summary Achilles Tendonitis consists of a series of 3 conditions affecting the achilles tendon which include: insertional Achilles tendonitis, retrocalcaneal bursitis & Haglund deformity, and Achilles tendonitis. Diagnosis can be made with radiographs showing spurs and intratendinous calcification and in the case of Haglund deformity, an enlargement of the posterosuperior tuberosity of the calcaneus. Treatment is a trial of nonoperative management of NSAIDs, activity modification, shoe wear modifications, and physical therapy. Surgical management is indicated in patients with progressive symptoms who fail conservative management. Insertional Achilles tendonitis Pain and tendon thickening at insertion of Achilles tendon Epidemiology demographics occurs in middle-aged and elderly patients with a tight heel cord Mechanism repetitive trauma leads to inflammation followed by cartilagenous then bony metaplasia Presentation symptoms posterior heel pain, swelling, burning, and stiffness shoe wear pain due to direct pressure progressive bony enlargement of calcaneus at insertion site physical exam inspection midline tenderness at insertion site of Achilles tendon Imaging radiographs lateral foot shows bone spur and intratendinous calcification MRI and ultrasound can demonstrate amount of degeneration Studies histology disorganized collagen with mucoid degeneration, although few inflammatory cells Treatment nonoperative activity modification, shoe wear modification, therapy indications first line of treatment techniques therapy physical therapy with eccentric training gastrocnemius-soleus stretching shoe wear heel sleeves and pads (mainstay of nonoperative treatment) small heel lift locked ankle AFO for 6-9 months (if other nonoperative modalities fail) injections avoid steroid injections due to risk of Achilles tendon rupture operative retrocalcaneal bursa excision, debridement of diseased tendon, calcaneal bony prominence resection indications failure of nonoperative management and < 50% of Achilles needs to be removed technique midline, lateral, or medial J-shaped incisions tendon augmentation or transfer (FDL, FHL, or PB) vs. suture anchor repair indications when > 50% of Achilles tendon insertion must be removed during thorough debridement heavier patients with more severe disease FHL transfer has been associated with increased ankle plantar flexion Retrocalcaneal bursitis & Haglund deformity Definitions Retrocalcaneal bursitis is inflammation of the bursa between the anterior aspect of the Achilles and posterior aspect of the calcaneus Haglund deformity an enlargement of the posterosuperior tuberosity of the calcaneus Epidemiology demographics more common in young patients Physical exam pain localized to anterior and 2 to 3 cm proximal to the Achilles tendon insertion fullness and tenderness medial and lateral to tendon pain with dorsiflexion bony prominence at Achilles insertion Imaging radiographs lateral of foot demonstrates Haglund deformity MRI rarely needed Treatment nonoperative activity modification, shoe wear modification, therapy, NSAIDs indications first line of treatment techniques therapy ice shoewear external padding of Achilles tendon injections avoid steroid injections due to risk of Achilles tendon rupture operative retrocalcaneal bursa excision, Achilles debridement and resection of Haglund deformity indications disease refractory to nonoperative management technique midline, lateral, or medial J-shaped incisions Achilles Tendonopathy Mechanism overuse imbalance of dorsiflexors and plantar flexors poor tendon blood supply genetic predisposition fluoroquinolone antibiotics inflammatory arthropathy Pathophysiology theorized to be due to abnormal vascularity 2 to 6 cm proximal to Achilles insertion in response to repetitive microscopic tearing of the tendon Classification Achilles tendinosis tendon thickening thought to be caused by anaerobic degeneration in portion of tendon with poor blood supply Achilles peritendonitis involves inflammation of tendon sheath inflammation of paratenon Presentation symptoms pain, swelling, warmth worse symptoms with activity difficulty running physical exam tendon thickening and tenderness 2 to 6 cm proximal to Achilles insertion pain throughout entire range of motion Imaging MRI disorganized tissue will show up as intrasubstance intermediate signal intensity thickened tendon chronic rupture will show a hypoechoic region between tendon ends Treatment nonoperative activity modification, shoe wear modification, therapy, NSAIDs, PRP injections indications first line of treatment techniques therapy heel lifts cast or removable boot (severe disease) outcomes nonoperative management is 65% to 90% successful glyceryl trinitrate patches, prolotherapy, and aprotinin injections indications evolving indications due to lack of evidence at this time operative percutaneous tenotomies indications mild to moderate disease techniques longitudinal tenotomy made in the degenerative area strip the anterior Achilles tendon with a large suture to free any adhesions open excision of degenerative tendon with tubularization indications moderate to severe disease outcomes 70% to 100% successful tendon transfer (FHL, FDL, or PB) indications degeneration of >50% of the Achilles tendon >55 years of age MRI evidence of diffuse tendon thickening without a focal area of disease subacute rupture in the setting of prior achilles tendinopathy