Achilles Tendinopathy

Non-insertional Achilles Tendinopathy (NIAT)

Introduction

  • seen as an overuse injury
  • causes pain in the midportion of the Achilles tendon
  • often seen in
    • athletes (classically middle / long-distance runners)
    • workers with heavy mechanical loads
  • 30% are not sports active

 

Causes

  • intrinsic factors:
    • poor blood supply
    • foot deformities
    • genetics
    • high BMI
    • hypertension
  • extrinsic factors
    • new or unaccustomed activities (sudden middle-aged fitness spree!)
    • sports overuse / training errors
    • poor footwear
    • medications incl quinolone antibiotics, steroids
  • Varioius pain theories including:
    • tendon degeneration
    • new blood vessel growth (neo-vascularisation)
    • nerve-related (ingrowth or altered neurotransmitters)
    • inflammation is debatable

 

Examination

  • midportion of the tendon (2-6cm proximal to its insertion)
  • fusiform thickening and tenderness
  • tests include:
    • painful arc
    • tendon loading
      • pain on passive dorsiflexion
      • single heel raise / hopping

 

Imaging

  • ultrasound: can be combined with colour Doppler to detect neovascularisation
  • MRI
  • both produce false positives / negatives; careful clinical correlation is essential

 

Non-operative management of NIAT

 

Exercise rehabilitation

  • mainstay of treatment
  • eccentric strengthening programmes e.g. Alfredson’s regime
  • activity modification (avoid aggravating factors)

 

Anti-inflammatory medication

  • weak evidence (Cochrane review)
    • contributes to controversial theory of inflammatory involvement

 

Extracorporeal shockwave therapy (ESWT)

  • sound waves trigger an inflammatory response in tissues
    • stimulates cells and fibroblasts, essential for collagen synthesis and tissue repair
    • helps reduce pain by altering local nerve endings and reducing the sensitivity of pain receptors
    • limited evidence

 

Injection

  • corticosteroid is controversial
    • superior to placebo but multiple case reports of rupture
  • hyaluronic acid
    • limited evidence
  • high volume injection
    • disrupts neural ingrowth and neo-vascularisation
    • evidence is mixed
  • Platelet rich plasma
    • no good evidence

 

Splints and orthoses

  • generally not recommended as they shorten / stiffen the calf complex

 

Surgical management of NIAT

 

May be recommended after >12 months of conservative measures with no improvement.

Open debridement

  • longitudinal incision, midline or medial
  • tendinopathic tissue (grey-ish, with loss of shiny appearance) is sharply excised
  • tendon repaired side-to-side or left un-sutured

 

Tendon augmentation

  • used in severe tendinopathy or
  • large gap after open debridement
    • turndown flap
    • V-Y advancement
    • tendon transfer, usually FHL
    • hamstring harvest

Complication rates up to 12%: infection, delayed wound healing being the most common

 

Less invasive options:

  • endoscopic debridement
  • multiple percutaneous longitudinal tenotomies
  • minimally invasive stripping

 

 

Insertional Achilles Tendinopathy (IAT)

 

Introduction

  • within 2cm of the Achilles insertion
  • syndrome of pain, swelling and stiffness
  • may be bone spurs and calcification in the tendon and at the insertion site
  • may be bursitis - superficial or retrocalcaneal

 

Causes

  • intrinsic factors:
    • increased age
    • co-morbidities e.g. seronegative spondyloarthropathies
    • medication e.g. corticosteroids
    • anatomy
      • hindfoot malalignment
      • prominent posterior or lateral calcaneal process
  • extrinsic factors:
    • increased loading
    • new or unaccustomed activities
  • Aetiology
    • multifactorial:
      • mechanical load
      • blood supply
      • biomechanical abnormalities
      • bone spur formation
    • histological analysis shows degenerative features, not inflammatory

 

Clinical presentation

  • sharp / burning pain over the posterior heel
  • solid swelling
  • often two distinct groups:
    • younger, active patients – sport or work-related
    • older, more sedentary patients – chronic
  • association with hyper-pronation and pes cavus
  • assess:
    • calf strength with a single heel rise
    • tenderness at the Achilles insertion
    • calf / gastrocnemius tightness

 

Imaging

  • Radiographs: standing lateral
    • enlargement of the postero-superior calcaneal process (Haglund’s deformity)
    • intra-tendinous spurs or calcifications
    • obliteration of Kager’s triangle may be seen in retrocalcaneal bursitis
  • MRI: gold standard
    • analysis of other pain generators:
      • tendon, bone, bursa, fat pad
  • USS is a useful adjunct and can be used to guide therapeutic injections

 

Non-operative management of IAT

 

  • activity modification
  • eccentric strengthening
    • patient satisfaction is lower than for NIAT
  • ESWT – poor evidence
  • orthoses:
    • heel lifts or shoe modifications
      • aim to limit dorsiflexion; reduces impingement of anterior tendon on enlarged calcaneal process and bursa
      • can lead to shortening of calf complex in longer term
  • NSAIDs to reduce bursitis / inflammatory component
  • Injections – no convincing benefit

 

 

Surgical management of IAT

 

Open debridement

  • posterior longitudinal approach (central / medial / lateral)
  • approach through, or to the side of, the tendon
  • debride diseased or calcified tendon at its insertion
  • remove inflamed retrocalcaneal bursal tissue
  • decompress Haglund’s and other bony prominence
  • reattach or augment the Achilles tendon

 

Endoscopic

  • debridement of the retrocalcaneal bursa
  • calcaneoplasty

 

Zadek Osteotomy (1939)

  • dorsal closing wedge osteotomy of the calcaneus
    • reduces the calcaneal pitch
    • advances the posterosuperior corner to reduce pressure on the anterior aspect of the Achilles tendon
    • can be performed using open or minimally invasive techniques

 

References

 

  • Rompe JD, Furia J, Maffulli N. Eccentric loading compared with shock wave treatment for chronic insertional achilles tendinopathy. A randomized, controlled trial. J Bone Joint Surg Am. 2008 Jan;90(1):52-61. doi: 10.2106/JBJS.F.01494. PMID: 18171957
  • Krogh TP, Ellingsen T, Christensen R, Jensen P, Fredberg U. Ultrasound-Guided Injection Therapy of Achilles Tendinopathy With Platelet-Rich Plasma or Saline: A Randomized, Blinded, Placebo-Controlled Trial. Am J Sports Med. 2016 Aug;44(8):1990-7. doi: 10.1177/0363546516647958. Epub 2016 Jun 2. PMID: 27257167
  • Boesen AP, Hansen R, Boesen MI, Malliaras P, Langberg H. Effect of High-Volume Injection, Platelet-Rich Plasma, and Sham Treatment in Chronic Midportion Achilles Tendinopathy: A Randomized Double-Blinded Prospective Study. Am J Sports Med. 2017 Jul;45(9):2034-2043. doi: 10.1177/0363546517702862. Epub 2017 May 22. PMID: 28530451
  • Wilson et al 2018 Exercise, orthoses and splinting for treating Achilles tendinopathy: a systematic review with meta-analysis. Br J Sports Med. 2018 Dec;52(24):1564-1574
  • Lohrer H, David S, Nauck T. Surgical treatment for achilles tendinopathy - a systematic review. BMC Musculoskelet Disord. 2016 May 10;17:207. doi: 10.1186/s12891-016-1061-4. PMID: 27165287
  • Mansur NSB, Matsunaga FT, Carrazzone OL, Schiefer Dos Santos B, Nunes CG, Aoyama BT, Dias Dos Santos PR, Faloppa F, Tamaoki MJS. Shockwave Therapy Plus Eccentric Exercises Versus Isolated Eccentric Exercises for Achilles Insertional Tendinopathy: A Double-Blinded Randomized Clinical Trial. J Bone Joint Surg Am. 2021 Jul 21;103(14):1295-1302. doi: 10.2106/JBJS.20.01826. PMID: 34029235
  • Zadek I. An operation for the cure of Achillobursitis. Am J Surg 1939; 43: 542-6
  • Tourné Y, Francony F, Barthélémy R, Karhao T, Moroney P. The Zadek calcaneal osteotomy in Haglund's syndrome of the heel: Its effects on the dorsiflexion of the ankle and correlations to clinical and functional scores. Foot Ankle Surg. 2022 Aug;28(6):789-794. doi: 10.1016/j.fas.2021.11.001. Epub 2021 Nov 10. PMID: 34794868
  • Poutoglidou F, Drummond I, Patel A, Malagelada F, Jeyaseelan L, Parker L. Clinical outcomes and complications of the Zadek calcaneal osteotomy in Insertional Achilles Tendinopathy: A systematic review and meta-analysis. Foot Ankle Surg. 2023 Jun;29(4):298-305. doi: 10.1016/j.fas.2023.04.007. Epub 2023 Apr 18. PMID: 37088671Rasmussen et al 2005