Noninsertional tendinitis

Peritendinitis is inflammation affecting only the paratenon. The Achilles tendon itself is uninvolved. In chronic cases, adhesions may form between the paratenon and tendon, leading to more profound pain and tenderness. Pain is noted most often at the initiation of activity (start-up pain) and improves with continued exercise. Acute pain typically resolves with rest. In chronic cases, however, the pain may persist and significantly impair further athletic participation. On examination, a localized, increased diameter that more commonly affects the medial side is appreciated with palpation of the tendon. Tenderness, and at times crepitus, is noted throughout all ankle range of motion (Fig. 7-2). Radiographs generally are unremarkable.

Figure 7-2 Tenderness with squeezing the Achilles and crepitance with range of motion are hallmarks of peritendinitis. The discomfort related to peritendinitis will be constant in location as the ankle is brought through a range of motion. With Achilles tendinosis the tenderness moves with the thickened tendon during range of motion.

Peritendinitis with tendinosis represents further inflammation with associated intratendinous degeneration. Pain is more marked and constant. The tendon is thickened and infrequently has palpable intrasubstance calcifications (Fig. 7-3). The painful arc sign may help to distinguish between tenderness associated with peritendinitis and that associated with tendinosis. Tenderness related to peritendinitis will be constant in location as the ankle is brought through a range of motion, whereas tenderness associated with tendinosis will change position with ankle motion.¹³

Figure 7-3 (A) Noninsertional Achilles tendinitis with characteristic swelling 2 to 5 cm above dorsal aspect of calcaneus. (B) Magnetic resonance imaging shows thickened Achilles tendon. A Haglund’s deformity also is noted. (C) Technetium bone scan demonstrating increased uptake in the Achilles tendon; the third phase of the scan, indicative of advanced intrasubstance degeneration.

Isolated tendinosis, or noninflammatory atrophic degeneration, is associated with normal aging and typically is accelerated by overuse. Most affected are middle-aged, recreational athletes. With repetitive trauma, microtears develop within the tendon, mostly in the hypovascular zone, leading to further fibrosis and degeneration.¹⁴ These athletes complain of weakness in push-off, with pain localized to the area approximately 2 to 5 cm proximal to calcaneus. Whereas ankle dorsiflexion commonly is limited, tendon elongation may develop with an associated increase in passive ankle dorsiflexion. Pathologic examination reveals fatty degeneration with disorganized collagen. Calcific deposits may be present (unnumbered box 7-2).

Insertional achilles tendinitis

Insertional tendinitis is an inflammatory reaction within the Achilles tendon affecting the enthesis, or tendon insertion onto the calcaneus. This disorder more commonly affects older, heavier, and less active athletes but can be seen in competitive athletes as well.¹² An abnormally enlarged, bony prominence may aggravate this condition. There is a high association with Haglund’s deformity and retrocalcaneal bursitis, but unlike these disorders, insertional tendinitis involves the tendon itself. This most often results from chronic overuse and poor training habits. Improper techniques include inadequate stretching, rapid increase in training, running on harder surfaces, and heel running. Although pain initially follows exercise, particularly uphill running, symptoms may become continuous over time.

Pain, swelling, and warmth are noted specifically at the tendon-bone junction, the enthesis. In athletes, there often is a localized area of pain with a small spur. Ankle range of motion is painful, with dorsiflexion typically limited because of a tight Achilles tendon. External irritation from a shoe’s heel counter plays less of a role in provoking symptoms in athletes with Achilles tendinitis than in retrocalcaneal bursitis and Haglund’s deformity. Radiographs generally reveal calcifications or a bony spur at the most distal aspect of the Achilles insertion (Fig. 7-4, A). Magnetic resonance imaging (MRI) will show degeneration where the tendon attaches to the calcaneus (Fig. 7-4, B).

Haglund’s deformity

Haglund is credited with first describing the presence of a prominent posterolateral superior calcaneal tuberosity in 1927.² This enlarged superolateral tuberosity predisposes the precalcaneal bursa to be compressed between it and any tightly fitting shoe heel counter, possibly leading to skin irritation and inflammation. Because of the association of shoewear, this disorder also has been referred to as a “pump bump” and “winter heel.” Although there is a frequent association with retrocalcaneal bursitis and insertional Achilles tendinitis, Haglund’s deformity generally does not involve the Achilles tendon.

Poorly fitting shoes generally are responsible for the development of symptoms of Haglund’s disorder. Other predisposing risk factors include the presence of a cavus foot and hindfoot varus. In rare cases, childhood apophyseal trauma may be a cause. In the nonathletic population, repetitive injury or trauma may result in bone overgrowth. Most affected are young women who wear fashionable high-heeled shoes. In the athletic population, we have observed this condition more commonly in males who participate in running sports. Long-distance runners are susceptible to this condition, as well as to the other Achilles tendon disorders (see Figs. 7-1 and 7-5).

Figure 7-5 Clinical photograph of Haglund’s deformity.

On examination, the affected heel has a swollen, red, and tender posterior prominence, predominantly on the lateral side of the calcaneus. The Achilles tendon itself is not tender. Numerous radiographic measurements have been used to quantify the size of the posterosuperior prominence. These techniques generally are not used by orthopaedists because they do not always correlate with the clinical findings.

Retrocalcaneal bursitis

Retrocalcaneal bursitis refers to inflammation affecting the bursa immediately anterior to the Achilles tendon. As with Haglund’s deformity and Achilles tendinitis, this condition is common in running athletes, including long-distance runners. In the general population, as with insertional tendinitis, those most commonly affected are older, less active recreational athletes. As the disorder becomes chronic, the bursa enlarges and may become adherent to the Achilles tendon. A prominent posterosuperior bony projection may be present.

Athletes typically complain of pain with activities that force the ankle into dorsiflexion, particularly uphill running, and thereby compress the inflamed bursa between the posterosuperior calcaneus and the Achilles tendon. Schepsis et al.¹⁴ described the two-finger squeeze test, in which pain is noted when two fingers compress medially and laterally immediately superior and anterior to Achilles insertion. This area will be warm with a notable soft-tissue bulge. Pain is elicited with passive dorsiflexion. Radiographs often are not useful but may demonstrate loss of the retrocalcaneal soft-tissue shadow, as well as the presence of a posterosuperior bony prominence. MRI demonstrates soft-tissue changes anterior to the Achilles tendon above its insertion in the retrocalcaneal region (Fig. 7-6).

Figure 7-6 Magnetic resonance imaging demonstrates Haglund’s deformity with enlarged posterior superior aspect of the calcaneus.

Nonsurgical treatment

The initial treatment for Achilles tendinitis is nonoperative. The majority of symptoms respond to rest; activity modification; improved training techniques; stretching; and, at times, shoe modifications and heel lifts. Surgical intervention should be considered only for recalcitrant cases.

Initial treatment should include anti-inflammatory medications and a supervised program of Achilles stretching. At times, a heel lift (one-fourth to three-eighths inch), night splint, or temporary immobilization in slight plantarflexion with a removable walking boot or cast may be required. Relative rest with limitations on intensity, duration, or frequency of training and concomitant institution of nonstressful cross training (exercise bike, pool running, elliptical trainer) also should be helpful. If the athlete has notable foot pronation, a semirigid orthotic may improve overall foot biomechanics by supporting the medial arch. An open-back shoe may benefit those with Haglund’s or retrocalcaneal bursitis (Fig. 7-7). Additionally, deepening the heel counter or use of a heel pad or sleeve may be considered.

Figure 7-7 Shoe alternatives and modifications for patients with Achilles tendinitis. Clockwise from the top left: (A) A higher-heeled, backless shoe, “a mule.” (B) A completely removed heel counter. (C) A partial heel counter cut to relieve external pressure. (D) A backless sneaker.

Intratendinous corticosteroid injections should be avoided because local use of these injections has been associated with tendon attrition and potential rupture. Although there is no strong evidence of similar deleterious effects after peritendinous corticosteroid injections, there are similar worries with an injection in the bursa. It would be advisable to immobilize the ankle temporarily after a retrocalcaneal injection because the retrocalcaneal bursa has a direct communication to the Achilles and may injure the Achilles tendon.^12,15–17 In general, we advise against corticosteroid injections and use them only in very limited and specific circumstances.

For refractory peritendinitis, we have found that brisement may provide symptomatic relief in a third to half of total cases.¹⁸ Brisement consists of injecting 5 to 10 ml of sterile saline or local anesthetic agents into the Achilles tendon sheath; this may forcibly disrupt any adhesions between the paratenon and Achilles tendon. Repeating the injections two to three times over several weeks may be necessary to achieve success.^14,18

After initial symptoms resolve, it is imperative to correct predisposing factors, including improper technique, excessive training, inappropriate shoewear, and poor flexibility. In addition, it may be critical to temporarily or permanently eliminate provocative, more rigid, and less compliant surfaces and terrain.

Reported results of nonoperative treatment of insertional and noninsertional Achilles tendinitis have been generally successful. Studies have found that 70% to 90% of patients have found symptomatic improvement after corrections in their shoewear, training habits, and mechanics.^8,18–22 There are, however, fewer predictable results with nonsurgical management in those with chronic tendinopathy and in the older athlete, as a result of greater degenerative tendon involvement.²¹

In our experience, athletes with isolated Haglund’s deformity can be managed with shoewear modification about 50% of the time. We have seen improvement in about 30% of patients with retrocalcaneal bursitis and in about 25% of those with insertional tendinitis. The presence of a prominence does not mandate surgery. One should not perform prophylactic resection because the degenerative process may be improved with mechanical means, rest, and other modalities, as described above.

Noninsertional tendinitis

For noninsertional tendinitis, the choice of procedure is based on whether the disease involves the paratenon, tendon, or both. In peritendinitis, all adhesions are excised, and the surgeon also performs a limited resection of any thickened paratenon. The extremity is immobilized for 3 to 5 days, followed by a range of motion program to limit the recurrence of scar formation (Fig. 7-8).

Figure 7-8 Release of the paratenon. Note that the incision is made 1 cm anterior to the margin of the Achilles tendon. The incision can be made much smaller than shown in this case.

When there is tendinitis and peritendinitis, elliptical excision of the tendon and longitudinal paratenon release is performed. Maffulli et al.²³ have reported a success rate of approximately 70% after percutaneous longitudinal tenotomy of the middle third of the Achilles tendon. In this technique a no. 11 or no. 15 blade is introduced posteriorly through the skin and tendon. With the blade held stationary, the ankle is dorsiflexed and the tendon is cut longitudinally. Next the blade direction is reversed 180 degrees and the ankle is plantarflexed. The process is repeated through four additional incisions in the zone of the degenerative tendon (Fig. 7-9).

Figure 7-9 The Maffulli technique: an incision is made with a no. 11 or no. 15 blade. The blade is held stationary and the ankle is dorsiflexed creating a longitudinal cut in the tendon. The blade then is turned 180 degrees, and the ankle is plantarflexed. The process is repeated until there are five longitudinal cuts.

Tendinosis

The type of procedure chosen for treatment of tendinosis depends on many factors, the largest, in our experience, being the extent of tendon involvement, determined by clinical findings, ultrasound, or MRI. When less than 50% of the tendon is involved, we longitudinally ellipse the diseased tendon; and when more than 80% of the tendon is involved, a debridement and tendon augmentation (e.g., turndown) or transfer is recommended (Fig. 7-10). When there is between 50% and 80% involvement, the decision is determined by the patient, the sport, and the surgeon’s preference.

Figure 7-10 Magnetic resonance imaging cross section of the Achilles tendon demonstrating more than 80% tendon involvement. This would indicate the need for tendon augmentation or transfer following debridement.

Debridement of tendon. For tendinosis, typically the degenerative portion of the Achilles tendon is debrided and the paratenon is released. If less than 50% of the tendon width is debrided, then the remaining section of intact longitudinal tendon should be strong enough to withstand stresses.

Typically a medial incision is made just anterior and parallel to the border of the tendon that is thickened, and the paratenon is entered. On the basis of maximal tenderness, MRI, or ultrasound localization of the degenerative zone of the tendon, an elliptical longitudinal excision of the diseased tendon is performed, leaving intact the anterior and posterior surfaces of the tendon. Essentially the zone of ellipsed tissue should include the degenerative fibers and the thickened tendon (Fig. 7-11). The tendon then is repaired with internally placed, nonabsorbable sutures with buried knots. The subcutaneous tissues are apposed, followed by closure of the skin. The leg is immobilized for 3 to 5 days in a splint, followed by range of motion exercise, strengthening, and nonimpact activities. A boot brace is worn for 6 to 12 weeks during ambulation to unload the healing tendon. Jogging and running may be introduced at 3 months, depending on the extent of involvement and the nature of the patient’s athletics.

Figure 7-11 Intraoperative photo of debridement of the Achilles tendon. Once the degenerative tissue is ellipsed from within the substance of the tendon, buried sutures are used to close the defect.

Tendon transfer. If more than 50% of the tendon width is involved, then one must consider the risks and benefits of either longitudinal tenotomy, debridement, or tendon transfer. The decision to consider tendon transfer is determined by the structural weakening of the tendon that may result from a large debridement.

Because most athletes use all their tendons for ultimate, lower-extremity performance, it is difficult to justify harvesting a working structure to improve the function of the Achilles. Thus depending on the demands of the athlete and nature of his or her skills, we have to balance the pros and cons of using the tendon transfer. If 50% to 80% of the width of the tendon is resected, we consider these factors. However, if 80% or more of the tendon is involved, our experience has been that the transfer becomes more critical to restore function. Alternative procedures in this latter scenario include a turndown procedure, tendon allograft, and V-Y advancement.

The flexor hallucis longus (FHL), flexor digitorum longus (FDL), or, less commonly, the peroneal tendons can be transferred. We prefer to use the FHL tendon in a nonsprinting athlete, nondancer, or rock climber. Transferring the FHL or any other tendon in a sprinting athlete or ballet dancer could lead to loss of agility, power, or balance. In these athletes, it is better to consider performing a turndown procedure, a V-Y advancement, or an allograft if a wide area of tendon is involved.

The patient is positioned prone and both legs are prepped for any tendon transfer, turndown procedure, or V-Y advancement because it usually is necessary to compare resting tensions with those of the contralateral side. In a tendon transfer, our preferred technique is to use a medial approach to the Achilles tendon, typically staying 1 cm anterior to the medial edge of the tendon. The incision is extended more inferiorly. The paratenon is opened, the degenerative tendon is excised, and the deep fascia between the superficial and deep compartment is released. It is felt that, by opening the fascia and exposing the deeper FHL muscle belly, there is an improved vascular bed for the Achilles. Ranging the big toe should facilitate identification of the moving FHL muscle belly and tendon. The FHL tendon may have a more distal origin and may not be viewed readily in the wound. Care should be taken while dissecting along the course of the muscle because the tibial nerve runs immediately medial to the tendon (Fig. 7-12, A through E).

Figure 7-12 (A) A medial approach 1 cm anterior to themedial edge of the Achilles tendon. (B) The deep fascia between the superficial and deep compartment is released. Ranging the big toe should allow palpation and identification of the moving flexor hallucis longus (FHL) (marked with two arrows). The tibial nerve runs immediately medial to the tendon, therefore dissection of the tendon must be carefully performed. (C) The tendon is released distally and secured with a whipstitch. The degenerative Achilles tendon is excised. (D) 4-0 or 2-0, nonabsorbable suture is buried within the tendon. (E) The defect is closed and the FHL tendon is sewn to an anchor into the calcaneus. This area of the calcaneus is prepared by locally elevating the periosteum. In this case the Achilles tendon length was normal, so the FHL was tensioned to permit full dorsiflexion.