Achilles Tendinitis / Tendinosis

 

(see also: Achilles Tendon Rupture)

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

• occurs proximal to retrocalcaneal bursa;
• generally responds well to non-operative treatment:
  • heel cord stretching (mild cases)
  • short period of immobilization followed by gradual mobilization w/ temporary avoidance of repetitive activities (running)
  • steroids:
    • injections of steroids into or around the Achilles tendon may provoke rupture and should generally be avoided;
    • there is plenty of anecdotal evidence, however, that steroid injections can offer good relief of tendinitis symptoms, and if injections are used, the patient must agree to avoid strenous activity for several weeks;
  • eccentric strengthening:
    • Nonoperative treatment of midportion Achilles tendinopathy: a systematic review
    • New regimen for eccentric calf-muscle training in patients with chronic insertional Achilles tendinopathy: results of a pilot study.
    • Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis.
    • Eccentric overload training in patients with chronic Achilles tendinopathy: a systematic review
    • Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial.
    • Chronic Achilles tendinopathy treated with eccentric stretching program.

insertional tendinitis

• tenderness is localized to calcaneal tendon insertion;
• pain is related to contact between posterior calcaneus and Achilles tendon;
• Haglund's deformity may be related to this condition;
• calcification of tendon insertion:
  • localized calcification within the Achilles tendon can be a cause of insertional tendinitis;
  • if excision of the calcified mass is being considered, an MRI should be obtained to ensure that there is not a more proximal degenerative tendinosis (which would not be expected to improve from excision of calcified mass);
  • alternatively, consider an ultrasound examination by an experienced radiologist can help determine the severity of the tendinitis;
• references:
  • Prediction of the success of nonoperative treatment of insertional achilles tendinosis based on MRI.
  • Calcific Insertional Achilles Tendinopathy: reattachment with bone anchors.
  • Surgical treatment of insertional Achilles tendinosis.

Work Up

diff dx

• consider systemic conditions such as gout, spondyloarthropathies (Reiter's syndrome), etc;

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

• Yodlowski, et al: evaluated 35 (41 feet) who had painful Achilles tendon syndrome unrelieved by 6 months of nonop measures that were treated surgically;
  • technique consists of a single incision along the lateral border of the Achilles tendon;
  • dissection exposes the retrocalcaneal bursa and fat pad, which are completely excised along with any scarred and thickened paratenon;
    • debridement must include resection of the prominent tuberosity, complete debridement of the bursa, excision of thickened, scarred paratenon, and removal of accessible calcific deposits within the tendon;
  • at a minimum follow-up of 20 months (average, 39), the patients’ pain scores (rated from 0 to 6) improved from 4.7 (SD, 1.1) preoperatively to 1.5 (SD, 1.3);
  • 90% had complete or significant relief of symptoms, 10% felt improved, and none felt unchanged or worse.
  • recovery may take up to one year;
• references:
  • Surgical Treatment of Achilles Tendinitis by Decompression of Retrocalcaneal Bursa and Superior Calcaneal Tuberosity
  • Insertional Achilles tendinitis: Surgical treatment through a central tendon splitting approach.
  • Comparison of retrocalcaneal decompression for retrocalcaneal bursitis and insertional Achilles tendinosis with calcific spur.
  • Chronic Achilles tendinopathy. A survey of surgical and histopathologic findings.
  • Etiology, histopathology, and outcome of surgery in achillodynia.
  • Surgical management of Achilles tendinitis.
  • Long-term results of surgical management of Achilles tendinitis in runners.

FHL Transfer

• FHL transfer/augmentation is a reasonable option for treatment of chronic Achilles tendinosis and rupture;
• in the report by Wilcox et al, 20 patients (mean age 61) underwent FHL transfer for treatment of chronic Achilles tendinopathy at a mean of 14 months following surgery;
  • despite a small loss of calf circumference, range of motion, and plantarflexion strength, 90% of patients scored 70 or higher on AOFAS scale
• references:
  • Treatment of chronic noninsertional Achilles tendinopathy with endoscopic Achilles tendon debridement and flexor hallucis longus transfer.
  • Treatment of chronic achilles tendon disorders with flexor hallucis longus tendon transfer/augmentation.
  • Flexor hallucis longus transfer for chronic Achilles tendonosis.
  • Flexor Hallucis Longus Tendon Transfer in Treatment of Achilles Tendinosis

References

• The soy isoflavone genistein inhibits the reduction in Achilles tendon collagen content induced by ovariectomy in rats.
• Achilles tendinitis in ballet dancers.
• Achilles paratendonitis: an evaluation of steroid injection.
• Tendon Problems in Athletic Individuals.
• Achilles tenditis and peritendinitis: etiology and treatment.