Updated: 11/17/2019

Achilles Tendonitis

Topic
Review Topic
0
0
Questions
9
0
0
Evidence
11
0
0
Cases
1
https://upload.orthobullets.com/topic/7022/images/32a_moved.jpg
https://upload.orthobullets.com/topic/7022/images/32b_moved.jpg
Introduction
  • A family of conditions that include
    • insertional Achilles tendonitis
    • retrocalcaneal bursitis & Haglund deformity
    • Achilles tendonitis
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
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
            • physical therapy with eccentric training   
            • modalities (iontophoresis, phonophoresis, and ultrasound)
          • shoewear
            • 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 
 

Please rate topic.

Average 3.9 of 45 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
Questions (9)
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

You have 100% on this question.
Just skip this one for now.

(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? Review Topic

QID: 4558
1

Plyometric

4%

(147/3850)

2

Isokinetic

5%

(192/3850)

3

Concentric

5%

(198/3850)

4

Eccentric

67%

(2573/3850)

5

Isometric

18%

(704/3850)

L 3

Select Answer to see Preferred Response

SUBMIT RESPONSE 4
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

You have 100% on this question.
Just skip this one for now.

(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? Review Topic

QID: 539
FIGURES:
1

Arizona gauntlet brace

1%

(19/2527)

2

Steroid injection

1%

(25/2527)

3

Achilles tendon debridement

9%

(220/2527)

4

Achilles tendon debridement, calcaneal exostectomy, and possible FHL transfer

89%

(2243/2527)

5

Ankle arthrodesis

0%

(7/2527)

L 1

Select Answer to see Preferred Response

SUBMIT RESPONSE 4
ARTICLES (17)
CASES (1)
Topic COMMENTS (4)
Private Note