ACHILLES TENDON RUPTURE TREATMENT

. Acute
. Nonoperative for acute ruptures
. Cast or brace immobilization (nonweight-bearing, 6–8 weeks)
. Operative for acute ruptures
. Open vs. percutaneous repair (Ma procedure)
. Ma (lower incidence of wound problems)
. Lower rate of rerupture with direct repair
. Chronic
. Nonoperative for chronic ruptures
. AFO or similar bracing (palliative care)
. Operative for chronic ruptures
. Achilles reconstruction using graft (salvage procedure)
. Flexor hallucis longus
. Fascial graft
. Peroneus brevis
. Rehabilitation
. Goals of physical therapy: ROM and strengthening
. 5–6months before return to contact sports
. Role of earlier ROMgaining greater popularity
Prognosis
. Results of conservative or operative repair generally good (greater
strength with repair)
. Results of treatment after chronic rupture not as good as with acute
Repair
. Reconstruction generally does not allow for return to competitive
Sports
. Complications
. Rerupture (greater with conservative treatment)
. Equinus (heel cord tightness)
. Skin slough, infection, painful scar
Caveats and Pearls
. Careful handling of the soft tissue is imperative to avoid wound
complications.

ACHILLES TENDON RUPTURE

History
. Mechanism
. Sudden contraction
. Susceptible tendons are weakened by degenerative disease such as obesity, diabetes, hypertension, and the effects of corticosteroids, all of which lead to vascular compromise.
. Acute rupture: complaints
. Stabbing pain in posterior calf
. Pts often complain that they were “kicked” in calf
. Pain, swelling, decreased or absent push-off
. Chronic rupture: complaints
. Difficulty walking, inability to run, chronic weakness, altered gait, pain and swelling
Physical exam
. Acute
. Palpable defect in posterior calf in area of Achilles tendon, along with ecchymosis and swelling
. Thompson test
. Chronic
. palpable defect of posterior calf
. Weakness in pure plantarflexion of foot
. Classification
. Acute ruptures
. Diagnosis within 0–4 weeks of injury
. Chronic ruptures
. Diagnosis 1–3 months after injury
Studies
. Radiographs
. AP, lateral,mortise views (lateralmost important)
. Radiographs generally normal
. Calcifications, traction spurs – Degenerative changes, degenerative
changes or partial tear (indicative of longstanding disease
of the tendon)
. MRI
. Generally not necessary for diagnosis of acute ruptures
. May be useful in cases of suspected chronic ruptures
. Useful in differential diagnosis
. Partial tendon tear
. Localization of tear
. Gastrocsoleus tear
. Plantaris tear

Differential diagnosis
. Achilles tendinosis
. Partial tear
. Avulsion
. Ankle sprain
. Isolated plantaris tear
. Gastrocsoleusmuscle tear

McChicken®

INGREDIENTS:

vegetable oil (in fryer)
1 egg
1 cup water
2/3 cup all-purpose flour
1/3 cup tempura mix
(or 1/3 cup flour for a total of 1 cup if tempura mix is unavailable)
2 teaspoons salt
1 teaspoon onion powder
1/2 teaspoon Accent®
1/4 teaspoon pepper
1/8 teaspoon garlic powder
4 chicken breast filets
4 sesame seed hamburger buns
1 cup chopped iceberg lettuce

McChicken® sauce:

1/4 cup mayonnaise
1/16 teaspoon onion powder
Stir together well, refrigerate until needed.

Preparing your McChicken® Sandwich

1. Beat the egg and then combine it with 1 cup water in a small, shallow bowl. Stir.

2. Combine the flour, salt, pepper, Accent®, onion powder and garlic powder in a one gallon size zip lock bag.

3. Pound each of the breast filets with a mallet until about 1/4-inch thick. Trim each breast filet until it is round.

4. Coat each filet with the flour mixture by shaking in the zip lock bag.

5. Remove and dredge each filet in the egg mixture, coating well. Then return each filet to the flour/seasoning mixture. Shake to coat. Put filets, bag and all, in the freezer for at least an
hour. Cover and refrigerate remaining egg mixture.

6. After freezing, repeat the "coating" process.

7. Deep fry the chicken filets at 375° for 10-12 minutes or until light brown and crispy.

8. As the chicken is frying, toast the buns using the standard method described in cooking regular hamburgers.

9. On the crown side of the bun, apply 1 tablespoon of mayonnaise mixture, followed by 1/4 cup chopped iceberg lettuce. Then top with the cooked chicken patty, and the heel of the
bun.

10. Wrap tightly in a 12x16 piece of waxed paper, and let stand 6-8 minutes.

11. Microwave on high, individually, for 15 seconds and serve.

McDonald's® McRib™ Sandwich

Ingredients:
1 JTM® Brand "Grillin' Ribs" pork patty
1 6 inch long sandwich bun
2 Tablespoons McDonald's® Barbecue sauce (see recipe under McNuggets®)
1 Tablespoon chopped white onion
3 sour dill pickle slices

Note** J-T-M™ is the only brand of these pressed and formed pork patties that I've seen. They are shaped like a rack of ribs, just like at McDonald's®. I get
them at Wal-Mart®. Look for them in the frozen meat section, near the pre-formed hamburger patties.
Cooking Your McRib®

1. Preheat your griddle to 400°. Cook the pork patty just like a quarter pound beef patty. (consult the package directions for cooking times and other cooking
options)
2. Toast the faces of both halves of the bun, using the bun toasting method described throughout this site.
3. On the toasted crown (top) half, apply the ready mixed barbecue sauce and follow that with the dill pickle slices, spread out evenly.
4. Put the cooked "rib" patty on next, then add the onions, followed by the heel. (bottom)
5. Wrap this masterpiece in a 12x16 sheet of waxed paper, let sit 5 minutes, then microwave on high about 15 seconds, still wrapped.
6. Enjoy a wonderful McRib® Sandwich!

ACHILLES TENDINITIS

history
. Mechanism
. Overuse, muscle imbalance, poor exercise biomechanics
. Initial complaints
. Pain, swelling, decreased activity tolerance
. Chronic complaints
. Pain with activity, difficulty running and jumping
. Swelling
. Common in runners
physical exam
. Acute
. Diffuse swelling, pain with palpation, pain with dorsiflexion
. Lateral pain – Associated with supination
. Medial pain – Associated with pronation
. Chronic
. Pain, decreased dorsiflexion, atrophy
. Longitudinal swelling rather than well localized
. Classification
. Insertional vs. noninsertional
studies
. Radiographs
. AP, lateral,mortise views (lateralmost important)
. Radiographs generally normal
. Calcifications, traction spurs – Degenerative changes, degenerative changes or partial tear
. MRI
. Tendinitis – Peritendinous fluid/edema, no tendinous signal changes
. Differential diagnosis usingMRI
. Tendinosis (intrasubstance signal changes)
. Partial tear
. Retrocalcaneal bursitis
. differential diagnosis
. Achilles tendinosis
. Partial tear
. Haglund’s deformity
. Retrocalcaneal bursitis
treatment
. Nonoperative
. Types of nonoperative treatment
. Immobilization (cast, walking boot)
. Heel lift
. Anti-inflammatory medications
. Achilles stretching
. Physical therapy (including icemassage)
. Steroids contraindicated due to risk of rupture
. Operative
. Debridement if refractory to conservative measures
. Lysis of adhesions
prognosis
. Pure tendinitis without associated tendinosis usually responds well to conservative measures.
. Surgical results for insertional Achilles tendinitis are worse than those for noninsertional Achilles tendinitis.
. Long-termcomplications
. Tendon ruptures after steroids bymouth or injection
. Chronic swelling or pain can result even after debridement.
caveats and pearls
. MRI very useful in distinguishing between tendinosis and tendinitis

CREATING the LOOK

Art direction is a broad concept encompassing many visual elements of film production—set design and Dear Educator, construction, locations, décor, props and costumes. Over the decades, the nature of art direction has changed considerably.The first film sets were devised by pioneer French filmmaker Georges Méliès at the turn of the 20th century.With their painted backdrops, Méliès’ sets resembled traditional theater scenery— immovable and two-dimensional. In 1916, D.W. Griffith’s silent epic Intolerance made cinema history, in part because of its full-scale sets. Unlike his predecessors, set builder Frank Wortman considered Griffith’s moving camera when designing for Intolerance, devising a completely integrated, three-dimensional space. William Cameron Menzies, designer on such classics as Gone with the Wind (1939), is considered the father of modern production design. Menzies’ sweeping cinematic vision and distinctive personal style helped elevate the art director’s position in the Hollywood hierarchy. In the 1950s, as film production became more costly and complex, the scope of art direction expanded. Studios recognized the need for full-blown production designers—artists who would be responsible for the overall look of a film—not just the sets. Production designers collaborate closely with the director and cinematographer to visualize the screenplay.Together they determine how visual components can best be combined to tell the screen story. As award-winning production designer Patrizia von Brandenstein notes,“The most beautiful ballroom on earth means nothing unless it helps the context of the story.” When devising sets or considering locations, production designers must first determine the volume, or overall size and shape of a space. Does the scene call for a large, rectangular space, such as the Xanadu mansion in Citizen Kane (1941), or a claustrophobic enclosed space, such as the submarine in U-571 (2000)? Just like painters, production designers exploit perspective to direct the viewer’s eye toward a particular spot in a set or to create a sense of depth. Scale can be used to evoke feelings about a space.The stairway in Scarlett O’Hara’s Atlanta mansion in Gone with the Wind, for example, is outsized. Its large size suggests Rhett’s excesses and his power over Scarlett. This sense of power becomes especially obvious when Rhett forcefully carries Scarlett up the stairs to the bedroom.Although architectural elements apply most significantly to sets, they can also be used in location filming.The mental institution in One Flew over the Cuckoo’s Nest was a real place, but its chain-link fences and barbed wire were manipulated to emphasize the inmates’ feelings of oppression. Ultimately, what separates production designers from their theater equivalents is the camera. Every set or location must accommodate the camera’s changing three-dimensional view.Whether the camera itself is moving, or the framing is changing, the set should facilitate the movement.A good designer will consider how the set or location will look from various angles and distances, and in different lighting conditions, as demanded by the script. Encourage your students to “see” the architectural components of production design by studying photos or paintings by artists like Vermeer and Giotto and point out examples of the defined architectural terms. Then have them focus on one scene in a selected film and discuss how camera movement and lighting work with the basic set design.