Achilles Tendonitis

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

 

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

- 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

 

Achilles Insertional Tendonitis XrayTendoachilles insertional calcification

 

Pavlov 

- 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

 

MRI

 

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 

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

 

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