue - Assess extent: If more than 50%, need FHL - Preserve paratenon for closure - Identify FHL at master knot of Henry - Harvest distally (detach from hallux) - Maintain 8-10cm length - Protect tibial nerve (medial) - Drill tunnel from posterosuperior calcaneus to plantar - Pass FHL through tunnel (from plantar to posterior) - Tension with ankle in plantarflexion - Fix to calcaneus (interference screw or suture anchors) - Weave into remaining Achilles (side-to-side) - Repair paratenon (prevent adhesions) - Layered skin closure - Backslab at 20 degrees plantarflexion **FHL is the ideal transfer** because: 1. **In-phase**: Plantarflexor like Achilles (vs FDL which is dorsiflexor) 2. **Strong**: Can generate 60-70% of Achilles force 3. **Available**: Minimal donor morbidity (hallux flexion maintained by FDL) 4. **Length**: Adequate excursion for transfer Patients can single-leg heel raise after successful transfer. {/* SECTION 10: SURGICAL TECHNIQUE DETAIL */} ### Pre-operative Planning - **Incomplete pain relief**: 20-30% have persistent symptoms - **Sural nerve injury**: 5-10% (lateral approach) - **Wound complications**: 10-15% (healing issues) - **DVT/PE**: Standard risk - **Re-rupture**: 2-5% (especially if extensive debridement) - **Prolonged recovery**: 6-12 months to full activity - **Thigh tourniquet**: Minimize blood loss - **Loupe magnification**: Identify pathological tissue - **Small retractors**: Protect neurovascular structures - **If FHL transfer**: Drill, interference screw or anchors - **Backslab materials**: Post-op immobilization ### Patient Positioning **Prone** on operating table - Face protection (avoid pressure on eyes/nose) - Arms positioned comfortably (avoid stretch) - Bump under ankle (allows ankle to rest in neutral) - Chest and iliac crests padded - Face turned to side (or prone headrest) - Genitals protected (males) - Contralateral leg secure - Thigh tourniquet applied - Pressure typically 300mmHg (adjust for patient size) - Exsanguinate with elevation ### Surgical Approach: Posteromedial - 8-10cm longitudinal incision - Just medial to Achilles midline - Center over palpable pathology (2-4cm proximal) - Avoid direct midline (tenuous skin) - Identify and protect sural nerve (lateral) - Incise paratenon longitudinally - Reflect paratenon medially and laterally (preserve for closure) - Expose Achilles tendon **Sural nerve** runs lateral to Achilles at this level. Injury causes lateral foot numbness and painful neuroma. Medial approach reduces risk but nerve can be variable in location. Identify and protect throughout. ### Debridement Technique - Palpate tendon for focal degeneration - Degenerate tissue is soft, gray/brown, friable - Estimate percentage involvement - Decision point: More than 50% = need augmentation (FHL) - Longitudinal incision through tendon - Extend incision to expose all pathology - Two or three longitudinal incisions if needed - Excise all degenerate tissue - Healthy tendon is white, firm, organized fibers - Multiple passes to ensure complete debridement - Send specimen for histology (confirm diagnosis) **If less than 50% debrided:** - Close tenotomy with absorbable suture - No augmentation needed **If more than 50% debrided:** - Proceed to FHL transfer (see transfer technique above) ### Closure Technique - Repair paratenon over tendon - Absorbable suture (3-0 or 4-0) - Creates gliding surface, prevents adhesions - Subcuticular closure preferred (avoid suture marks) - Skin glue or staples acceptable - Dressing: Non-adherent, compressive - Backslab or boot at 20 degrees plantarflexion - Non-weight-bearing initially - Protects repair for first 2 weeks ### Technical Pearls - **Complete debridement**: All gray/degenerate tissue must go - **Preserve paratenon**: Essential for tendon gliding - **FHL if needed**: Don't under-augment large defects - **Ankle plantarflexion**: Reduces tension on repair - **Meticulous hemostasis**: Prevents hematoma - **Incomplete excision**: Leaves pathological tissue - **Over-debridement without augmentation**: Re-rupture risk - **Damage sural nerve**: Causes permanent numbness - **Tight closure**: Compromises blood supply - **Early weight-bearing**: Risks repair failure {/* SECTION 11: COMPLICATIONS */} **Fluoroquinolones increase rupture risk 3-4 fold** and the effect persists for months. If a patient on fluoroquinolones develops Achilles pain: - **Stop antibiotic** if possible (consult prescriber) - **Immobilize** if severe pain (backslab) - **Imaging** to exclude partial rupture - **Counsel** about rupture risk and avoid impact activities - **Document** medication exposure for medicolegal reasons **Re-rupture after surgery:** - Risk highest if more than 50% tendon excised without augmentation - Peak risk 6-12 weeks post-op (during rehab progression) - FHL transfer reduces re-rupture risk - If occurs: Requires revision surgery with augmentation {/* SECTION 12: POSTOPERATIVE CARE */} - Backslab or boot at 20 degrees plantarflexion - Non-weight-bearing - Crutches for mobility - Elevation and ice - Wound check at 2 weeks - Transition to CAM boot (gradual heel wedge removal) - Weight-bearing as tolerated in boot - Gentle ankle ROM exercises (no resistance) - Continue elevation - Remove sutures if not absorbable - Wean from boot (transition to shoes with heel lift) - Begin eccentric exercises (modified Alfredson) - Progress to concentric strengthening - Proprioception exercises - Pool exercises (reduce load) - Progress resistance training - Sport-specific exercises - Gradual return to running (if runner) - Monitor VISA-A score - Full activity by 4-6 months typically - Cast or boot at 20 degrees plantarflexion - **Strict non-weight-bearing** for 6 weeks - No ankle motion (protect transfer) - Upper body and contralateral leg exercises - Careful with transfers (crutch technique) - Transition to boot (gradual to neutral) - Partial weight-bearing (25-50%) - Gentle passive ROM to neutral - No active plantarflexion yet - Continue protection - Full weight-bearing in boot - Active ankle ROM (all directions) - Begin isometric plantarflexion - Progress to eccentric exercises (gentle) - Wean from boot by week 16 - Progressive resistance training - Single leg heel raises (goal: 25 reps) - Proprioception and balance - Pool exercises for load reduction - Sport-specific training begins - Gradual return to high-impact activities - Running progression (10% weekly increase) - Plyometric exercises - Sport-specific drills - Maintain strengthening program - Full recovery may take 12 months **FHL transfer requires 6-12 months** for full recovery. Rushing return to sport risks re-rupture. The transfer needs time to incorporate and strengthen. Single-leg heel raise (25 reps) is a good functional milestone before return to running. **Key rehabilitation principles:** - **Eccentric loading** remains cornerstone even post-surgery - **Gradual progression** - 10% rule for increasing load - **Pain monitoring** - some discomfort acceptable, sharp pain is not - **Functional milestones** guide progression (heel raise, hopping, running) - **Long-term maintenance** - continue strengthening to prevent recurrence {/* SECTION 13: OUTCOMES */} **Conservative treatment outcomes:** **Surgical outcomes:** - **Debridement alone**: 70-80% good/excellent results - **FHL transfer**: 75-90% good/excellent results - **Insertional surgery**: 65-80% good/excellent (worse than mid-substance) - **Return to sport**: 70-80% at pre-injury level (takes 6-12 months) **Prognostic factors for poor outcome:** - **Long duration**: More than 12 months pre-treatment - **Insertional location**: Less responsive than mid-substance - **Systemic disease**: Diabetes, inflammatory arthropathy - **Bilateral disease**: Suggests systemic factors - **High BMI**: Mechanical overload - **Poor compliance**: With rehab protocol - **Mid-substance location**: Better than insertional - **Short duration**: Less than 6 months - **Younger age**: Under 40 years - **Good compliance**: With eccentric protocol - **No systemic disease**: Isolated tendon issue - **Appropriate load management**: Return to sport gradual **Conservative treatment requires patience.** Most patients see improvement by 6-12 weeks of eccentric loading, but full recovery takes 6-12 months. Surgery is considered only after 6-12 months of comprehensive conservative treatment. After surgery, return to full activity takes another 6-12 months. {/* SECTION 14: EVIDENCE BASE */} {/* SECTION 15: VIVA SCENARIOS */} Thank you. This gentleman has **mid-substance Achilles tendinopathy** - a degenerative condition of the tendon substance, not an inflammatory process. The gradual onset, location 3-4cm proximal (watershed zone), morning stiffness, and warm-up phenomenon are classic features. **Assessment:** I would take a thorough history including training changes (sudden increase in mileage or intensity), footwear, running surfaces, and any systemic factors. Importantly, I would ask about fluoroquinolone use as these increase rupture risk. On examination, I've noted the mid-substance tenderness and thickening. I would assess for calf tightness (gastrocnemius contracture), foot posture (overpronation), and perform the Royal London test (single-leg heel raises - inability to complete 25 suggests functional impairment). **Investigations:** This is primarily a clinical diagnosis. I would consider **ultrasound** to confirm tendinosis (thickening, hypoechoic areas, loss of fibrillar pattern) and assess for neovascularization on Doppler. MRI is not routinely needed but would show increased T2 signal if performed. **Management:** The **VISA-A score of 52 indicates moderate-to-severe dysfunction**. My first-line treatment would be the **Alfredson eccentric loading protocol** - this is the gold standard with 70-85% success rate. The protocol involves: - 3 sets of 15 repetitions, twice daily - Two variants: straight knee (gastrocnemius) and bent knee (soleus) - Eccentric loading only - good leg lifts, affected leg lowers slowly - Performed on step edge for full dorsiflexion excursion - **Through controlled pain** - this is critical for success - Duration: 12 weeks minimum Adjuncts include heel lift (1cm to reduce load), addressing biomechanics (orthotics if overpronation), and load management (reduce running volume initially). I would monitor with VISA-A scores monthly. If no improvement by 3 months, I would consider shockwave therapy or PRP injection. I would specifically counsel about **avoiding corticosteroid injection** (rupture risk) and the need for patience - recovery takes 6-12 months even with optimal treatment. } keyPoints={[ "Mid-substance Achilles tendinopathy in watershed zone (2-4cm proximal)", "Degenerative process (tendinopathy), not inflammatory (not tendinitis)", "Classic features: morning stiffness, warm-up phenomenon, gradual onset", "VISA-A score 52 = moderate-to-severe dysfunction", "Clinical diagnosis confirmed with ultrasound if needed", "Alfredson eccentric protocol is gold standard (70-85% success)", "Protocol: 3×15 reps twice daily, through pain, 12 weeks minimum", "Adjuncts: heel lift, biomechanics correction, load management", "Avoid corticosteroid injection (rupture risk)", "Recovery takes 6-12 months - requires patience and compliance" ]} traps={[ "Calling it tendinitis (inflammatory) rather than tendinopathy (degenerative)", "Not assessing for fluoroquinolone use", "Not mentioning Alfredson protocol as first-line", "Suggesting complete rest (makes it worse)", "Not warning about corticosteroid injection risk", "Unrealistic timeline expectations" ]} followUp={[ "Walk me through the Alfredson protocol in detail", "The patient asks about PRP injection - what would you say?", "How long would you try conservative treatment before considering surgery?", "What is the VISA-A score and how do you use it?" ]} /> Thank you. This patient has **insertional Achilles tendinopathy** associated with **Haglund's deformity** (posterosuperior calcaneal prominence). This is a more challenging condition than mid-substance tendinopathy and has a worse prognosis with conservative treatment. **Why Different from Mid-Substance:** Insertional disease involves the enthesis (bone-tendon junction) and often has a mechanical component from Haglund's prominence causing impingement. It responds less well to eccentric loading than mid-substance disease. **Assessment of Conservative Failure:** She has completed 6 months of treatment including eccentric loading with persistent symptoms (VISA-A 45 = severe dysfunction). I would verify: - Was eccentric loading performed correctly (through pain, adequate duration)? - Have biomechanical factors been addressed (heel lift, orthotics)? - Has shockwave therapy or other adjuncts been tried? - Is there retrocalcaneal bursitis component (squeeze test)? **Further Conservative Options:** Before surgery, I would consider: - **Heel lift** (2cm) - reduces Achilles tension at insertion - **CAM boot** trial for 4-6 weeks (rest the insertion) - **Shockwave therapy** (ESWT) - can help insertional disease - **Activity modification** - avoid uphill running, jumping **Surgical Indications:** Given 8 months failed treatment and VISA-A under 50, surgery is reasonable. I would counsel about: - 65-80% good outcomes (lower than mid-substance) - Risks: wound healing (thin skin), sural nerve injury (5-10%), incomplete relief - Prolonged recovery (6-12 months) **Surgical Plan:** My approach would be: 1. **Posteromedial approach** to Achilles insertion 2. **Detach Achilles** from calcaneus (if needed for exposure) 3. **Excise degenerate tissue** at insertion 4. **Calcaneoplasty** - resect Haglund's prominence 5. **Reattach Achilles** to calcaneus with suture anchors 6. **Assess excision extent** - if more than 50% debrided, consider FHL augmentation Post-operatively: Cast at 20 degrees plantarflexion, non-weight-bearing 6 weeks, gradual mobilization, return to activity 6-12 months. The key message is insertional disease is more refractory and surgery has less predictable outcomes than mid-substance disease. } keyPoints={[ "Insertional tendinopathy at enthesis - different from mid-substance", "Haglund's deformity is posterosuperior calcaneal prominence", "Responds less well to conservative treatment than mid-substance", "8 months failed treatment + VISA-A 45 = surgery reasonable", "Verify conservative treatment was optimal before proceeding", "Consider further non-operative options: boot, shockwave, heel lift", "Surgical plan: debridement + calcaneoplasty + reattachment", "If more than 50% excised, need FHL augmentation", "Outcomes: 65-80% good (worse than mid-substance)", "Risks: wound healing, nerve injury, incomplete relief" ]} traps={[ "Treating same as mid-substance disease", "Not recognizing Haglund's component", "Jumping to surgery without optimizing conservative", "Not mentioning FHL transfer if large debridement", "Underestimating recovery timeline", "Not counseling about lower success rate vs mid-substance" ]} followUp={[ "Describe your surgical approach to insertional debridement", "How do you reattach the Achilles to the calcaneus?", "What is the squeeze test and what does it indicate?", "When would you augment with FHL transfer in this case?" ]} /> Thank you. This is a challenging scenario of **persistent pain after Achilles debridement**. The VISA-A improvement is minimal (45 to 55) at 6 months post-op, which is concerning. I need to systematically assess why the surgery may have failed. **Differential Diagnosis for Persistent Pain:** 1. **Incomplete debridement** - residual degenerate tissue (MRI shows signal change) 2. **Adhesions** - scar tissue limiting tendon gliding 3. **Paratenonitis** - inflammation of paratenon from surgery 4. **Sural nerve injury/neuroma** - post-surgical nerve pain 5. **Unrealistic expectations** - 20-30% have some persistent symptoms 6. **Biomechanical factors not addressed** - continued overload 7. **Systemic factors** - diabetes, inflammatory disease **Assessment:** I would take a detailed history: - Nature of pain: Same as pre-op vs different? - Rehabilitation compliance: Has eccentric loading continued post-op? - Activity level: Has he returned to pre-injury activities too soon? - Location: Mid-substance (incomplete debridement) vs lateral (nerve)? Examination: - Focal tenderness (suggests residual pathology) - Sural nerve distribution (lateral foot numbness?) - Adhesions (loss of tendon glide) - Calf strength (Royal London test) **Imaging Interpretation:** MRI showing **signal change at 6 months** could be: - Residual tendinopathy (incomplete excision) - Normal post-surgical changes (can persist 6-12 months) - Scar tissue vs pathological tissue (difficult to differentiate) **Management Approach:** **Non-Operative First (give more time):** 1. **Optimize rehabilitation** - ensure eccentric loading continued 2. **Shockwave therapy** - may help residual pathology 3. **Address biomechanics** - orthotics, heel lift, gait analysis 4. **Manage expectations** - 6 months may be too early to judge 5. **Monitor VISA-A** - monthly tracking for trends **Consider Revision Surgery if:** - Failed further 6 months conservative (total 12 months post-op) - VISA-A under 50 persistently - Clear residual pathology on imaging - Functional limitation significant **Revision Surgery Considerations:** - **Higher complication risk** - scar tissue, adhesions - **May need FHL augmentation** - already 40% excised, further debridement risky - **Outcomes less predictable** - revision surgery generally worse results - **Counsel realistically** - may not achieve complete pain relief **Critical Point:** I would have an **honest discussion** about realistic expectations. 20-30% of patients have some persistent symptoms after Achilles surgery. If functional improvement has occurred (even if not pain-free), further surgery may not help. } keyPoints={[ "Persistent pain after surgery in 20-30% - not unusual", "Minimal VISA-A improvement (45→55) is concerning at 6 months", "Differential: incomplete debridement, adhesions, nerve injury, expectations", "MRI signal change could be residual pathology or normal post-op", "Assessment: detailed history, exam for focal pathology, nerve symptoms", "Non-operative first: optimize rehab, shockwave, biomechanics, time", "Revision surgery only if failed 12 months total and significant disability", "Revision considerations: higher risk, may need FHL, worse outcomes", "40% already excised - further debridement may require augmentation", "Honest discussion about realistic expectations is critical" ]} traps={[ "Rushing to revision surgery at 6 months", "Not considering non-surgical causes (adhesions, nerve, biomechanics)", "Not recognizing 6 months may be too early to judge outcome", "Not addressing patient expectations", "Not considering FHL augmentation if revising (40% already gone)", "Promising pain-free outcome with revision" ]} followUp={[ "How would you differentiate sural nerve pain from tendon pain?", "What are the indications for FHL transfer in revision setting?", "How long would you give before considering revision surgery?", "What would you counsel about expected outcomes from revision?" ]} /> {/* SECTION 16: MCQ PRACTICE POINTS */} **Q: Where is the watershed zone of the Achilles tendon and why is it clinically significant?** A: The **watershed zone is 2-4cm proximal to the calcaneal insertion**. This area has the poorest blood supply (watershed between proximal muscular branches and distal calcaneal vessels) and is where **75% of Achilles tendinopathy occurs**. **Q: What is the key histological difference between tendinopathy and tendinitis?** A: **Tendinopathy shows degenerative changes** (collagen disorganization, hypercellularity, neovascularization) with **NO inflammatory cells**. Tendinitis implies inflammation which is rarely the chronic pathology. This is why NSAIDs have limited long-term benefit. **Q: What is the Alfredson eccentric loading protocol and what is its mechanism of action?** A: **3 sets of 15 repetitions, twice daily, for 12 weeks.** Two variants: straight knee (gastrocnemius) and bent knee (soleus). Eccentric only - lower on affected leg, raise on good leg. **Must be performed through controlled pain.** Mechanism: promotes collagen remodeling and disrupts pathological neovascularization. **Success rate 70-85%**. **Q: What is the association between fluoroquinolones and Achilles tendon?** A: **Fluoroquinolones increase Achilles rupture risk 3-4 fold.** The effect persists for months after cessation. Avoid in athletes and active individuals. If Achilles pain develops on fluoroquinolones, stop medication if possible and consider imaging to exclude partial rupture. **Q: What are the indications for FHL transfer in Achilles surgery?** A: **FHL transfer is indicated when more than 50% of Achilles must be debrided.** The FHL is ideal because it is an in-phase plantarflexor, has adequate strength (60-70% of Achilles), and causes minimal donor morbidity. It allows aggressive debridement while maintaining plantarflexion function. **Q: What is the VISA-A score and how is it used clinically?** A: **VISA-A (Victorian Institute of Sports Assessment - Achilles)** is a validated 10-question outcome measure scoring 0-100 (higher = better). **Under 60 indicates severe dysfunction.** Used to monitor treatment response and guide surgical decision-making. Score improvement more important than absolute value. {/* SECTION 17: AUSTRALIAN CONTEXT */} - **High participation**: Running, AFL, rugby - common Achilles overload - **Sports Medicine Australia**: Guidelines for tendinopathy management - **Medicare rebates**: Item numbers for physiotherapy (consultation) - **Eccentric programs**: Widely available through sports physios - **PRP availability**: Growing but not PBS-funded (patient pays) - **NSAIDs**: PBS-listed for acute pain (celecoxib, ibuprofen) - **Fluoroquinolones**: Common for UTI/respiratory (ciprofloxacin, norfloxacin) - **Warning required**: TGA mandates Achilles rupture warning on fluoroquinolones - **Alternative antibiotics**: Consider if Achilles symptoms develop **Medicare item numbers (surgical):** - **50312**: Repair of ruptured Achilles tendon - $663.65 - **50324**: Tendon transfer (FHL) - $772.60 - **50330**: Tendon lengthening or recession - $554.25 - **Note**: Debridement may be coded under 50312 or 50330 depending on technique **Key documentation requirements:** 1. **Fluoroquinolone history**: Document if patient has taken (litigation common) 2. **Corticosteroid warning**: Document counseling about injection rupture risk 3. **Conservative duration**: Document 6-12 months conservative treatment before surgery 4. **Surgical consent**: Include incomplete relief, wound healing, nerve injury, re-rupture 5. **FHL transfer**: Document indications (more than 50% debridement) and donor morbidity counseling 6. **Return to sport timeline**: Realistic expectations documented (6-12 months) **Common litigation scenarios:** - Rupture after corticosteroid injection - Rupture on fluoroquinolones without warning - Rushed to surgery without adequate conservative treatment - Sural nerve injury without documented consent - Unrealistic expectations about pain-free outcome **Australian guidelines:** - **Sports Medicine Australia**: Tendinopathy management - eccentric loading evidence-based - **ACSQHC**: VTE prophylaxis post-surgery (LMWH or mechanical) - **Therapeutic Goods Administration**: Fluoroquinolone black box warning for tendon rupture In Australia, Achilles tendinopathy is common in recreational runners and football codes (AFL, rugby). Eccentric loading programs are widely available through sports physiotherapists. PRP is available but not PBS-funded (patient self-pays typically $500-1000 per injection). Surgery is generally reserved for cases failing 12 months of conservative treatment due to healthcare system emphasis on non-operative care. {/* SECTION 18: EXAM CHEAT SHEET */}

Posterior Shoulder Instability

Posterior Shoulder Instability