Fig. 33.1
Lateral radiograph demonstrating cavus foot and prominent Haglund’s lesion on posterior calcaneal tuberosity
Fig. 33.2
Radiograph demonstrating calcaneal enthesophyte with intrasubstance calcifications
Fig. 33.3
Axial radiograph of the heel demonstrating calcaneal enthesophytes
Magnetic resonance imaging (MRI) can provide useful information regarding the Achilles tendon in both acute and chronic settings. MRI can show thickening of the Achilles tendon substance as well as intrasubstance degenerative changes (Figs. 33.4 and 33.5). MRI can also show pathology at the Achilles insertion including tendon thickening, retrocalcaneal bursitis, and the impact of Haglund’s deformity (Fig. 33.6). One study evaluated 118 painful Achilles tendons and found that 15% had intrasubstance abnormalities within 2 cm of the insertion, 19% had an enlarged retrocalcaneal bursa, and 8% had increased signal in the calcaneus (Karjalainen et al. 2000). Nicholson et al. used MRI scans to classify the degree of tendon degeneration in 157 patients with insertional Achilles tendinopathy and were able to predict the success of nonoperative treatment based on these findings (Nicholson et al. 2007). They determined that tendons with confluent areas of intrasubstance signal abnormalities are unlikely to respond to nonoperative treatment.
Fig. 33.4
T2-weighted axial MRI scan image demonstrating increased signal in tendon substance representing degenerative tendinosis
Fig. 33.5
T2-weighted sagittal MRI scan image demonstrating thickening of the midsubstance Achilles tendon with increased signal consistent with tendinosis
Fig. 33.6
T2-weighted sagittal MRI scan image demonstrating Haglund’s lesion with surrounding edema and thickening of the Achilles tendon above the insertion
The role of diagnostic ultrasound has increased in recent years as a less-expensive alternative to MRI scan, allowing dynamic examination of the tendon. Astrom et al. compared ultrasound images with MRI images and surgical pathologic findings in 27 patients with chronic Achilles tendinopathy. They concluded both ultrasound and MRI provide similar useful information and both may be utilized as a prognostic instrument (Astrom et al. 1996). Bakkegaard et al. (2015) prospectively evaluated 92 patients with Achilles tendon complaints and found that ultrasound findings of tendon thickness, hypoechogenicity, and increased flow at any time point were significantly correlated to pain with activity, palpatory pain, and morning pain (Bakkegaard et al. 2015).
33.7 Conservative Treatment
Conservative treatment is commonly the first strategy in management for Achilles tendinopathy. In general, 3–6 months of conservative care is instituted before alternative options are implemented and at least 6 months before surgical option is considered. The outcome of surgical treatment after failed conservative management can be unpredictable and generally involves extensive postoperative rehabilitation before return to full activities. (Alfredson 2011; Bohu et al. 2009). Due to the invasiveness and potential pitfalls of surgical interventions, great effort has been undertaken to identify effective conservative treatment modalities in order to avoid surgery, yet achieve optimal clinical outcomes. To date, there is no single modality that has been consistently effective at eradicating symptomatic Achilles tendinopathies, but there are a number of tools that have been shown to be effective in certain patients.
Maffulli’s group (Rowe et al. 2012) recently published a systematic review of conservative treatments for non-insertional Achilles tendinopathy, combining graded evidence with qualitative analysis of clinical reasoning. A brief summary of their findings is found below. They also identified important areas requiring future research, including the effectiveness of orthoses, effectiveness of manual therapy, etiological factors, optimal application of loading related to stage of presentation, and optimizing protocols for different types of patients (e.g., the older patient with the metabolic syndrome versus the athletically active).
33.7.1 Eccentric Exercises
Eccentric loading exercises have the strongest supporting evidence of all the conservative treatment modalities in the literature. A high degree of success has been shown in both sedentary and athletic patients with eccentric exercises. However, clinical outcomes vary widely and superior clinical outcomes have been reported for non-insertional tendinopathy, compared with insertional tendinopathy. Most studies use an eccentric training protocol similar to that described by Alfredson et al. (1998). In Rowe et al.’s investigation, physiotherapists commonly used eccentric training and reported using complex clinical reasoning to adapt research protocols for individual patients. As an example, eccentric loading protocols were varied for patients where pain prevented adherence to published protocols by utilizing mixed concentric/eccentric or isometric loading initially (Rowe et al. 2012).
33.7.2 Extracorporeal Shockwave Therapy (ESWT)
ESWT is one the few conservative modalities with a strong support in clinical evidence (Rowe et al. 2012). Low-energy ESWT has the most available evidence and is much less expensive than high energy. One investigation of low-energy ESWT found that VISA-A and pain scores improved at 4 months when ESWT was combined with eccentric exercise training compared with eccentric exercises alone (Rompe et al. 2009). However, at 12 months’ follow-up, there was no difference in outcome between the groups. The authors suggested that ESWT might be a useful addition to eccentric exercise for athletic patients desiring a more rapid return to sport.
33.7.3 Continued Tendon Loading or Physical Activity
One excellent quality is that RCT showed no detrimental effect of continued tendon-loading activity (i.e., sporting activity), as long as pain was monitored and a threshold of 5/10 on a VAS was not exceeded (Silbernagel et al. 2007). There are no significant differences in symptomatic outcome between continued tendon loading and active rest groups at a 5 year follow-up (Silbernagel et al. 2011). However, physiotherapists frequently recommend a reduction in the level and frequency of tendon-loading activities (i.e., relative rest), citing anecdotal evidence that this improves treatment outcomes (Rowe et al. 2012).
33.8 Surgical Procedures
33.8.1 Non-insertional Achilles Tendinopathy
As discussed above, at least 6 months of conservative treatments should be tried before surgical intervention. The goal of surgery is to remove degenerative tissue and stimulate tendon healing. In cases of insufficient tendon substance, augmentation with autologous or allogeneic grafts can be implemented as well. Conventional surgical treatment consists of open removal of degenerative tissues, repair of healthy remaining tissues, and release of adhesions with or without resection of the paratenon. If greater than 50% of the tendon is unhealthy and requires debridement, augmentation or reconstruction is recommended to ensure sufficient substance to optimize function and minimize risk of rupture. Other surgical treatments include percutaneous longitudinal tenotomies, gastrocnemius lengthening, endoscopic tendon stripping and tenolysis, open tenosynovectomies, open debridement and tubularization, and tendon augmentation with flexor hallucis longus (FHL) (Fig. 33.7). Further study of most of these treatments is necessary before clear recommendations can be made in terms of their utility.
Fig. 33.7
Clinical photograph of transferred FHL tendon adjacent to the Achilles tendon
Complications are not uncommon following surgical treatment procedure. In a large series of 432 consecutive patients, Paavola et al. reported an overall complication rate of 11% of cases. These included wound necrosis in 3%, superficial infection in 2.5%, and sural nerve injury in 1%, with other complications including hematoma, seroma, and deep vein thrombosis (Paavola et al. 2000).
Clinical outcomes following surgical treatment for non-insertion Achilles tendinopathy are good in general. Khan et al. performed a systematic review of 62 high-quality studies, finding that the overall success rate for surgery is 83.5%. They also noted that the quality of study methodology (as measured by the Coleman methodology score) improved over time, correlating with a decrease in success rates (Khan et al. 2015). This most likely represents an improvement in the study quality, rather than worsening of outcomes.
33.8.2 Insertional Achilles Tendinopathy
Patients who do not respond to conservative treatment for non-insertional Achilles tendinopathy may also need operative management. There is currently no consensus regarding the duration before surgery, although as in non-insertional disease, most clinicians consider 4–6 months as the minimum time necessary to evaluate the effect of conservative treatment (Kearney and Costa 2010). The surgical strategy for insertional Achilles tendinopathy is removal of all degenerative tissues contributing to pain and dysfunction. Typically this includes one or more of the following structures:
- 1.
Excision of degenerative tendon at or above the insertion on the calcaneus, including intratendinous calcifications
- 2.
Excision of the inflamed retrocalcaneal bursa
- 3.
Resection of the prominent posterior calcaneal prominence (i.e., Haglund’s deformity)
