Chronic Achilles tendinopathy is a tendon disorder. Its causes can range from overuse injuries to tearing of the tendon.

The Achilles tendon itself the biggest and strongest tendon in the lower leg. It produces plantar, or downward, flexes and movements of the foot and ankle. It’s also responsible for push-off during jumping and other activities. 

The Design of the Tendon

The gastrocnemius muscle (a longer muscle that originates above the knee) and the soleus muscle (a shorter muscle that begins in midcalf) combine to form the Achilles tendon. Additionally, a less important muscle known as the plantaris helps in the movements of the gastrocnemius and soleus muscles. It’s noteworthy that the gastrocnemius soleus mechanism within the 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. This broad attachment continues down around to the bottom (plantar) aspect of the heel. It combines there with the attachments coming back from the plantar fascia. Additionally, a small sac (bursa) is present between the back of the superior (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 is known as the critical zone and is a site of frequent Achilles tendon injury, poor healing, and rupture.

The Symptoms

Patients with chronic Achilles tendinopathy often complain of a swollen tender lump in the mid Achilles, usually around the critical zone. Initially, the lobe may be tender to touch only.  Repetitive use, however, can produce pain and discomfort in and around the lobe. Patients with this problem at an increased risk of the tendon rupturing at that site.

As the disorder advances, the lobe may become particularly painful with push off, walking, and running type activities.  This pain may be the result of old Achilles tendon injury and replacement by scar tissue. (The scar tissue and/or cyst in the damaged area are not as elastic or compliant as normal Achilles tendon tissue.) It may also be due to incomplete healing and the formation of a small cyst in the midportion of the injured area. Rarely, the swollen area of Achilles tendinosis may be caused by a tumor (such as a xanthoma or synovial cyst) invading the Achilles tendon.  

Another 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.  A physical exam may not be able to distinguish between these two conditions.  Usually, an MRI is obtained to evaluate the damaged area.

The Treatment

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. 

Conservative Treatment

  • 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.

At Pittsburgh Foot & Hand Center, we are currently pioneering the use of platelet rich plasma (PRP) for the treatment of these conditions. In this treatment method, 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 patients have been promising. This includes my (Dr. Bowman’s) own Achilles tendon.

Surgery

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, conducted 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 of debridement, leaving a normal tendon.

In cases of resistant Achilles tendinopathy with no cyst or tumor, a 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 is removed and the tendon is repaired directly. 

In cases where the remaining tendon is very weak, a tendon transfer utilizing the plantaris or FHL may be required to augment the tendon. This procedure is performed on an outpatient basis with general, spinal or block anesthesia.  The patient is in a protective boot. They are also ordered to avoid weight-bearing activities for 6 weeks, with progressive weight-bearing and strengthening exercises to follow. 

Surgical risks associated with this condition include anesthesia-related problems, wound healing problems or infection, tendon tearing, continuing discomfort, and sural nerve irritation or numbness.

Differentiating Diagnosis’

It is our responsibility as your medical team to differentiate between similar medical problems. One similar issue, mentioned earlier, is Achilles peritendinitis. Another is Haglund’s syndrome.

Haglund’s syndrome refers to a collection of soft tissue and bony abnormalities that cause pain, thickening, and/or inflammation of the Achilles tendon.

Specifically, the small retrocalcaneal bursa (between the posterior superior top of the calcaneus and the Achilles tendon) becomes inflamed and painful.  Patients will complain of pain in the posterior heel, just above the insertion of the Achilles tendon. In these cases, pain often travels up the Achilles tendon, a symptom similar with Achilles tendinosis. 

Causes

Causes of Haglund’s syndrome include the following:

  • a tight Achilles tendon producing irritation of the bursal
  • or a square configuration of the superior calcaneus, known as Haglund's deformity, which is present in approximately 7% of the population
  • Obesity, overuse, and inflammatory conditions such as arthritis, lupus, and gout can also cause Haglund’s syndrome

Diagnosis

Careful examination is required to distinguish Haglund’s syndrome from other causes of posterior heel pain, such as Achilles tendinosis.

In Haglund’s syndrome, the retrocalcaneal pinch test is usually positive with squeezing pressure just in front of the Achilles tendon insertion over the retrocalcaneal bursa. An x-ray may also be obtained to ascertain the configuration of the posterior calcaneus and confirm a Haglund's deformity.  Additionally, an MRI may be obtained to confirm the retrocalcaneal bursitis and evaluate the integrity of the Achilles tendon at its insertion.

Conservative Treatment

Initial treatment of Haglund’s syndrome is usually conservative.  Anti-inflammatories, ice, and Achilles stretching are all utilized. 

Patients are asked to examine their shoes and to avoid the use of any that have an overly stiff back or heel counter that rubs the heel.  Open back shoes may be utilized as a part of treatment. 

Additionally, careful injection in the retrocalcaneal bursa with Xylocaine and Cortisone may be used.  Patients will be cautioned about activity afterward to reduce any risk of future tendon injury.

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

Surgical Treatment

Surgical treatment for Haglund’s 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 allowed for two weeks.  The sutures are removed at two weeks, and progressive weight-bearing exercises and therapy are initiated for strengthening and balance. 

Risks with this procedure and condition include anesthesia-related risks, wound healing problems infection, or continued discomfort.