Achilles Tendinopathy

Epidemiology

  • Usually middle-aged individuals involved in sports

Aetiology

  • Non-Insertional (2-6cm from insertion) – most common
  • Insertional (<2cm from insertion) – often associated with Haglund’s deformity
  • Retrocalcaneal Bursitis – may co-exist with insertional tendinopathy
  • Peritendinitis – inflammation of the paratenon only
    • Hard to differentiate from non-insertional clinically

Pathoanatomy

  • An enthesiopathy similar to other areas in the body
  • Fibrocartilaginous metaplasia with collagen fiber disorganization, hypercellularity, and neovascularization
  • Attritional tears and intra-tendinous calcification may be found
  • Non-insertional tendinopathy occurs in a watershed area of blood supply
    • Located 2-6 cm from insertion on the posterior calcaneal tuberosity

Incidence of Rupture

  • No proven evidence that tendinosis is a prelude to rupture
  • However, they can occur together
  • Ruptured tendons in asymptomatic individuals show the same histopathology as tendinosis

Achilles Biomechanics

  • Achilles transfers ~10x body weight during terminal stance and pre-swing (3rd rocker)

Clinical Features

  • Activity-related pain
  • Swelling can be very prominent
  • Shoe wear can be uncomfortable

Examination

  • Location of swelling and pain is the main differentiator
  • Retrocalcaneal bursitis has swelling that doesn’t move with the tendon
    • Located adjacent to either side of the tendon proximal to insertion
  • Symmonds test to check for tendon continuity

Investigations

X-ray

  • May show Haglund’s deformity associated with insertional tendinopathy
  • Calcaneal cystic changes consistent with insertional tendinopathy

MRI

  • Not usually necessary
  • May show:
    • Longitudinal intratendinous splits
    • Intratendinous calcification and hypovascularity
    • Retrocalcaneal bursal or insertional high signal

Non-Surgical Management

  • Activity modification
  • Heel raise
  • Padding around the heel
  • Eccentric exercise programme – especially for non-insertional tendinopathy
  • Steroid injections
    • Avoid into tendon or paratenon
    • Consider for retrocalcaneal bursitis
  • Platelet injections – unproven but may be tried in non-insertional tendinopathy

Surgical Management

Non-Insertional

  • Debridement of tendon and paratenon
  • Excision of calcifications
  • If >50% debridement required → FHL/plantaris tendon transfer

Insertional

  • Debride tendon
  • Excise Haglund’s deformity if present
  • Re-attach tendon using anchors or drill holes

Dealing with Tendon Deficiency

  • VY plasty
  • Achilles turndown
  • Allograft
  • FHL transfer
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