Clinical assessment and investigation

The clinician will take a history from the patient, to determine the severity of the problem and then the physical examination of the patient will narrow the potential diagnoses.

MRI and/or ultrasound may be used to improve the accuracy of diagnosis and to assist with planning of surgery. Both of these modalities have a specificity of only 0.5 approximately, while there sensitivities are 0.8 to 0.95. Therefore if the diagnosis is obvious clinically they may not be of significant value to the surgeon. I find these modalities most useful for the grossly thickened and tender TA to determine if there is significant pathology within the tendon body rather than paratenon (layer of connective tissue lining the TA) and whether or not this requires surgery. Significant intra-tendinous discontinuity (due to degeneration or partial tearing) may warrant a repair of the tendon and/or reconstruction if more significant.

Plain x-rays are useful in those cases where the problem is clearly at or near the insertion of the TA to bone. X-rays may reveal calcification at or near the insertion, and there may also be a bone prominence in the os calcis (heel bone) anterior the tendon (that is in front of it). The bone prominence is called a Haglund’s deformity and may have to be excised at surgery to take the pressure off the tendon.

Terminology

I use the pathological terms referred to above to describe the site and nature of the problem. The term “acute” is used if symptoms have been present for less than 3 weeks, “subacute” if 3 weeks to 6 weeks, and “chronic” if more than 6 weeks.

Treatment

Non-operative treatment

Most of these chronic tendon disorders will settle with appropriate non-operative treatment, but can take up to 6 months to settle. The treatment is usually a progressive strengthening program supervised by a sports physiotherapist.

Surgical treatment

This depends upon the specific pathology present. The options include: debridement, local tissue transfer, and augmentation.

ACHILLES PARATENONITIS

The paratenon is a very thin layer of very vascular (well supplied with blood) covering the TA. It is uncommon in elderly patients for this to be the primary site of pathology, while in the younger athletic patient it is relatively common.

When the paratenon is inflamed the tendon is thickened and tender. There may also be a squeaking sensation or crepitus when the ankle is moved.

Most cases will settle with non-operative treatment. In an elderly patient this may include a short period in a below knee cast. In younger patients relative rest from running, use of NSAIDs, RICE and correction of any training or footwear errors is usually sufficient.

“Brisement” is a treatment that injects saline and local anesthetic into the paratenon under ultrasound control to break down “adhesions” (tissue stuck to the tendon). The treatment has to be repeated up to 3 times, and in 50% of patients it will significantly improve symptoms. Most patients will have tried this or similar, before presenting to a surgeon.

Surgery

This is required on rare occasions for this condition, when all other treatments have failed. Usually the conditions has been unremitting for a period of at least 6 months and often longer. The procedure is performed in an operating theatre under sterile conditions and the patient under a general anesthetic.

An incision is made on the posteromedial aspect of the tendon, and sharp dissection performed down to the paratenon. Areas of thickened pathological paratenon are excised on the back and both sides of the tendon. The paratenon in front of the tendon has to be left alone as this is where the blood supply enters the tendon. The intra-operative photograph below shows this approach.

Following surgery, the patient is placed in a removable fracture boot for the first 3 weeks. Over the next 3 weeks the patient is weaned off the boot before a strengthening program is instituted.

The success rate reported in the literature for this procedure is 87% (Schepsis et al. 2002).

ACHILLES TENDINOSIS

This is a degenerative condition of the tendon proper. In the earlier stages it usually does not cause any symptoms, but can become symptomatic when partial tears in the tendon develop secondary to weakness of the tendon.

On examination there is a thickening of the tendon proper, while the paratenon tends not to be thickened. Often the tenderness is very localized to the lump. There are multiple theories as to the causation of the degeneration but none are proven. A common theme in these theories is the poor reparative capacity of the tendon in the region 2-6m above its insertion into the heel bone, the site where it most commonly occurs.

Treatment

Non-operative treatment is often successful. In addition to the standard measures, excessive foot pronation may be a causative factor and if present should be corrected with appropriate footwear and/or orthoses. The latter is more appropriate to the younger physically active patient. Physiotherapy tends to concentrate on a progressive eccentric strengthening program, and in most cases is successful.

In 25% of cases, non-surgical treatment fails and if symptoms persist for 6 months, surgery may be indicated. An MRI is useful in these cases to confirm the intra-tendinous location and severity of the degeneration. If more than 50% of the tendon is discontinuous, then some form of augmentation or reconstruction is often required.

Surgery

The surgical approach is similar to that above. Once the paratenon is exposed this has to be divided to expose the tendon proper which often appears thick, soft and yellowish, due to the accumulation of mucinoid (degenerate) material within it. The tendon is split longitudinally (in the direction of the fibers which tend to spiral) and the degenerate areas are excised.

If more than 50% of the tendon is discontinuous (de-functioned) then the tendon repair may have to be augmented using a neighboring tendon (toe flexor or plantaris tendon), a fascial turn down (my preference) or a synthetic graft (my least preferred option).

The literature reports an 88% good or excellent outcome with this surgical approach (Den Hartog 2003)

ACHILLES PARATENONITIS WITH TENDINOSIS

When both of these conditions are present together, the general consensus is that the prognosis is worse than for the isolated condition and surgery more likely to be required. Both the surgical techniques described above are performed. The post-operative rehabilitation is similar.

RETROCALCANEAL BURSITIS

The primary pathology in this condition is inflammation of the bursa which lies between the TA and the os calcis. Specific causative factors include wearing shoes with a firm heel counter that presses on this area, and/or running up hills, for when the ankle is dorsiflexed there is increased pressure exerted on the bursa as it is compressed between the two structures (tendon and bone).

The most convincing finding on examination is the localized tenderness in the gap between the TA and the os calcis, on both sides when squeezed.

The non-operative treatments includes those modalities referred to above and correction of any contributing factor.

If this fails, then a surgical intervention may be indicated. Plain x-rays may demonstrate a Haglund’s deformity (an increase prominence of the posterosuperior os calcis) which increases the pressure on the bursa. The surgery performed includes and excision of the inflamed bursa, as well as any Haglund’s deformity.

INSERTIONAL ACHILLES TENDINOSIS

In this case the primary pathology is tendon degeneration at the insertion onto the heel bone. The symptom are similar to those of retrocalcaneal bursitis, but the site of maximal tenderness is located at the TA insertion and not the bursa, although both conditions may co-exist.

Calcification of the areas of degeneration may occur, leading to the formation of a spur within the tendon attachment, and clearly visible on x-rays. This is sometimes referred to as a “pump bump”. There may also be a Haglund’s deformity as well. For this reason x-rays are particularly useful for the investigation of this condition.

Surgery

Unfortunately this condition is unlikely to respond to non-operative treatment and often requires surgery. The procedure includes release of the diseased areas of tendon from bone, excision of any areas of calcification or spurs, and / or excision of Haglund’s deformity if also present. More often than not, the tendon has to be repaired back to bone using suture anchors. Surgery for this condition is indicated when non-operative measures have failed and the conditions is having an unacceptable negative effect on lifestyle.

The operation consists of detaching the Achilles tendon (TA) from bone, removing the boney spur and “Haglund’s deformity” as well as the degenerate end of the tendon, and then reattaching the tendon to bone using combination of very strong suture material (called “fibre tape”) and suture anchors. The goal is to remove the pain producing component of the tendon, and then allowing the tendon to heal to bone. The patient will need to be in a surgical boot for 6-8 weeks post surgery, with non-weight-bearing for the first 2 weeks, and then partial weight bearing thereafter, as long as pain free.

The complete rehabilitation may take 4-6 months

One third of patients will return to running within this time span, one third may require 12 months, and unfortunately one third of patients do not make a return to running.