Insertional Achilles Tendinopathy: Occupational Outcomes in the Military

Return to military duty following anterior cruciate ligament reconstruction is associated with preoperative Body Mass Index and postoperative physiotherapy

PURPOSE

To determine the rate and time of return to duty following anterior cruciate ligament reconstruction (ACLR) in military members, and to determine whether their outcomes are influenced by patient characteristics or surgical parameters.

METHODS

We prospectively assessed 280 military members that underwent ACLR. 27 were excluded due to multi-ligamentous injuries or revision surgery, two did not provide informed consent and 62 were lost to follow-up. Patient demographics, pre-injury physical workload, complications and whether/when patients resumed duty and sports were noted, as well as clinical outcomes at a minimum follow-up of one year, including Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee score (IKDC), Lysholm, and Tegner scale.

RESULTS

The final cohort of 189 military members (82% men) had mean age of 25.5 ± 3.4 (range,19-38) at ACLR. At 3.3 ± 1.6 years (range, 1.0-6.3), the Tegner score was 6.1 ± 2.0, Lysholm was 87.0 ± 13.7, IKDC was 80.1 ± 15.7, and KOOS was 81.1 ± 14.8. Only 144 patients (76%) resumed duty, at 9.5 ± 5.3 months (range,1-28), and 141 patients (75%) resumed sport, at 10.2 ± 6.2 months (range,1-35). Multivariable analysis revealed that return to duty was less likely in patients with higher BMI (OR,0.89;p = 0.025), but more likely in patients that followed military physiotherapy (OR,2.76;p = 0.017) and with higher pre-injury physical workload (OR,3.93;p = 0.010).

CONCLUSION

At a follow-up of 3.3 ± 1.6 years, 76% returned to duty at 9.5 ± 5.3 months, and 75% returned to their main sport at 10.2 ± 6.2 months. Patients with higher BMI are significantly less likely to resume military duty and sports; those that followed military physiotherapy were most likely to resume duty, while those that had greater pre-injury physical workload were more likely to both resume duty and sport.

Low-volume Hydrodissection for the Treatment of Chronic Achilles Tendinopathy

Chronic Achilles tendinopathy (AT) is a common ailment for many active duty service members that adversely affects readiness. Patients present with pain, swelling, and limited functional ability. Kager's fat pad is a mass of adipose tissue that protects the blood vessels supplying the Achilles tendon and preserves its function. A popular hypothesis is that scarring, tethering, and neovascularization play a significant role in the pathogenesis of AT. Current literature supports the effectiveness of high-volume (40-50 mL) hydrodissection, a procedure in which fluid is injected under ultrasound guidance into the tissues surrounding the Achilles tendon to mechanically separate the paratenon from the underlying Kager's fat pad. There may also be a beneficial effect of scar tissue and neoneurovascular breakdown. However, high-volume injections result in short-term discomfort and decreased mobility. Lowering injection volume (2-10 mL) may reduce this morbidity and facilitate use in limited-resource environments. This case report presents a 29-year-old active duty male with recalcitrant post-traumatic AT who achieved significant pain reduction and faster return to full service using low-volume hydrodissection. The use of 10 mL volume has not been described previously and provides additional support for using lower volumes in chronic AT. This technique is a direct adjunctive treatment option with rehabilitation at a military treatment facility or in the operational environment.