Insertional and Noninsertional Achilles

TendonitisSelene G. Parekh, MD, MBA

Associate Professor of SurgeryPartner, North Carolina Orthopaedic Clinic

Department of Orthopaedic SurgeryAdjunct Faculty Fuqua Business School

Duke UniversityDurham, NC919.471.9622

http://seleneparekhmd.comTwitter: @seleneparekhmd

Etiology

Etiology

• Intrinsic factors of note:• HTN• Diabetes• Obesity• Exposure to steroids/estrogen• Advancing age• Exposure to quinolones• Variants in gene of MMP-3

Pathophysiology

• Cellular & molecular response to microscopic tearing chronic degenerative process• Incr # tenocytes• Incr concentration GSG• Disorganized/fragmented collagen• Neovascularization• Incr concentration glutamate• Incr concentration lactate

Classification

• Histopathologic• Paratenonitis

• Paratenonitis with tendinosis

• Tendinosis

Classification

• Paratenonitis• Definition

• Inflammation of only the paratenon, either lined by synovium or not

• Histo• Inflammatory cells in paratenon/peritendinous

areolar tissue• Clinical

• Warmth, edema, tender• Paratenon thickened and adhered to normal tissue

Classification

• Paratenonitis w/ tendinosis• Definition

• Paratenon inflammation w/ intratendinous degeneration

• Histo• Same as paratenonitis w/ loss tendon collagen,

fiber disorientation, scattered vascular ingrowth• Clinical

• Same as paratenonitis w/ nodule

Classification

• Tendinosis• Definition

• Intratendinous degeneration w/ atrophy• Histo

• Noninflammatory intratendinous collagen degeneration, fiber disorientation, hypocellularity, occasional necrosis and calcification

• Clinical• Often nodule in nontender, little edema

Classification

• Duration symptoms• Acute < 2 wks• Subacute 3-6 wks• Chronic > 6 wks

• Insertional vs. noninsertional

Presentation

• Symptom triad• Pain

• Swelling

• Impaired performance

Presentation

•Physical exam•Pain/tenderness @ Achilles•Morning pain, increases w/ usage•Pain will progress from activity-related to constant•Fusiform swelling

Presentation

•Physical exam•Pain/tenderness @ Achilles•Morning pain, increases w/ usage•Pain will progress from activity-related to constant•Fusiform swelling

Presentation

•Peritendinitis•Tendon normal•Peritenon thickened, fluid, adhesions

•Tendinosis•Tendon thickened, nodular, softened, yellow, & degenerated

Imaging

• X-ray• Calcifications• Haglund’s deformity

• “Pump bump”• Parallel pitch lines

Imaging

• Plain radiographs• Calcification

Imaging

• Plain radiographs• Calcification

• MRI• Helpful to evaluate extent of disease• AP diameter < 6mm

• US• User dependent

Nonsurgical Treatment

• Rest and activity modification• AFO/shoe inserts/casts/night splints• 2-6 weeks

• No studies demonstrate the efficacy of rest

Nonsurgical Treatment

• Ultrasound• Rat study suggest stimulation of tenocyte

migration

• No well designed studies show support of use

Nonsurgical Treatment

• Low level laser therapy• May increase collagen production, down regulate

MMP, decrease capillary flow of neovascularization

• 2 studies• Decr pain: rest, activity, palpation• Decr immediate pain threshold

• Insufficient evidence to support usage

Nonsurgical Treatment

• Eccentric/Concentric exercise therapy• Decrease neovascularization

• Tensile force temporary ceases blood flow repetition neovessels obliterated w/ pain receptors

• Studies• Improved pain @ 12 weeks (2)• Structural and compositional changes

• Resolution of structural anomalies• Decr tendon thickness

Nonsurgical Treatment

• Eccentric/Concentric exercise therapy• Studies

• Eccentric vs concentric exercises (4)• Eccentric exercise does not offer significant

decrease in pain over concentric exercise• @ 12 wks: eccentric patients more satisfied

and return to activities

• Specific role in treating noninsertional Achilles tendonitis unclear

Nonsurgical Treatment

• Shockwave therapy (SWT)• High energy eliminates pain

• Stimulating soft tissue healing, regenerating tendon fibers, inhibiting pain receptors

• Studies (4)• Low energy (3), differing doses, short f/u, small

cohorts

• Insufficient evidence to support SWT: most effective dose and duration unknown

Nonsurgical Treatment• Glyceryl trinitrate

• Prodrug of NO• Increase fibroblast collagen synthesis

• Topical transdermal treatment over point of maximal tenderness

• Studies• Decr tenderness, night pain, activity pain, and

improved functional outcomes• No changes in neovascularity, wound fibroblasts,

collagen synthesis, NO production• 20% discontinue treatment due to headaches

• Conflicting evidence of efficacy

Nonsurgical Management

• Corticosteroid injection• Decr pain• Decr tendon thickness• Intratendinous injection concerns re: catabolic

effects on the tendon

• Evidence of usage is insufficient. Concerns re: rupture outweighs its usage.

Nonsurgical Management

• Platelet rich plasma therapy (PRP)• Delivery of hyperphysiologic doses of cytokines• Some success HSS/Baltimore

• Evidence of usage is insufficient.

Nonsurgical Management

• Sclerosing injections/Prolotherapy• Polidocanol

• Thrombosis of vessels and destroys nerves• Proliferation of fibroblasts• Synthesis of collagen possible remodeling of

tendon• 25% dextrose solution

• Dehydrate cells influx inflammatory cells tendon healing

• Poor evidence to recommend usage

Nonsurgical Management

• Aprotinin injections• Collagenase inhibitor• Can have systemic allergic reactions• Studies

• RCT: no difference than placebo injection

• Insufficient evidence to recommend usage

Operative Management

• Used for recalcitrant cases• 3-6 months of conservative treatment

• Goals• Resect calcaneal bone• Resect degenerative tissue• Augment tendon if needed

• >50%

Operative Management

• Percutaneous longitudinal tenotomy• Mild/moderate disease• 67-97% success rates• Worse outcomes:

• Multinodular disease• Severe disease• Paratendinopathies

Operative Management

• Minimally invasive stripping• Large diameter sutures passed through stab

incisions• Slide anterior to tendon to strip it

• No studies to show efficacy

Operative Management - I• Excision of Haglund’s deformity

• Position• Prone vs. supine

• Incisions• Lateral, medial both, or central

• Inflamed bursa excised• Enlarged tuberosity resected

• Tendon transfers• FHL (Wapner)

• Better length than FDL• Better biomechanics than FDL

Operative Management - I

• Prone

• Central, Achilles tendon splitting approach

• Elevate 70-80% of tendon insertion

• Resect Haglund’s check on fluoro

Operative Management - I

• Debride Achilles• < 50% involvement

• Anchors into calcaneus• Tie Achilles• Close Achilles split

Operative Management - I

• Debride Achilles• > 50 % involvement single incision technique

• Open deep fascia and find FHL muscle belly• Find FHL tendon and trace into canal• Plantarflex ankle and toe and pull on tendon• Release tendon• Drill hole anterior to Achilles insertion• Pass FHL tendon and screw• Repair Achilles insertion, split and skin

Operative Management - I

• Debride Achilles• > 50 % involvement double incision technique

• Medial foot approach and find knot of Henry• Release FHL• Open deep fascia and find FHL muscle belly• Find FHL tendon and trace into canal• Pull FHL tendon through• Create 2 drill holes: one anterior to Achilles

insertion and one medial to lateral• Pass FHL tendon and tie to self

Operative Management - NI

• Debridement with/without tenosynovectomy• Moderate/severe disease• Debride all tendinopathic tissues

• <50%• +/- tubularization

• >50%• FHL transfer (single/double incision)

• Studies• Improved pain, functional outcomes,

• Fair evidence supports treatment

Post-Op Protocol

• No Tendon Transfer• NWB in Bulky Jones splint x 2wks• SLNWBC x 2 wks• SLWBC x 2 wks

• Tendon Transfer• NWB in Bulky Jones splint x 2wks• SLNWBC x 4 wks• WB CAM boot x 4 wks, start PT

Operative Management

•Complications•11% rate•1 year f/u

•Satisfied w/ outcomes •Return to activities

•Skin edge necrosis•Superficial/deep infections•Seroma/hematoma formation

•Sural neuritis•Partial ruptures•Sensitive/hypertrophic scars•Weakness of plantarflexion

Incision

Partial Insertion Detachment

Resect Calcified Tissue

Haglund’s Resection

Haglund’s Resection

Debride Tendon

Incise Deep Fascia

Drill Hole Anterior to Achilles

Pass Tendon

Anchors

Tie Tendon

Close Tendon

RE ECT

the ankle

the foot