Achilles Tendonopathy



Inflammation of achilles tendon; insertional or noninsertional




Tendonitis / Tendonosis / Rupture




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




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


Pump Bump Clinical Photo


C. Retrocalcaneal Bursitis

- retrocalcaneal bursa lies between tendon & posterior surface of calcaneum

- normal lubricating structure

- may become inflamed


Ankle Retrocalcaneal Bursa


DDx insertional

- seronegative enteropathy

- gout

- corticosteroids

- oral fluoroquinolones

- hyperlipidaemia






- inflammation limited to paratenon



- tendon thickened

- focal areas of degeneration

- increased type 3 collagen

- may be partial tear


Clinical Features


Non Insertional



- pain 2-6 cm proximal to insertion

- usually worse in morning & post exercise

- may present with tendon rupture



- localised tenderness

- tendon may be palpably thickened

- pain with DF and PF

- DF may be limited





- pain at bone-tendon interface

- worse after exercise



- localised tenderness & thickening

- bony lump

- DF may be limited



Some younger patients may present only with pump bump / Haglund's

- no tendonitis

- just problems with foot wear




Haglund's Deformity

- may be calcification of bone-tendon interface with spur in insertional tendonitis

- can define with Pavlow lines / Fowler's angle


Achilles Insertional Tendonitis XrayTendoachilles insertional calcification



- lateral weight bearing x-ray

- draw parallel pitch lines

- defines Haglund's deformity to be removed (above second line)


Achilles Haglund's and Pavlov linesPavlov's Lines


Fowler's angle  


Normal < 70°

Abnormal > 80°


Fowler's Angle




Thickening of the tendon with some intra-substance degeneration


Tendoachilles Noninsertional Tendonitis Sagittal MRITendoachilles Noninsertional Tendonitis Axial MRI


Non-Insertional Management


Non-operative (ELMPOPI) 


1) Education 


2) Lifestyle modification - Rest 


3) Physiotherapy - Alfredson protocol

- 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





- failure non operative > 12 months




Para-tenon resected

- tendon debrided

- tears in tendon repaired


Percutaneous vertical tenotomies

- may stimulate revascularisation


> 50% tendon degenerative

- may need augmentation





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






As for non-insertional




Arthrex open technique video

Arthrex - Achilles SpeedBridge™ System



- 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


Insertional Achilles Tendonitis Surgery