Chronic Achilles Tendinopathy

Michael W. Bowman M.D. FACS

The Achilles' tendon is the biggest and strongest tendon in the lower leg.  It produces plantar or downward flexion of the foot and ankle and is responsible for push off during jumping and other activities.  The gastrocnemius muscle (longer muscle that originates above the knee) and the soleus muscle(shorter muscle that begins in midcalf) combine to form the Achilles' tendon. In 85% of patients a small muscle called the plantaris is safe and runs medially along the Achilles' tendon. The gastrocnemius soleus mechanism and Achilles' tendon is very strong and can withstand forces up to 9 times body weight.  The Achilles' tendon attaches in the mid posterior(back) of the heel or calcaneus.  This broad attachment continues down around to the bottom or plantar aspect of the heel.  It combines there with the attachments coming back from the plantar fascia. a small sac or bursa is present between the back of the superior or top of the calcaneus and the Achilles' tendon as it comes down to attach to the heel.  This is called the retrocalcaneal(behind the calcaneus) bursa.  This bursa protects the Achilles' tendon at the edge of the calcaneus.  Blood supply to the Achilles' tendon comes from the muscle above, the insertion below at the heel attachment and very slightly from fluid around .the tendon in the peritenon or tissue around the tendon.  Approximately 2 to 5 cm proximal or above the attachment of the Achilles is an area of the Achilles where the blood supply is the poorest.  This area known as the critical zone he is a site of frequent Achilles' tendon injury, poor healing and rupture.

Patients with Chronic Achilles Tendinopathy complaint of a swollen tender lump in the mid Achilles, usually around the critical zone.  Initially the lobe may be tender to touch only.  Later it may become painful with push off, walking and running type activities.  This may be the result of old Achilles' tendon injury and replacement by scar tissue or incomplete healing and the formation of a small cyst in the midportion of the injured area. the scar tissue and/or cyst in the damaged area is not as elastic or compliant as normal Achilles' tendon tissue. Rarely the swollen area of Achilles tendinosis may be caused by a tumor such as a xanthoma or synovial cyst invading the Achilles' tendon.  Repetitive use can produce pain and discomfort.  Patient's with this problem at an increased risk of the tendon rupturing at that site. The other condition that produces a swollen lump in the mid Achilles' tendon is Achilles peritendinitis, where the peritenon or tissue around the Achilles' tendon become swollen and inflamed.  Physical exam may not be able to distinguish between these two conditions.  Usually an MRI is obtained to evaluate the damaged area.

Treatment of chronic Achilles tendinopathy or Achilles peritendinitis is initially conservative.  When no tumor or large cyst is present in the tendon, conservative treatment may be used.  Protected weight-bearing in a boot may be used if there is discomfort walking.  Therapy, consisting of ice, soft tissue massage, Achilles stretching and eccentric strengthening is utilized.  Progressive strengthening and exercises are permitted when the discomfort and tenderness results. In the case of Achilles peritendinitis, a brisement, or injection in the peritenon with a Xylocaine may be utilized.

We are currently pioneering the use of platelet rich plasma (PRP) for the treatment of these conditions.  Approximately 30 cc of patient blood is obtained and prepared using a special centrifuge process.  The buffy coat portion of the plasma containing the platelets and human growth factors are obtained.  This is then injected into the damaged tendon area or peritenon to promote healing.  Several injections may be required.  Early results in the NFL, NHL and our patient's have been promising. This includes my own Achilles' tendon.

Surgical treatment for chronic Achilles tendinopathy or Achilles peritendinitis is determined by the exact pathology and may be used when conservative treatment fails.  This is an outpatient procedure with general or spinal anesthesia.  A longitudinal incision is made along the swollen tender area of the Achilles. in cases of peritendinitis, the swollen inflamed peritenon is trimmed or debridement, leaving a normal tendon. in cases of resistant Achilles tendinopathy with no cyst or tumor, and radiofrequency probe is utilized to make small perforations in the diseased tendon, promoting vascularity and increased healing.  We are currently also utilizing PRP injections of the tendon along with this technique. In cases of Achilles tendinopathy with a cyst or tumor , the tendon is split, exposing the excessive scar tissue, cyst or tumor.  The abnormal tissue was removed and the tendon is repaired directly.  In cases where the remaining tendon is very weak were poor, a tendon transfer utilizing the plantaris or FHL may be required to augment the tendon. this procedure is performed as an outpatient with general, spinal or block anesthesia.  The patient is in a protective boot, nonweightbearing for 6 weeks, followed by progressive weight-bearing and strengthening.  Surgical risks and wrists with this condition include anesthesia related problems, wound healing problems or infection, tendon tear, continuing discomfort and sural nerve irritation or numbness.

 

Haglund`s syndrome is present when the small retrocalcaneal bursa between the posterior superior top of the calcaneus and the Achilles' tendon becomes inflamed and painful.  Patient's complaining of pain in the posterior heel just above the insertion of the Achilles' tendon.  There can be referred pain up the Achilles' tendon often confused with Achilles tendinosis.  Causes for Haglund syndrome are a tight Achilles' tendon producing irritation of the bursal or a square configuration of the superior calcaneus known as Haglund's deformity and present in approximately 7% of the population.  Obesity, overuse and inflammatory conditions such as room for arthritis, lupus and gout can also cause Haglund syndrome.

Careful examination is required to distinguish Haglund syndrome from other causes of posterior heel pain such as Achilles tendinosis, a posterior calcaneal spur/insertional Achilles tendinitis or calcaneal stress fracture.  In Haglund syndrome the retrocalcaneal pinch test is usually positive with squeezing pressure just in front of the Achilles' tendon insertion over the retrocalcaneal bursa. and x-ray may be obtained to ascertain the configuration of the posterior calcaneus and confirm a Haglund's deformity.  An MRI may be obtained to confirm the retrocalcaneal bursitis and evaluate the integrity of the Achilles' tendon at its insertion.

Initial treatment of Haglund syndrome is usually conservative.  Anti-inflammatories, ice and Achilles stretching is utilized.  Patient's were asked to examine their shoes and to avoid any that have an overly stiff back or heel counter with rubs the heel in that area.  Open back shoes may be utilized.  A1 time careful injection in the retrocalcaneal bursa with the Xylocaine and Cortisone may be used.  Patient's are cautioned about activity afterwards to reduce any risk of tendon injury.

We are currently pioneering the use of platelet rich plasma (PRP) for treatment of Haglund syndrome.  Approximately 30 cc of plasma is obtained from the patient, concentrated with a special centrifuge and the buffy coat containing the platelets and human growth factors obtained.  This was then injected in the retrocalcaneal bursa for treatment.  A protected postinjection protocol is then used.

Surgical treatment for Haglund syndrome is utilized when conservative treatment has failed.  This procedure is an outpatient procedure, performed with general, spinal or block anesthesia.  A small incision is made on the lateral side of the heel near the Achilles insertion.  A small wedge of the posterior and superior corner of the calcaneus is removed along with the bursa.  This decompresses the space behind the Achilles and reduces the inflammation.  A protective boot is applied and there is no weight-bearing for two weeks.  The sutures are removed at two weeks and progressive weight-bearing in therapy are initiated for strengthening and balance.  Risks with this procedure and condition include anesthesia related risks, wound healing problems infection, or continued discomfort.