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 login to view 1 more bullet 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 login to view 12 more bullets operative retrocalcaneal bursa excision, debridement of diseased tendon, calcaneal bony prominence resection login to view 4 more bullets tendon augmentation or transfer (FDL, FHL, or PB) vs. suture anchor repair login to view 4 more bullets 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 login to view 9 more bullets operative retrocalcaneal bursa excision, Achilles debridement and resection of Haglund deformity login to view 4 more bullets 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 login to view 8 more bullets glyceryl trinitrate patches, prolotherapy, and aprotinin injections login to view 2 more bullets operative percutaneous tenotomies login to view 6 more bullets open excision of degenerative tendon with tubularization login to view 4 more bullets tendon transfer (FHL, FDL, or PB) login to view 5 more bullets