Definition
Inflammation of achilles tendon; insertional or noninsertional
Spectrum
Tendonitis / Tendonosis / Rupture
Anatomy
Triceps surae
- medial and lateral gastrocnemius
- soleus
- surrounded by paratenon which allows gliding and supplies nutrition
Inserts middle 1/3 calcaneal tuberosity
- 2 x 2 cm area
- 90o rotation distally
Retrocalcaneal bursa (x2)
- proper is between tendon and calcaneum
- superficial is between tendon and skin
Aetiology
1. Non-insertional form
Younger / fitter / more active patients
- overuse and over training
Occurs in area of hypo-vascularity & fibre rotation
- 3-5 cm from insertion
- due to repetitive loading associated with jumping
- Angiofibrotic Dysplasia
Risk Factors
A. Pronated foot
- mid-foot pronation is coupled with IR force on tibia
- opposite to the normal ER in knee extension
- forces are concentrated at the hypovascular area of TA producing high tensile stresses
B. Heel cord tightness
C. Changes in activity level
2. Insertional form
Occurs at site of insertion
- more common in the overweight / middle aged / comorbidities
- have combination of tendonitis / retrocalcaneal bursitis / spur
- also occurs in athletes 30s - 40s
Risk factors
A. Poor women's shoe-wear
B. Bony protuberance of Os Calcis
- Haglund's Deformity / Pump bump
- Patrick Haglund, 1928, Swedish orthopaedic surgeon
- prominence of posterosuperior & lateral calcaneus
- causes impingement & mechanical abrasion of T achilles at insertion
C. Retrocalcaneal Bursitis
- retrocalcaneal bursa lies between tendon & posterior surface of calcaneum
- normal lubricating structure
- may become inflamed
DDx insertional
- seronegative enteropathy
- gout
- corticosteroids
- oral fluoroquinolones
- hyperlipidaemia
- DISH
Pathology
Peritendinitis
- inflammation limited to paratenon
Tendinosis
- tendon thickened
- focal areas of degeneration
- increased type 3 collagen
- may be partial tear
Clinical Features
Non Insertional
Presentation
- pain 2-6 cm proximal to insertion
- usually worse in morning & post exercise
- may present with tendon rupture
Findings
- localised tenderness
- tendon may be palpably thickened
- pain with DF and PF
- DF may be limited
Insertional
Presentation
- pain at bone-tendon interface
- worse after exercise
Findings
- localised tenderness & thickening
- bony lump
- DF may be limited
Note:
Some younger patients may present only with pump bump / Haglund's
- no tendonitis
- just problems with foot wear
X-ray
Haglund's Deformity
- may be calcification of bone-tendon interface with spur in insertional tendonitis
- can define with Pavlow lines / Fowler's angle
Pavlov
- lateral weight bearing x-ray
- draw parallel pitch lines
- defines Haglund's deformity to be removed (above second line)
Fowler's angle
Normal < 70°
Abnormal > 80°
MRI
Thickening of the tendon with some intra-substance degeneration
Non-Insertional Management
Non-operative (ELMPOPI)
1) Education
2) Lifestyle modification - Rest
3) Physiotherapy - Alfredson protocol
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2658946/#ref35
- Eccentric exercise program originally devised by Curwi
- Duration extended and scientifically validated by Alfredson
- 90% success rate if adhered to
4) Orthotics - Heel cups ; raises ; medial arch supports
5) Pharmacologics - NSAIDs
6) Injectables - Steroids contraindicated ; alternatives PRP , Autologous blood , sclerosing agents
Limited evidence for any injectable currently
Gross et al FAI 2013
http://www.ncbi.nlm.nih.gov/pubmed/23637232
Operative
Indication
- failure non operative > 12 months
Technique
Para-tenon resected
- tendon debrided
- tears in tendon repaired
Percutaneous vertical tenotomies
- may stimulate revascularisation
> 50% tendon degenerative
- may need augmentation
- FDL / FHL
Results
Rompe Am J Sports Med 2009
- RCT of eccentric v eccentric + ECSW
- improved results with combined treatment
Kearney 2012 Foot Ankle Int
- systematic review
- some evidence for eccentric loading and ECSW
- minimal evidence for surgery / case series only
Insertional
Non-operative
As for non-insertional
Operative
Arthrex open technique video
Arthrex - Achilles SpeedBridge™ System
Indication
- if fails to settle in one year
- high risk
- these patients have poor tendon and skin
Open / Arthroscopic Technique
Supine positioning
Sandbags & rolled towel under knee on operative side
Tilt bed away from operative side (increases ER)
Lateral approach
- preserve sural nerve (blunt dissection superficially)
- open plane between lateral achilles tendon & deep fascia
- usually need release portion of achilles tendon
Retrocalcaneal bursa excised
Osteotome resection Haglund's if present
Resection of bone spur if present
Tendon debrided
- remove inflammed paratenon
- vertical tenotomies
- reattach tendon with anchors
- if tendon severely compromised, transfer required