Updated: 6/7/2021

Achilles Tendonitis

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Cases
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  • 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
        • lateral foot shows bone spur and intratendinous calcification
      • lateral foot shows bone spur and intratendinous calcification
      • MRI and ultrasound
        • can demonstrate amount of degeneration
    • lateral foot shows bone spur and intratendinous calcification
    • 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 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
          • 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

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(SBQ18FA.39) A 58-year-old active man with worsening heel pain in the setting of chronic ankle pain for the last 2 years after missing a step off a curb. An MRI was obtained and is depicted in Figure A. He elects to undergo surgical intervention. Intraoperatively, a 4 cm gap is observed. Which of the following would lead to the best functional outcome?

QID: 211528
FIGURES:
1

Open primary repair with suture anchors

2%

(32/1556)

2

Debridement and augmentation with a tendon that inserts on plantar aspect of great toe metatarsal head

12%

(186/1556)

3

Debridement and augmentation with a tendon that inserts on plantar aspect of the metatarsal heads of the lesser toes

4%

(57/1556)

4

Debridement and augmentation with a tendon that inserts on plantar aspect of great toe distal phalanx

80%

(1245/1556)

5

Debridement and augmentation with a tendon that inserts on dorsal aspect of distal phalanges of the lesser toes

1%

(21/1556)

L 2 A

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(OBQ16.16) A 65-year-old man complains of left ankle pain for 9 months. A sagittal MRI image of the left ankle is shown in Figure A. He is given a brochure with exercises on them. The exercises are depicted in Figures B through E and instructions given. Which of the following statements is correct?

QID: 8778
FIGURES:
1

The exercises shown in Figures B and C are most likely to relieve pain and return him to his previous activity level

13%

(222/1768)

2

The exercises shown in Figures B and D are most likely to relieve pain and return him to his previous activity level

61%

(1078/1768)

3

The exercises shown in Figures C and E are most likely to relieve pain and return him to his previous activity level

14%

(246/1768)

4

The exercises shown in Figures D and E are most likely to relieve pain and return him to his previous activity level

7%

(126/1768)

5

Surgery is necessary

4%

(77/1768)

L 3 B

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(OBQ12.198) Which of the following exercises is important to incorporate into an Achilles tendinopathy rehabilitation protocol following a period of diminished intensity of activities?

QID: 4558
1

Plyometric

4%

(160/4252)

2

Isokinetic

5%

(208/4252)

3

Concentric

5%

(217/4252)

4

Eccentric

67%

(2859/4252)

5

Isometric

18%

(768/4252)

L 3 B

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(OBQ08.153) A 48-year-old male complains of 5 years of heel pain while running. Initially the pain was relieved with Achilles tendon stretching, orthotics, and open-backed shoe wear. Over the past year these modalities are no longer helpful and he is beginning to have pain with walking. Clinical photograph and radiograph are provided in figures A and B. Which of the following treatment options is the best choice to relieve pain and improve function?

QID: 539
FIGURES:
1

Arizona gauntlet brace

1%

(22/3036)

2

Steroid injection

1%

(32/3036)

3

Achilles tendon debridement

8%

(243/3036)

4

Achilles tendon debridement, calcaneal exostectomy, and possible FHL transfer

89%

(2714/3036)

5

Ankle arthrodesis

0%

(8/3036)

L 1 C

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Evidence (19)
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