- See:
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:
- in some cases, there will be a 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 30's and 40's;
- 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;
-
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;
- Work Up:
-
diff dx: consider systemic conditions such as
gout,
spondyloarthropathies (
Reiter's syndrome),
ect;
-
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:
- in the report by Marilyn L. Yodlowski, MD, PhD. et al, the authors
evaluated 35 (41 feet) who had
painful Achilles tendon
syndrome unrelieved by 6 months of nonoperative 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 the Retrocalcaneal Bursa
and the Superior
Calcaneal Tuberosity
Marilyn L. Yodlowski, MD, PhD. The American Journal of
Sports Medicine 30:318-321 (2002)
- Insertional Achilles tendinitis: Surgical treatment
through a central tendon splitting approach.
Foot Ankle Int 2002;23:19-25.
- Comparison of results of retrocalcaneal decompression for
retrocalcaneal bursitis and insertional
Achilles tendinosis with calcific spur. Foot Ankle Int 2000;21:638-642.
-
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;