Melanie Cole, MS (Host): Welcome to the podcast
series from the Specialists at Penn Medicine. I'm Melanie Cole, and joining me
today is Dr. Lorraine Boakye. She's the Director of Clinical Research, Foot and
Ankle Division and Assistant Professor in the Department of Orthopedic Surgery
at Penn Medicine. She's here to highlight tendonopathy and rupture for us
today.

Dr. Boakye, thank you so much for being with us. I'd like
you to start by providing a little background on your role as an Orthopedic
Surgeon at Penn Medicine and an overview of what we're discussing here today.

Lorraine Boakye, MD: Absolutely. Well, thank you so
much for having me. Again, my name is Lorraine Boakye, I'm an Assistant
Professor in the Department of Orthopedic Surgery at Penn Medicine. My
subspecialty training is in foot and ankle surgery. I also serve as the
Director for our clinical Research within our division, and we'll be talking
about Achilles rupture and tendinopathy.

Host: How prevalent is this?

Lorraine Boakye, MD: Well, it's one of the most
common injury complexes, whether it's the actual instance of rupture or
tendinopathy. But it's among one of the most common, acute on chronic things
that we face at least as foot and ankle physicians.

Host: Dr. Boakye, can you speak a little bit about
some of the most common causes that you see and even in the acute process, and
differentiate for us about chronic overuse versus acute for these injuries?

Lorraine Boakye, MD: Absolutely. When we think about
it, we sort of wonder what makes a tendon more prone to rupture, or some sort
of acute on chronic either inflammatory or degenerative process that ends up
causing people significant pain and functional limitation. And the reasons for
this are pretty multifactorial. And in fact, that's one of the things that many
folks within our realm are sorting out in terms of what they think is maybe the
most compelling of the causes. But certainly among those, we see it more
frequently in men, typically thirties, forties, fifties range. But really no
group is immune to either pathology and it's usually some sort of injury caused
by overuse. Whether it's repetitive activity or a sudden increase in activity
from a relatively sedentary sort of lifestyle. And it's usually in cases of
rupture at a site that is a few centimeters above the insertion of the Achilles
tendon, where it's known to be what's called a watershed region, where the
actual vascular supply to this area is lessened.

So we think that on sort of a mechanical level as well, this
sort of spot is predisposed just because of the amount of relative blood flow
restriction compared to other portions of the tendon. And when we think about
tendinopathy, there is both insertional and non-insertional. And when we think
about the factors that cause the tendon to be inflamed or irritated, right as
it inserts onto the calcaneus, we think about whether there are external factors,
like a certain shoe ware or other gear for certain athletic activities.

Or if there is a bony prominence called the Hagunds, which
is a little extra bit of bone posterior superior aspect of the calcaneus that
kind of predisposes the tendon to more friction and impingement. And so, we
think about really on sort of a cellular level that the potential histologic
impact of what the actual tendon may look like. But then also what are the
lifestyle and comorbidity factors that may influence this. So whether it's
diabetes or rheumatoid arthritis, or end-stage renal disease or other factors
that may cause a tendon to have less blood supply or less nutrient supply, that
may cause ultimate injury or rupture.

Host: So I'd like you to speak about treatment options
and what you're offering for patients with Achilles tendonopathy and or
rupture.

Lorraine Boakye, MD: When thinking about management
for rupture, there are essentially two camps of non-operative and operative
management. And ultimately when we're thinking about who may do well with
surgery, we have to think about the overall picture of health and sort of what
their goals are in terms of functional level of activity. And the real kind of
take homes are trying to figure out when it is safe to operate, especially in
these cases where the patient is prone, we want to make sure that the
anesthesia risk isn't undue. But sort of outside of that, the goals of surgery
for rupture are to essentially approximate the tendon ends and make sure that
we're able to take the rupture site and physically put it back together and
make sure that it is at a reasonable resting length intention. And that gives
us the best chance of kind of expediting or optimizing healing.

And we started to think, all things being equal, what are
the sort of advantages of surgery? And as far as studies go, we've sort of seen
that ideally, it gives us a bit of a faster recovery, meaning you cut down some
of the weeks that you are actually within our treatment paradigms, and
potentially giving people earlier range of motion.

So preventing a bit of stiffness because you're able to
progress through the range of motion and strength and rehabilitation protocol a
little more quickly. There's some thought that there is a lower risk of
re-rupture. Recent literature has maybe refuted this, but I think anecdotally,
many of us still favor having a lower risk of re-rupture with operative
management.

in terms of non-operative management, if the patient either
can't or does not elect to undergo surgery and we think there's a reasonable
risk of them healing, if it's an acute rupture, in those cases, if there isn't
a big risk of kind of interposed fat or degenerative tissue, or a really large
amount of retraction; then the hallmark is really putting someone, in a position
of kind of best healing, and that's with planter flexion. We have modalities
where we put people in resting planter flexion splints, and essentially have
them or advise them to be non-weightbearing for the first two weeks, and then
essentially in both post-op protocol and the non-operative protocols, we sort
of systematically advance people through non-weightbearing with protected
weight bearing, and then up through weight bearing with just a boot, and then
eventually kind of switching into a regular shoe with a heel lift. And this is
alongside physical therapy or functional rehab for both.

Host: Well, when you're speaking about patient
selection, what would make a patient decide no or yes, in this shared decision
making that you're doing with patients. Tell us a little bit about selection.

Lorraine Boakye, MD: Absolutely. I think that's a
really big part of specifically this treatment paradigm for rupture in that, if
we are able to say that all things being equal, the two treatment protocols are
about the same, then folks that either can't undergo surgery due to kind of
life restrictions or plans, and those sorts of logistic barriers or actual
health concerns, whether it's cardiac or pulmonary issues, or even things that
are sort of chronic, not active medical problems, but may cause someone to have
a higher risk for wound healing issues or infection, such as diabetes or
vascular disease, or patients that are long-term smokers. That's, a case where
we start to think about what the risks of actual operative management are and
how those may be impacted by their overall disease state.

Host: Dr. Boakye, please speak to other providers,
coaches, trainers, people out there that would refer to you, why are they
sending patients to an orthopedic foot and ankle surgeon for this condition?
And when do you feel that it's important that they refer?

Lorraine Boakye, MD: I think in terms of rupture,
it's most commonly handled by foot and ankle orthopedic surgeons. And as you
know, these are folks that have done four years of med school, five years of
residency, and an additional year of subspecialty training. And so by volume we
see a lot of this and we're able to kind of contextualize the treatment
paradigms, both within the context of the comorbidities as a patient, but then
also the relative biomechanics of their specific lower extremity.

 In the cases of
tendinopathy, I think it sort of depends on how comfortable people are with
managing sort of the initial steps of care. And typically it's physical
therapy, alteration to shoeware, potentially even bracing, and really a sort of
panoply of non-operative modalities and because the Achilles tendon is a more
common pathology; it may be sort of within other folks' wheelhouse, but we're
happy to be involved on the sooner end so that we can sort of sway how care
progresses, and kind of figure out when, and if someone does need to go onto
surgery for a tendinopathy.

And as far as rupture, in terms of referral, we've seen that
folks may feel like they want to have a full diagnostic picture before they
send them over to us. But that may actually cause a delay, you know, if they're
getting ancillary testing that takes a bit to schedule or it to result. And so
if there's really any concern in terms of the clinical presentation, or even
the history that a patient has; we're happy to have those patients come to our
office sooner than later so that we can examine them, and make sure they get
care as soon as safely possible.

Host: What's exciting in your field, Dr. Boakye, in
this field specifically, but anything in orthopedic surgery. What really
excites you on the horizon?

Lorraine Boakye, MD: I think really in orthopedic
surgery we've come a long way in terms of really getting our research to be on
the same level as other subspecialties in so far as using randomized control
trials and kind of pushing the envelope with the level of evidence that we're
able to bring to the table, and have these findings actually change healthcare
and change the way that we practice. So a lot of the work that we're doing here
at Penn, in conjunction with the McKay lab are basic science colleagues and
PhDs in the orthopedic surgery department here; we're really looking to
optimize essentially every avenue of care, specifically for the Achilles.

 That's kind of our
big interest figuring out, you know, when is the soonest that we can get people
safely back in walking and returning to sport, like after an rupture repair
surgery. So working to figure out how much a tendon is actually being loaded
and using machine learning algorithms to figure out how much data we need to
get from these very cool new sensors where we can attach them to a boot and
have someone walk around and get a sense of their specific loading profile,
their walking speed, other biomechanics that are helpful in sort of giving
objective data, about how they're healing.

So the more that we're able to glean, how a patient is
doing, whether it's objective data from these new sort of gizmos that we were
able to optimize to help us better understand patients or even implementing
patient reported outcomes, which are a bunch of surveys that patients are able
to sort of self-reflect on their disease state and tell us sort of how they're
feeling, in the context of their everyday life is honestly really helpful in
terms of really driving evidence-based medicine, and sort of being on par with
other subspecialties that way.

Host: Well, return to play is certainly a topic in
its own, and I want to hear more about those cool sensors. So you'll have to
come and join us again and tell us about some of those exciting technology in
your field. As we wrap up, I'd like you to speak to other providers. Tell them
what you would like the key takeaways to be. Anything you'd like to mention as
far as Achilles tendinopathy and or rupture and why it's so important to refer
to the specialists at Penn Medicine.

Lorraine Boakye, MD: This is an area of specific
interest for us at Penn Medicine in the foot and ankle division. And so we're
sort of on the forefront, of all of the new literature and surgical advances
and all of the new devices that we can use to really optimize care. So if
there's anything I'd take away from this, it's that, you know, if there's any
suspicion of an Achilles rupture, I would tell them no weight bearing. Give
them some crutches or a walker or an knee scooter or whatever, gets them safely
around, and send them our way. And in terms of tendinopathy, that is a longer
process, but certainly we want to mitigate any potential risk factors for
eventual rupture. These are more attritional. So in that case, you know, if
it's been some time and a patient is still having symptoms, we're certainly
happy to see them so that we can try to optimize them with whatever we have in
our arsenal.

Host: Thank you so much Dr. Boakye for joining us and
sharing your incredible expertise in this area. To refer your patient to Dr.
Boakye at Penn Medicine, please call our 24/7 provider only line at
877-937-PENN, or you can submit your referral via our secure online referral
form by visiting our website at pennmedicine.org/referyourpatient. That
concludes this episode from the Specialists at Penn Medicine. Please always
remember to subscribe, rate, and review this podcast and all the other Penn
Medicine podcasts. I'm Melanie Cole. Thanks so much for joining us today.