Insertional Tendinopathy Of

Tendoachilles

Dr. Chandrashekhar Sonawane

-Dept. Of Orthopaedics

Case

47 years old male with left heel pain since 15 days pain more in the morning, aggravated by weight bearing, relieved with medications and rest. no H/O trauma, swelling, fever, any other joint pain, no H/O DM , koch’s

O/E - tenderness over posterior part of left heel and painful dorsiflexion of foot

conservative treatment anti-inflammatory drugs along with heel support

No improvement after 6 months

Surgery haglund bump excision by a central tendon splitting method

Cases in ESIC-PGIMSR,MGMH

Total no. of cases in last year - 24

Conservative management - 22 Oprative management - 02

Functional Anatomy

The largest and strongest tendon in the human body

Formed from the tendninous contributions of the gastrocnemius and soleus muscles

The tendons converge appr. 15 cm proximal to the insertion at the posterior calcaneus

Functional Anatomy

The right Achilles tendon appears to spiral counterclockwise 30‐150º toward its insertion at the calcaneus

The spiraling allows for elongation and elastic recoil within the tendon, facilitating storage and release of energy during movement

Blood supply for the tendon

posterior tibial artery and its contributions to the musculotendinous junction, as well as vessels which cross the paratenon.

The watershed zone is an area 2‐6 cm proximal to the calcaneus, in which the blood supply is less abundant and becomes even sparser with age

HistologyThe osteotendinous junction of the Achillestendon is made up of 1) Bone,

2) Fibrocartilage, and

3) Tendon.

-Complex interlocking between calcified fibrocartilage and bone at the insertion site

-Interlocking is of fundamental importance in anchoring the tendon to the bone.

IntroductionThe triad of Pain,

Swelling (diffuse or localized),

and Impaired Performance constitutes

tendinopathy.

Tendinopathy classificationClain and Baxter classified Achilles tendondisorders into

Noninsertional and

Insertional Tendinopathy

in 1992

The exact incidence is unclear.

Often diagnosed in older, less athletic, and overweight individuals as well as in older athletes , those wearing improper footwear

Risk Factors

Improper footwear

Obesity

Older athletes

Improper exercise

Overuse Injury on a Weak Tendon

Insertional tendinopathy could be considered an overuse injury, but with predisposition caused by preexisting weakening of the tendon.

Etiopathophysiology Repetitive Traction Forces flat foot, pes cavus, obesity, overuse, poor training

Degeneration , attrition , mechanical and chemical irritation chronic inflammatory response spur formation and calcification

Histopathology Edema, mucoid degeneration, disruption of collagen bundles, necrosis, small hemorrhages, and calcification are noted

Also, areas with proliferating blood vessels with lymphocytes and histiocytes suggesting a reparative process

-Increased activity of NADP-diaphorase, LDH, β- glucuronidase, and alkaline phosphatase.

-Submicroscopic calcification and fibrillar degeneration.

-Increased levels of type II and III collagen and decreased levels of type I collagen

Clinical Features Early morning stiffness,

Pain that deteriorates after exercise

Thickening or nodularity at the insertion.

Range of motion of the ankle may or may not be limited

Insertional tendinopathy of the Achilles

tendon seems to present

more often as a triad rather than as a solitary pathology.

Haglund’s triad-

Insertional tendinopathy of the Achilles tendon,

Retrocalcaneal bursitis,

Haglund’s deformity, the prominent

posterosuperior calcaneal process

HAGLUND’S DEFORMITY

( PUMP/ HUMP DEFORMITY)

Two bursae are appreciated in relation to distal attachment of the Achilles tendon .

Retrocalcaneal bursae.

Tendoachilles bursae

COMPONENTS OF HAGLUNDS DEFORMITY

RETROCALCANEAL BURSITIS

MARROW EDEMA IN THE CALCANEUM

THICK ACHILLES TENDON WITH PARTIAL TEAR

TENDOACHILLES BURSITIS

Differential DiagnosisSystemic affections -

Gout, Sarcoidosis, Systemic corticosteroids,Oral fluoroquinolones, Diffuse idiopathic skeletal hyperostosis, and Seronegative spondyloarthropathies

Local ConditionsHaglund’s deformity, Retrocalcaneal bursitis, Os trigonum, Posterior talar process fracture, Flexor hallucis longus tendinopathy,Peroneal tendinopathy, Tibialis posterior tendinopathy, Osteochondral lesions of talus

Investigations-Blood investigations to rule out systemic conditions

-(MRI scan and US scan) can help to confirm the diagnosis

-Radiographs help identify ossification of insertion of the Achilles tendon or a spur (fishhook osteophyte) on the superior portion of the calcaneum

Radiographic classification

Radiopacities of the Achilles tendon were classified into three types by Morris et al.

Type I - Radiopacities at the Achilles insertion or superior pole of the calcaneus.

Bony changes to the calcaneus are often seen in type I lesions.

Insertional tendinopathy of Achilles tendon causes type I abnormality

Type II -Radiopacities are intratendinous and areLocated 1–3 cm proximal to the Achilles insertion, and are separated from calcaneal surface

Type III. Radiopacities are located proximal to the insertion zone, upward to 12 cm above theinsertion zone. Type III is subdivided into IIIA (partial tendon calcification) and IIIB (complete tendon calcification).

Classification based on ultrasonographic changes at the Achilles tendon insertion was introduced by Paavola et al.

Ultrasonographic Classification of Insertional AchillesTendon Abnormality

Classification Insertional ChangesNo alteration No calcification. Homogeneous fiber structure in the insertional area.Mild abnormality Insertional calcification, length 10 mm or less and thickness less than 2 mm. Homogeneous fiber structure in the insertional area.Moderate Insertional calcification, length more than 10 mmabnormality and thickness less than 2 mm. Slight alterations in the echo structure of tendon in the insertional area.Severe abnormality Insertional calcification, length more than 10 mm or thickness more than 2 mm. Moderate to severe variety in the echo structure of tendon in the insertional area.

Management-Success rates of 85% to 95% have been reported with simple measures like rest, ice, modification of training, heel lift, and orthoses

-stretching and strengthening exercises can also be effective.

-Tendon loading stimulates collagen fiber repair and remodeling. Therefore, complete rest of the injured tendon is not advisable

SurgerySurgical options are considered after 3 to 6 monthsof conservative management

-Debridement of the calcific or diseased portion, Excision of the retrocalcaneal bursa, and Resection of the Haglund’s deformity, if present.

Various surgical procedures have beendescribed

We prefer to reattach the Achillestendon using bone anchors if one-third or moreof the insertion is disinserted.

A midline posteriorskin incision combined with a centraltendon-splitting approach for debridement, retrocalcaneal bursectomy, and removal of the calcaneal bursal projection as described by McGarvey

Calcified areas being probed with needle

Haglund’s bump excised after splitting tendo achilles

Postoperative Management

First two weeks- Protected weight bearing along with leg elevation as much as possible

2 weeks to 4 weeks- A synthetic anterior below-knee slab is applied, with the ankle in neutral and secured to the leg with three or four removable Velcro straps for 4 weeks

After 6 weeks- the anterior slab is removed.

-Stationary cycling and swimming from 8th

week -gentle training

-Gradual progression to full sports activity at 20 to 24 weeks

Follow-up - Patients are reviewed at 3, 6, and 9 months from the operation, and at 6-month intervals thereafter.

Conclusion

Insertional tendinopathy of the Achilles tendon is a degenerative rather than an inflammatory lesion, though the accompanying bursitis may paint an inflammatory picture

Type I collagen contributes to the tensile strength in tendons, allowing them to resist force and tension and to stretch. Therefore, tendons with an increased type III and a reduced type I collagen content are less resistant to tensile stresses

The diagnosis is mainly clinical, and radiographs help in confirming the diagnosis as do ultrasound scan or MRI scan

THANK YOU