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