Risk factors, so this is Bruckner and Kahn's image here. And they got a great section, some great images if you want to go back to it. And I hear they got a fourth edition coming out. It's going to be very exciting. You know, relative energy deficiency in sport is not a commonly spoken of risk factor for Achilles tenopathy. But I threw that in there because it is for sure a risk factor for any form of an overuse injury. So someone who's not getting better, someone who has kind of chronic injuries, consider relative energy deficiency in sport. What I find is that abnormal foot mechanics are pretty big culprits in this one. So people who have just extreme pronation or supination one way or the other, or if they have pes planus, you can see that. Calf weakness is listed in Bruckner and Kahn. But gosh, I work with D1 athletics, and a lot of these people are pretty strong. Fluoroquinolone antibiotics for sure flare up a lot of tendons with Achilles tendon as well. And then really it just comes down to an imbalance of too much work, not enough rest. Right? The gastrocnemius crosses two joint lines. So you want to make sure that the range of motion to your ankle and your kind of your gastroc heel cord complex is assessed because you can get a lot of tightness there that can predispose people to this. Now, not relevant to our 21-year-old division one collegiate athlete, but if someone is taking corticosteroids oral, if they're very old, we see a male predominance of Achilles tendinopathy, they have diabetes, post-menopausal or obese. Those are other risk factors, just to keep in the back of your mind if you have a broader sports medicine clinic. Now, here's the rabbit hole. I love this rabbit hole. So a bunch of smart people over at IDSA said, this is how you treat a urinary tract infection. Number one, not Cipro. Number two, also not Cipro. Number five, okay, Cipro. And then they say, should be considered alternative because of a propensity for collateral damage. So for all of you out there who are doing full-spectrum sports medicine, including taking care of the medical management of them, just I know UTIs are common, Cipro is easy to go to, but if we can dodge it, let's dodge it. And even the urologists are saying, huh, I guess Achilles tendon problems are real. And we know that, right? So no Cipro. I always tell my fellows and residents, start your examination where you don't want to examine. So clearly, when someone comes in with mid-portion Achilles tendinopathy, you want to look at it. But as sports medicine doctors, we're always sniffing around for other etiologies. We're always concerned. Is this coming from the back? Is it a ridiculous symptom or something that's being referred down? And then looking at those feet, looking at those ankles, really important with Achilles tendon. So someone who has just super flat feet, you know, pes planus, that's going to predispose them to that. And then someone who has a marked loss of range of motion, you're going to see a lot of Achilles tendinopathy with that one as well. So here's the classic, I mean, just look at this big old engorged fat tendon, right? So this is obviously not the patient we're talking about, but this is a nice picture of an inflamed Achilles tendon, and you want to, you just want to squeeze it, right? You want to pinch it. You want to see if it's nodular. And then here, one thing that I want to talk about is the location of Achilles tendon symptoms. So the vast majority of them are going to be mid-portion Achilles tendinopathies rather than the insertional Achilles tendinopathy. And depending on which study you look at, maybe 70%, maybe up to 85% of the Achilles tendinopathies will actually be mid-portion. And the reason is that's in a watershed zone. And there's a cool study that looked at with exercise, you're doing dynamic blood flow studies. When you get above the 7 centimeter mark, so when you are more proximal, the blood flow increases to this zone at fourfold. So it's a huge amount of increased blood flow. But when you go into this kind of mid-portion zone, classically, I think it's right about 7, excuse me, 3 centimeters, but the range is pretty broad, 2 to 7 centimeters. The blood flow increase with strenuous activity only increases about twofold to 2.5 fold at tops. So there's a huge discrepancy in blood flow supply during strenuous activity, which is why we see a lot of problems with these repetitive use athletes like runners. So long-distance runners having a big incidence of this one. So that's where our watershed zone is. And that's why we see a lot of problems there. Now, you want to break it up into kind of two different buckets. And they can, they can actually present somewhat similarly. Sometimes you'll have pain that's in mid-portion, but it also tracks down to the insertional point. And it's not as clear as you might want it to be. It's not as clear as that one picture I showed you where you had a huge, massive swollen Achilles tendon. So really what you want to do is you want to do a thorough physical examination. You really want to palpate the entire, the entire gastrocnemius soleus complex, the whole heel cord, and you really want to make sure that you're palpating all the bony prominences of the calcaneus as well. And Haglund's is when you have a prominence, an over-prominence of the superior tuberosity of your calcaneus, and that can predispose to some friction there on the very distal end, the kind of insertional aspect of the Achilles tendon. And then if you have a young, skeletally immature patient, you're always thinking about an apophysitis as well. So Severs disease. So here we have an ultrasound image of some apophysitis as well. So those are kind of the distal versus the watershed zones are the two, two buckets that we're looking at. And it's important to differentiate it because the management strategies are different as well. One of the fun thing to feel is the squeakiness, so crepitus in there. This is an old, old, old, old study. And it's, I don't know, I don't know what language that's in, but it almost looks like it's a gynecological paper. I'm not entirely sure on that one, but they talked about some of the basic science, fiber and precipitation around the peritoneum that actually causes the, the squeaking and the crepitus in there. Now, this is so cool. You know, Kieger's fat pad is such an interesting structure to me. Hoffa's fat pad in the knee is just insanely fascinating as well. But Kieger's fat pad, I used to disregard it, but now I give it a lot of respect, a couple of things that it does, number one, it's, it's a mold that kind of helps our vascular supply stay in place and protect our blood vessels that are going into it. So it's kind of a shock absorber and a guiding almost like in a bowling alley, how there's a gutter. It has these nice little gutters for our vassal vessels to insert onto our Achilles tendon and feed that. Another cool thing that it does is this paper attempts to differentiate the Kieger's fat pad into different lobes. And this is the calcaneal wedge lobe. And one of its main functions, they argue is that when we go through dorsiflexion plantar flexion, you can see this wedge actually coming in and out to protect the distal end of the Achilles tendon, this is an ultrasound image and a sagittal plane. So a long axis plane, this is our calcaneus bone here, and this is the normal, I call it the seagull shape of the calcaneus bone right here. So here's our tendon coming in and inserting there. And here's this Kieger fat pad wedge sliding in to protect and offload the friction of the tendon. Pretty cool stuff. Now imaging on our workup of our 21 year old gymnast, a couple of things to consider after our physical examination. I like playing films. I like them. Um, I find that sometimes people will have, um, an Oztrigonum, which can give you an, a posterior impingement, uh, with gymnasts, with dancers, ballerinas, uh, soccer players, um, you can get a posterior impingement syndrome that can just kind of give them this, this pain in the back that can mimic an Achilles tendinopathy. And I find that ultrasound imaging of the Oztrigonum to be challenging. Um, it's a deeper structure. You get some edge artifact from some of the hyper echoic Achilles tendon structures. Um, sometimes if you have a retro calcaneal bursa, you'll get some edge artifact on that one, as well as the sound waves are arcing around the bursal sac. So I think plain film radiographs are just a fantastic idea. And I know that we live in an ultrasound world where it's so fast. It's so easy. There's no radiation, you know, it's right there. Um, but this is, this is a spot where I still, I still like x-rays. So what I'm looking for on my x-ray, I'm looking for a very prominent calcaneal superior tuberosity consistent with a Hagelin's deformity. I'm looking for Oztrigonum. Also looking for any form of enthesopathy. Now, granted ultrasound is fantastic at enthesopathy as well. Ultrasound also gives us a lot of other really useful information, gross appearance of the tendon fibers. You can see there's fusiform thickness, hyperemia, neovascularization. Um, it's pretty fun stuff. I'm going to go ahead and, um, hijack some images out of Jacobson's book here to show you some ultrasound, um, model staging and kind of transducer placement. And I want you to notice that I use the word transducer and not probe. I think Doug Hoffman will tell you that probe is an action verb and transducer is a noun. Um, I can't see Doug if he's laughing or not. I hope he is. So this is straight out of Jacobson's book. I prefer to use the larger footprint linear array transducer. So high-frequency transducer, sometimes, um, people will, when we get down to the nuances of the calcaneal insertion, we might swap on over to the smaller footprint. I feel like it's a waste of time and you can get a lot of goodness out of those, um, those larger footprint, high-frequency transducers. When I start my exam, I actually like to start up high. I like to take a look at the gastroc soleus. I like to see if I can see the, uh, plantarus as well. Here's a little bit of just gross anatomy on a, on a, uh, transverse plane here. We have lateral head of the gastrocnemius here, medial head of the gastrocnemius here. We've got our soleus cruising in here. And then when we move on to short axis, I'm sorry, and you can start to see a little thickening of the, uh, under, underneath the medial head of the gastrocnemius will be the plantarus tendon. And this is, you know, an image that Jacobson can get that's challenging to get, um, at times, but here we have medial head of the gastroc. We got soleus and just a beautiful picture of the plantarus tendon, um, in the aponeurosis plane, right in through there. And this plane is going to thicken and thicken and thicken and form our Achilles tendon complex. Now, if we were to scan more distally, uh, we would see another muscle belly just deep to this. And that'll be the flexor hallucis longest muscle belly. Now I like to have the patients, um, kind of scooch down to the edge of the bed. And, uh, and then I'll either with my knee, um, if I'm on a stool, kind of bop them into some, uh, dorsiflexion here, really, I want to flatten out those skin folds because those skin folds can really inhibit your image. Image quality. If you have any air pockets in there, air is the enemy of a, of ultrasound, right? You, you definitely need ultrasound coupling gel to help with this one. Now, here are images from Jacobson's book. Um, and, and this is a nice picture of that clear, crisp, linear, um, structure of the Achilles tendon. You see it coming into the calcaneus here. I know you see a big Kieger's fat pad structure here. We can't really make out the flexor, um, hallucis structure too well down here. And then here's a cross section right in here. And you just see beautiful, uh, tendon fibers here with the Kieger's fat pad structure, uh, distal or deep to it. Now, one thing that I wanted to show you on this one, look at this huge acoustic standoff, uh, window that they're using. And that's a really great idea. So if you either have some of those cool acoustic standoff pads, or you just want to throw a ton of gel on there, um, that's good kind of pro tip. Um, I keep a bottle of ultrasound coupling gel in the refrigerator in clinic, um, because it's much, much more viscous and it'll actually hold, um, hold its form a little bit more and it won't just drip off of the, uh, off of the patient. I of course warn them. I say, you know, Hey, this is cold jelly. And I mean it because it actually is cold jelly, but that's a, that's a pretty good way to go about examining this. And you'll see that when we're measuring the Achilles tendon, we want to look for signs of enlargement, thickness, whitening. Um, and you'll see that they'll measure from inside the peritoneum to inside the peritoneum. And it looks like there's maybe a little bit of age variation, but it doesn't meet a lot of statistical significance here. And then they look at foot dominance. If you're right footed versus left footed, there's not a lot of deviation here. So really, um, you'll see in the literature, 6.1 is the most commonly cited, um, average AP diameter of the Achilles tendon in my mind when I'm scanning, I just think, is it bigger than six? Is it less than six? Um, and then also I want to look at the gross appearance of it as well, but you will see a lot of variation. There is also some, the study goes into the variation of how big the human is, how tall they are versus the, the, um, overall diameter. And this is kind of surprising. There's not a lot of change in the diameter with very big people versus very small people. It seems to be right around 6.1 centimeters is the average thickness. Now, this is, this is what we don't want to see in our athletes. This is evidence of the fusiform edema. So you see, it's kind of swollen out. It's pooching out. You'll see that rather than having those nice, crisp linear bands of, um, I've heard it described as bundles of copper wire together or finally combed hair. You kind of get this, um, almost looks like someone just kind of smudged it, just kind of smudged it out a little bit. And you kind of get that loss of that fibular pattern. We also see that when we threw on some power angiography, we're seeing hyperemia here. And, um, shoot me, Derek, you're going to have to remind me on that rheumatologist that is just totally awesome at, um, tendon exams. It does a lot of hand stuff, but he showed me how to zero the power angiography, which I thought was super cool. So step one, you want to use the lightest amount or no pressure whatsoever on your transducer. So you really want to try and float that transducer on a big mound of coupling gel. You want to then put your transducer over a bony prominence. Put your window, um, your, your power angiography or your Doppler, uh, window deep to that bony structure, right? There are no sound waves going there. And then what you do is you dial your gain all the way up until their signal deep to the bone, which it shouldn't be happening. Right. And then you just slowly ratchet it down until that signal is then gone. And that's how you zero your angiography for that scan. And so, um, what you would do is you would just go over the calcaneus crank up your, your gain to get that, um, flow way high. And you'll see hyperemia, um, in the bone, which you can't see you dial it down and then you're good to go. And then here's a cross section of, and this is what we would call neo vascularization. Really fascinating stuff. The, the physiology behind the neo vessels. So when you have, um, uh, a tendon that's in a bad state and there, um, they start to release a lot of, uh, vascular endothelial growth factors. So VEGF, and so you get these, these blood vessel formations, but the thing is, they're not like normal blood vessels. They're much, much leakier and they actually are not very good at delivering nutrients the way that a normal blood vessel would. And so, um, we see that when we go in and we separate these, uh, neo vessels, either through hydro dissection or sclerotherapy or scraping, um, pain is better, the vessels are no longer present on, um, angiography, um, and you see people feeling better. Here is a long axis view. You're just seeing some more hyperemia and Kieger's fat pad here. Um, you see the neo vascularization going from the fat pad up through the tendon. You see it in the tendon as well. And then, um, I wanted to point out chronic tendinopathy, just like all the other tendons in our body. If you have chronic Achilles tendinopathy, you'll definitely see a lumpy roly poly appearance to the bony insertion here. So this is abnormal. And what I want to do is I want to show you, um, one more time, the normal seagull shaped appearance of the calcaneus, right? So that's, that's the normal healthy tendon, or is this lumpy, bumpy, roly poly stuff? That's no bueno. That means that they have chronic, uh, tendinopathy here. And down here, you'll just see some, um, hyper-echoic structures from long-term, uh, fibrinous deposits. And I call it scar tissue. You'll see here, this is the retro calcaneal bursa there. Commonly do not see the retro calcaneal bursa with fluid unless there's a problem going on. There is a, there's a problem, problem right there. Big old retro calcaneal bursa there. I commonly will see more of a retro calcaneal bursopathy in the setting of an insertional tendinopathy and less so in the setting of a mid portion tendinopathy. So I see this getting more, um, aggravated when we have insertional problems. So when you see that, try and think of either maybe a mixed picture or more of an insertional tendinopathy. And, um, we just looked at a bunch of abnormals. I want to show you some normal ones as well. Normal tendon, nice, crisp, linear fibers coming in. There's the seagull shaped calcaneus. That's totally normal. And what you'll see is you'll just see normal anisotropy as those tendon fibers are making that hard turn to go down and insert into the bone. And here's a lot of, um, anisotropy here. So what you do is you just, you just heel toe your transducer, get rid of that, uh, anisotropy. Short axis, it looks like you're either looking at a, um, the end of a paintbrush. So you see all these beautiful, crisp patterns here. And then with anisotropy, you can see them going a little bit more, uh, hypochoic. And at the end of the day, this is what we're all trying to avoid, right? We're trying to avoid the complete rupture of an Achilles tendon, which you see the tendon stumps here, large fluid in between there. Um, sometimes people will be able to see the, um, plantarus tendon becoming very, very prominent in the setting of Achilles tendon rupture, um, and the fluid around it gives it this beautiful acoustic window and it just shines. And you might think that it's a incomplete Achilles tendon rupture, but, um, just be mindful of the plantarus kind of being a false, a false negative for a complete tendon rupture. Moving into some treatment. Um, there are a lot of ways you can skin this cat. Uh, I was just talking with Doug and Ryan before the call that it basically depends on where you trained and what hospital system you're in and what you have available. Um, here's a table I hijacked from a paper. Um, we, we love the eccentrics, right? So, I mean, number one, rest, focus on good nutrition, focus on rest, decreasing those reps, focus on your eccentric exercises. It looks like it increases, um, a more healthy collagen type, uh, lay down and collagen organization with those eccentric exercises, shockwave therapy. I don't have access to one, um, physicians that have it. Love it. Um, awesome. More power to you. Um, other easy ones, low hanging fruit are the nitroglycerin patches. I find that in my patient demographic, young, healthy people, they're all borderline hypotensive or utensive and have drops their pressures gives them orthostasis and headaches. So that's not really where I go. Um, Some people will do PRP, a whole blood sclerotherapy. Um, Ryan was asking me what we like. We're big fans of a dextrose hydro dissections, right? And that's not super well evidence-based and I acknowledge that. Um, but what we really like separating those tissue planes with inappropriate adhesions with just a little bit of D five W and a local anesthetic, we will obliterate those neo vessels. Pain is better. Um, see some pretty positive results with that. I have a lot of gymnasts that will come back, um, almost on a monthly, um, basis to, to get that done. So with that, I'll go ahead and close up shop and, uh, give you all a moment for some questions.

2nd Edition, CASE 11

2nd Edition

Foot and Ankle

Achilles tendinopathy

overuse injuries

imaging techniques

eccentric exercises

shockwave therapy

foot mechanics