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Updated: Feb 12 2024

Achilles Tendonitis

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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
      • 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
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