NIEK VAN DIJK Las Vegas 2017 Achilles Tendinopathy Isolated Syndesmotic Instability Arthrodesis still the Best Option Academic Medical Centre Amsterdam Ripoll de Prado Sport Clinic Madrid Clinica Do Dragao Porto www.ankleplatform.com
NIEK VAN DIJK Las Vegas 2017 Achilles Tendinopathy Academic Medical Centre Amsterdam Ripoll de Prado Sport Clinic Madrid Clinica Do Dragao Porto www.ankleplatform.com
Achilles Tendinopathy Isolated Syndesmotic Instability Arthrodesis still the Best Option Disclaimer This presentation and the information contained herein was prepared exclusively by the presenter, Dr. C. Niek van Dijk, M.D. The views and opinions expressed in this presentation are those of the presenter and do not reflect the position, opinion, or guidelines for clinical care of any other person, institution, scientific association, or product manufacturer.
Achilles Tendon Pathology • Non-insertional - Paratendinopathy - Paratendinopathy + Tendinopathy - Tendinopathy • Insertional - Retrocalcaneal Bursitis - Retrocalc. Bursitis + Insertional Tendinopathy - Insertional Tendinopathy Hindfoot Endoscopy 2005
Achilles Tendon Pathology MRI
Tendinopathy Conservative Treatment Eccentric Calf Muscle Training Set A: extended knee 90x Set B: 30° flexed knee 90x Alfredson H, Am.J.Sp.M. 1998 Conservative treatment
Polidocanol by Alfredson and co-workers Rationale: Sclerosing injections obliterate neovessels – 2005: 95% good results AMC (n=53) accepted AJSM: – 56% still complaints at 6 wks – 2.7-5.2 yr FU (n=40): all had additional treatments 3 (7.5%) same complaints M van Sterkenburg et al ,2010 Ohberg 2002 (AT), Alfredson 2005 (AT), 2005 (shoulder), 2006 (PT)
RCT Platelet Rich Plasma De Vos 2010 JAMA PRP vs. saline : Same outcome at 6 months De Vos, Tol 2010
Surgical Treatment 70’s Kvist &Kvist 1980 Outcome 50-50 Induction of Chemical Inflammation
Tendinopathy + Paratendinopathy Endoscopic Treatment 1995 Complaints > 1 year • • Localized symptoms • Mechanically intact tendon • MRI < 40% degeneration • Medial pain Extra-Articular Endoscopy
Tendinopathy + Paratendinopathy 1995-2002 n=21 • Sport Resumption : 42 days (35-70) • Work Resumption : 21days (10-56) • FAOS Pain 93 (8) Other Symptoms 90(10) ADL 99 (2) • SF 36 : Normal Sports 92(10) • Overal Satisfaction : All Patients Satisfied with the Outcome F.Steenstra 2005
Tendinopathy Origin of the Pain?
Achilles Tendinopathy: Cause of pain? Tendinopathy Adequate repair Increased demand Origin of the Pain? Increased vulnerable to injury Inadequate repair of microrupture Further decrease Tendinopathy of collagen& matrix Cycle Inadequate collagen& matrix Tenocyte disruption production
Achilles Tendinopathy: Cause of pain? Adequate repair Increased demand Increased vulnerable to injury Inadequate repair of microrupture Further decrease Tendinopathy of collagen& matrix Cytokines: Cycle VEGF PDGF EGF Neoangiogenesis & Nerve proliferation Inadequate collagen& matrix Tenocyte disruption production Neurogenic Inflammation
Achilles Tendinopathy: Cause of pain? Adequate repair Increased demand Increased vulnerable to injury Inadequate repair of microrupture Further decrease Tendinopathy of collagen& matrix Cytokines: Cycle VEGF PDGF EGF Neoangiogenesis & Nerve proliferation Inadequate collagen& matrix Tenocyte Degradation of extracellular matrix disruption production Neurogenic Inflammation
Achilles Tendinopathy: Cause of pain? Adequate repair Increased demand Increased vulnerable to injury Inadequate repair of microrupture Further decrease Tendinopathy of collagen& matrix Cytokines: Cycle VEGF PDGF EGF Neoangiogenesis & Nerve proliferation Inadequate collagen& matrix Tenocyte Degradation of extracellular matrix disruption production Myofibroblast proliferation Neurogenic Inflammation
Achilles Tendinopathy: Cause of pain? Adequate repair Increased demand Increased vulnerable to injury Inadequate repair of microrupture Further decrease of collagen& matrix Cytokines: VEGF PDGF EGF Neoangiogenesis & Nerve proliferation Inadequate collagen& matrix Tenocyte Degradation of extracellular matrix disruption production Myofibroblast proliferation Scarring & Shrinkage Neurogenic Inflammation
Achilles Tendinopathy: Cause of pain? Adequate repair Increased demand Inadequate repair of microrupture Cytokines: VEGF PDGF EGF Neoangiogenesis & Nerve proliferation Degradation of extracellular matrix Myofibroblast proliferation Obliteration of vessels Scarring & Shrinkage
Achilles Tendinopathy: Cause of pain? The Rationale for Endoscopic release of the paratenon & Release of the Plantaris Tendon Denervation Endoscopic surgery
Conclusion • The pain originates from neonerves in peritendineum • Operative treatment options have traditionally been directed towards tendon • Treat the peritendineum: denervation! • Consequences for degenerative tendon proper unknown – no evidence that tendinopathy rupture Achilles Tendinopathy
Tendinosis Reconstruction Achilles Tendon Pathology
Tendinosis Reconstruction Achilles Tendon Pathology
Achilles Tendon Pathology • Non-insertional - Paratendinopathy - Paratendinopathy + Tendinopathy - Tendinopathy • Insertional - Retrocalcaneal Bursitis - Retrocalc. Bursitis + Insertional Tendinopathy - Insertional Tendinopathy Hindfoot Endoscopy 2005
Achilles Tendon Pathology • Non-insertional - Paratendinopathy - Paratendinopathy + Tendinopathy - Tendinopathy • Insertional - Retrocalcaneal Bursitis - Retrocalc. Bursitis + Insertional Tendinopathy - Insertional Tendinopathy Hindfoot Endoscopy 2005
Endoscopic calcaneoplasty Technique Achilles Tendon Pathology
Endoscopic calcaneoplasty Hindfoot Endoscopy 2006
Endoscopic calcaneoplasty Technique Hindfoot Endoscopy 2006
Endoscopic calcaneoplasty Technique Hindfoot Endoscopy 2006
Hindfoot Endoscopy 2006
Endoscopic calcaneoplasty Technique Hindfoot Endoscopy 2006
Insertional tendinopathy Achilles Tendon Pathology
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Insertional tendinopathy www.ankleplatform.com
Insertional Tendinopathy www.ankleplatform.com Achilles Tendon Pathology
Keepers for Technique Guide; note Fig. 7 & 8 replaced 1/14 with images that show lasermarks Fig_03_48_Sec_ACTR_3D_STILL Fig_01_27_Sec_ACTR_3D_COMPOSITE Fig_02_35_Sec_ACTR_3D_STILL Fig_04_57_Sec_ACTR_3D_STILL Fig_05_107B_Sec_ACTR_3D_STILL Fig_07_127_Sec_ACTR_3D_CORRECT_STILL Fig_08_127_Sec_ACTR_3D_INCORRECT_STILL Fig_09_141_A_Sec_ACTR_3D_STILL Fig_10_09_Sec_ACTR_3D_STILL
Thank You End
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