Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Achilles Tendinitis

Basics
Description
  • Common overuse injury
  • Represents a spectrum of disorders involving the Achilles tendon, paratenon, and retrocalcaneal bursa
  • Ranges from painful inflammation of the Achilles tendon and its sheath to chronic degenerative tendinosis and tearing
  • Definitions:
    • Retrocalcaneal bursitis: Inflammation of the retrocalcaneal bursa, sparing tendon
    • Paratenonitis: Paratenon inflammation
    • Achilles tendinitis: Acute inflammation of the tendon with paratenon inflammation
    • Tendinosis: Intrasubstance degeneration of the tendon
  • Location: Noninsertional (several centimeters above attachment to the calcaneus) versus insertional (at insertion point on the posterior calcaneus)
General Prevention
  • Avoid excessive running uphill.
  • Avoid training errors, such as overly rapid increase in running mileage.
Epidemiology
  • Occurs particularly in recreational and competitive athletes, especially long-distance runners
  • Common in active middle-aged individuals
  • The Male:Female predominance approximately parallels the percentage of Male:Female participation in a given athletic activity.
  • Degenerative tendinosis also occurs in middle-aged to elderly individuals, regardless of sports participation.
Incidence
Occurs in 6% of runners
 
Risk Factors
  • Large posterosuperior calcaneal tuberosity (Haglund process)
  • Microvascular disease: Diabetes, lupus, rheumatoid disease
  • Hemodialysis or peritoneal dialysis: Renal disease
  • Connective-tissue disease
Pathophysiology
  • Achilles tendon anatomy:
    • 95% type-I collagen
    • Wavy configuration at rest
    • Surrounded throughout its length by a thin gliding paratenon that functions as an elastic sleeve, permitting free tendon movement
    • Achilles tendon blood supply:
      • Intrinsic vascular system at the musculotendinous and osteotendinous junctions
      • Extrinsic vascular supply via paratenon
      • Zone of hypovascularity 6 cm proximal to tendon insertion
    • Paratenonitis/tendinitis: Chronic inflammatory changes (uncommon)
    • Tendinosis: Chronic mucoid degenerative changes with disorganization of collagen fibers (common)
Etiology
  • Training errors (80%): Sudden increase in training regimen (mileage), change in shoe wear or terrain
  • Rough terrain or uneven surfaces
  • Improper shoe wear
  • Adverse weather conditions (ice, snow, cold)
  • Biomechanical abnormalities of the lower extremity, from lumbar spine to foot
    • Hyperpronation
    • Cavus foot
    • Leg-length discrepancy
  • Chronically inappropriate, short, or absent warm-up and stretching period
Associated Conditions
Diagnosis
Signs and Symptoms
  • A gradual increase in painful swelling and warmth occurs at any point along the tendon substance, from the musculotendinous junction to the bony insertion (os calcis).
  • Most pain is 5 cm proximal to the insertion onto the calcaneus.
  • Microtrauma, such as continued running, or even gross trauma, such as a single leap (in jumpers), exacerbates the symptoms.
  • Pain is relieved somewhat by rest.
Physical Exam
  • Check for pain on dorsiflexion of the ankle.
    • Palpate the tendon to localize the pain.
    • In severe cases, the tendon sheath may be swollen and crepitant with ankle motion.
  • Feel for nodular swelling in the tendon.
  • Use the Thompson test to rule out tendon rupture.
  • Swelling, warmth, or bogginess immediately anterior to the tendon insertion suggests retrocalcaneal bursitis.
  • Test single-limb heel rise.
  • Note any intrinsic foot, ankle, or leg deformities: Pes cavus, leg-length discrepancy, scoliosis, equinus deformity
Tests
Lab
  • Usually none are indicated.
  • Serum chemistry study with glucose is recommended if diabetes is suspected.
  • Evaluate for inflammatory arthritis if clinically indicated.
Imaging
  • Standing foot radiographs:
    • AP, lateral, oblique views
    • Assess Haglund prominence.
    • Identify:
      • Insertional spurring of the calcaneus
      • Intratendinous calcification, indicative of chronic tendinosis
  • MRI is indicated if the clinical picture suggests tendinosis .
    • MRI of a normal Achilles tendon:
      • Homogenous low signal on all sequences
      • Flat or concave anterior margin
      • Crescentic shape
      • Ovoid shape at its insertion onto the calcaneus
      • Normal thickness <8 mm
    • MRI of acute paratenonitis:
      • Loss of sharp interface between tendon and pre-Achilles fat
      • On T2-weighted views, high signal intensity around the tendon and pre-Achilles fat
      • Low signal intensity within tendon itself
    • MRI of chronic Achilles tendinopathy:
      • Thickened >8 mm, enlarged tendon
      • Loss of normal concave margin anteriorly
      • On T1-weighted views, heterogeneous increased signal intensity within tendon
    • MRI of Achilles rupture:
      • Usually occurs 5 cm above calcaneal insertion
      • Partial rupture has focal areas of high signal intensity on T2-weighted sequence images within the tendon substance, with preservation of continuity of the tendon.
      • Complete rupture shows loss of continuity with gap formation (high signal area on T2-weighted views).
  • Ultrasound:
    • Technique is technician-dependent.
    • Shows fluid around tendon or peritendinous adhesions
Differential Diagnosis
  • Precalcaneal bursitis
  • Retrocalcaneal bursitis
  • Peroneal tendinitis or rupture
  • Posterior tibialis tendinitis or rupture
  • Achilles tendon rupture, partial or complete, may represent terminal stage.
  • Inflammatory arthritis
Treatment
General Measures
  • Early, acute phase:
    • NSAIDs, ice, rest, heel lift, foot-wear modification, and orthotic correction of the foot and leg abnormality
    • Modify activities; perform Achilles stretching.
    • Retrocalcaneal bursa injection also may help relieve symptoms and inflammation.
    • For patients unresponsive to the previously-listed treatments, a trial of cast or boot immobilization is appropriate.
    • Corticosteroid injection of the tendon sheath may precipitate rupture and should be avoided.
Special Therapy
Physical Therapy
  • Ultrasound therapy (during proliferative phase healing), phonophoresis, iontophoresis, and short-term heel wedge use (to unload tendon unit)
  • Eventually, flexibility, strengthening, and conditioning through eccentric exercise to gain maximal benefit
Medication
First Line
  • NSAIDs
  • Analgesics
Surgery
  • For patients for whom nonoperative treatment for 6 months has failed:
    • Paratenonitis:
      • Treatment involves removal or release of the paratenon through a straight medial incision.
    • Achilles tendinosis:
      • Requires intratendinous debridement, retrocalcaneal bursectomy, and Haglund exostectomy
      • May require augmentation or local tendon transfer (e.g., plantaris or flexor hallucis longus) if Achilles tendon has extensive disease
Follow-up
Prognosis
The prognosis is good, but recovery can be prolonged.
 
Complications
Tendon degeneration and eventual rupture with loss of function, particularly with a high rate of surgical failure, are possible.
 
Patient Monitoring
Routine follow-up is indicated until the symptoms have resolved.
 
Patient Teaching
Activity
Proper shoe wear and terrain adjustment, with avoidance of steep hills and stairs
 
Prevention
Adequate pretraining stretching and warm-up
 
FAQ
Q: What is the most common location for Achilles tendinosis?
A: In the zone of avascularity, 6 cm proximal to the tendon’s insertion onto the calcaneus.
 
Q: How long should nonoperative treatment be attempted for Achilles tendinosis before proceeding with surgery?
A: At least 6 months of nonoperative treatment are recommended before surgical treatment.
 
Q: What are the MRI findings in Achilles tendinopathy?
A: On T1-weighted MRI images, a thickened (>8 mm) Achilles tendon with loss of normal concave anterior margin and increased signal intensity within the tendon.

1 comment to Achilles Tendinitis

  • Думаю, что ничего серьезного….

    Paratenonitis: Paratenon inflammation

    Achilles tendinitis: Acute inflammation of the tendon with paratenon inflammation

    Tendinosis: […….