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Achilles Tendinitis / Tendinosis

The indication for an Achilles tendon debridement is  painful Achilles tendinosis which has failed to respond to conservative managements.

These conservative managements including tried and tested physiotherapy regimens, orthotic off loading and injection therapies can be expected to work in 70% of patients , irrespective of the extent (and often nature) of the Achilles involvement. Shockwave therapy also may have a role in conservative management though its effectiveness is lower.

A debridement can be expected to work in 90% of patients with a return to limited weight-bearing possible in most after 2 weeks if using a post-operative boot.

Full weight bearing is usually possible after 5 weeks and after a period of functional rehabilitation a return to full activity is the norm.

Author: Mark Herron FRCS

Institution: The Wellington Hospital , London

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(see also: Achilles Tendon Rupture)LEG24A

Discussion

  • while there are many causes of posterior ankle pain, there are two distinct conditions which may affect the Achilles tendon:
    • tendinitis and tendinosis, each having a distinct prognosis;

Tendinitis / Tendinosis

  • peritendinous inflammation which does not generally progress to degenerative tendinosis (nor rupture);
  • in other situations, there will be clinical inflammation, but objective pathologic evidence for cellular inflammation is lacking, and
    • in these conditions the term tendinosis is more appropriate;
    • degenerative process which can occur w/o signs of inflammation (mucoid degeneration);
    • teninosis may be related to region of diminished blood supply just above the tendon insertion;
    • often the tendinosis remains subclinical until it presents as a rupture;
  • often results from training errors in adults in their 30s and 40s;
  • most commonly affects runners;
  • heel cord contracture will exacerbate the patient's symptoms;
  • on exam, patients generally have no strength deficit and do not have tenderness to deep palpation;
  • two forms of the condition are recognized (insertional and non-insertional);

non-insertional

insertional tendinitis

There are three main varities of pathology effecting the area of the achilles tendon insertion and to which the description of a Haglunds’ deformity is commonly(and loosely) applied.

Most often the pathology is one of degenerative change at achilles the insertion associated intra-tendinous calcification. There may or may not be an element of anatomical prominence of the postero-lateral calcaneus associated. This tends to produce a fairly broad based swelling across the back of the heel. Usually the painful area is located laterally but it can on occasion be postero-medial.

Less commonly the achilles tendon is normal and the issue is an anatomical prominence of the postero-lateral corner of the calcaneus, causing pressure when in shoe-wear.

The third variation is a calcaneus that is anatomically  prominent posteriorly, laterally and also  superiorly. This can cause direct impingement upon the deep(anterior) aspect of the Achilles in the retro-calcaneal area.

These cases should be imaged using cross sectional imaging to determine  the location of both bony deformity and tendinopathy. This will assist in deciding upon the surgical approach to be taken. This will also on occasion show evidence of associated retro-calcaneal bursitis which should be intercurrently treated.

These variations in pathology can be treated using the same surgical principles and with successful outcome expected in the majority of patients. The key is to identify the exact location and nature of the pathology causing symptoms. Non-operative treatment is somewhat less successful when adopted here than for problems with the main body of the achilles tendon.

In my practice I use the Speedbridge for cases of insertional achilles tendinosis where there is significant intra-tendinous calcification that will require extensive detachment of the tendon for adequate access. The Speedbridge provides a far more robust level of fixation for the achilles than any alternatives. One can be as extensive as required therefore with the level of dissection. The technique is though without doubt more involved than simply using a postero-lateral or postero-medial approach and fixing the tendon back with a Bio-corkscrew anchor, which covered on OrthOracle at Haglunds deformity: Arthrex Bio-corkscrew fixation and a postero-lateral approach.Generally the surgery is easier performed with the patient prone but as this technique demonstrates it cab be done with the patient well supported in a lateral position.

The Arthrex SpeedBridge implant itself is very much a really useful part of the surgical armamentarium available to treat Haglunds cases. It should be remembered however that of greater importance is identifying the various potential sources of symptoms and treating them all. Also whatever the operative technique used careful skin handling throughout is required as well as in the post-operative period. The soft tissue cover here is thin and prone to delayed healing.

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Work Up

diff dx

exam

  • deep palpation will elicit tenderness;
  • there may be palpable nodularity in the tender aspect of the tendon;
  • weakness is evidenced by inability to raise up on toes;

radiographs

  • may show calcification within the Achilles tendon, which may indicate a more proximal tendinosis;

MRI

  • may be indicated in cases of tendinosis with suspected multiple partial tears;

Treatment

Achilles Tendon Debridement

FHL Transfer

The Flexor Hallucis Longus transfer for Achilles reconstruction is a straight-forward and effective operation for salvaging various situations which have resulted in a deficient and de-functioned Achilles tendon.

The flexor hallucis longus tendon is easily accessed sitting just anterior to the Achilles tendon and can be safely harvested  as long as care is taken to identify and avoid the posterior tibial neuro-vascular bundle. It has not been my experience in performing this procedure for over 15 years that any more than a single incision is required to access and harvest adequate length of the FHL for reconstruction. If the tendon is slightly too short for a bone anchor it can be woven into the native Achilles insertion and sutured.

The Arthrex Biotenodesis screw is a useful implant to anchor the harvested tendon into the calcaneus, though the tendon can be woven into the native Achilles insertion also. The key is appropriate tensioning of the transfer.

Despite the slightly more involved nature of surgery compared to primary Achilles repair  the period of immobilisation and recovery and outcome are little different.

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This overview is brought to you by Orthoracle - the online e-learning Orthopeadic Surgery Atlas

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References