Surgery for Chronic Achilles TendonProblems

The author introduces a new procedure for surgical treatment of Achilles tendocalcinosis and othertechniques for treatment of various chronic Achilles pathologies. Results of 21 procedures on 19patients are presented.

Amol Saxena, DPM, FACFAS1

Ahilles tendon pathologies can encompass multipl eentities. Williams classifies them into rupture, focaldegen eration, tendonitis, peri tendonitis (peritendono­sis), mixed lesions, origin/insertion lesions, and othercases, such as those with met abolic/rheumatic causes (1) .Etiologies include trauma, poor flexibility, and abnormalbody mechanics (such as excessive pronation or supina­tion, and limb length inequalities) (1-7).

The anatomy of the Achilles tendon is different fromthat of other tendons inserting into the foot. It lacks atrue synovial sheath but rather has a paratenon. Due tothe decreased vascularity, the Achilles tendon is partic­ularly vulnerable at its "watershed" region , which is 2 to6 em. proximal to its insertion (8). Achilles peritendo­nosis involves inflammation of the peritendinous tissues(the paratenon). Achilles tendonosis may consist of focaldegenerative changes of the Achilles tendon itself. Inchronic conditions, this may result in mucoid or fattydegeneration of the Achilles tendon (9, 10).

Differentiating peritendonosis and Achilles tendono­sis may be confusing. Chronic Achilles problems maycoexist with peritendonosis (1, 2, 4, 5, 10, 11). Clinically,peritendonosis manifests itself as peri tendinous crepitusas the tendon tries to glide within the inflamed covering(2, 3, 7). The patient's symptoms often increase withactivity. Diffuse swel1ingand fibrosis along the length ofthe watershed region may be noted. In contrast, tendo­nosis (chronic tendonitis) symptoms tend to decreasewith activity, and fibrosis and tenderness are morelocalized (2, 4, 11). Some cases of tendonosis may beassociated with previous partial or complete rupture (1).

Tendocalcinosis involves calcification of the Achillestendon insertion, though calcification may occur in otherregions. Proximal, posterior, or distal to the calcifica-

--- ----- -From the Department of Sport s Medicine, Palo Alto Medical

Foundation, Palo Alto , Californi a.1 Address correspondence to: 913 Emerson Street, Palo Alto, CA

94301.1067-2516/95/3403-0294$3 (JO/OCopyr ight © 1995 by the American College of Foot and AnkleSurgeons

tions, symptoms such as tendonosis and bursitis mayoccur (1, 12). In addition, a prominent posterior supe­rior calcaneus (Haglund's deformity) may also result inposterior heel pain, and be a coexisting deformity (4, 6,11, 13). Symptoms include localized pain and a posteriorsuperior prominence, resulting in symptomatic bursitisand retro-Achilles tenderness.

Evaluation of Achilles pathology includes weightbear­ing and nonweightbearing examinations with a review ofneurovascular status; a biomechanical evaluation, espe­cially ankle range of motion, is also performed. Aradiographic examination using plain film radiography ismandatory. In addition, xerograms, bone scans, andmagnetic resonance imaging may be appropriate. Con­servative treatment consists of combinations of rest ,anti-inflammatory medication, physical therapy (such asultrasound, electrical stimulation, ice, and massage),heel lifts, accommodative padding, and functional ortho­ses (2, 3, 5, 7). Some authors report patients receivingrclieffrom acupuncture and dimethyl sulfoxide (DMSO)(1, 3). Surgical treatment involves tenolysis, tendonrepair, excision of calcinosis or other prominences/bursae, and tenodesis as appropriate (2, 7, 11, 14, 15).Various surgical techniques and postoperative protocolsfor peritendonosis, tendonosis, and tendocalcinosis/te­nodesis are discussed in the following section.

Surgical Techniques

Procedure I. Tenolysis of the Peritenon(Decompression of the Achilles Tendon)

A linear incision parallel to the Achilles tendon isused on the side of greatest pathology. Care is taken toavoid the sensory branches of the tibial nerve medially,and sural nerve laterally. The abnormal fibrotic tissue isexcised (Fig. lA, B). The paratenon may have a trans­parent mucinous appearance and deep to it will liefocally degenerated abnormality within the tendon (Fig.2). This area is curetted and excised. The defect isrepaired with 3-0 absorbable suture. After medial,

294 THE JOURNAL OF FOOT AND ANKLE SURGERY

Figure 1. Abnormal paratenon shown in magnetic reso­nance image (A) and intraoperatively (B).

Figure 2. Mucoid degeneration of paratenon (in forceps)and focal degeneration of Achilles tendon (arrow).

Figure 3. Magnetic resonance image showing fusiform,bulbous swelling of Achilles tendon with partial tear (A) andintratendinous degeneration (B).

lateral, and posterior tenolysis is performed, only sub­cutaneous tissue and skin are reapproximated.

The patient is kept nonweightbearing for 1V2 to 3weeks. The patient progresses to partial and then fullweightbearing over the next 4 weeks. Physical therapy(consisting of electrical stimulation, contrast baths,range of motion and isokinetic exercises) is initiatedbetween 2 to 6 weeks, depending on the amount of

VOLUME 34, NUMBER 3, 1995 295

Figure 4. Achilles tendon in the region of chronic inflamma­tion (same patient as in Fig. 3).

Figure 5. Excision of intratendinous degeneration (samepatient as in Fig. 3).

paratenon excised. Gradual return to running sports isallowed at 4 to 8 weeks postoperatively, depending onthe amount of immobilization needed.

B

Procedure II. Surgical Management of Tendonosis

A similar paralinear incision is placed over the nodu­lar fibrosis (Fig. 3A, B). The degenerated paratenon isexcised and then the nodularly thickened portion of thetendon is linearly incised. The mucoid material that liesintratendonously is excised (Fig. 4). The normal-appear­ing white linear Achilles tendon fibers are often notpresent in this region of nodular fibrosis. Any yellowish,soft, degenerative fibers that occupy this region areexcised (Fig. 5). The remaining Achilles tendon is re­paired by using #2 nonabsorbable braided polyestersuture in a buried-knot fashion. Partial ruptures, ifencountered, are repaired in a modified Bunnell's man­ner.

Postoperative care consists of 3 to 4 weeks nonweight­bearing in an equinus-position, below-the-knee cast. A

Figure 6. Incision placement for removal of Achilles tendo­calcinosis and associated Haglund's deformity.

gradual progression of partial to full weightbearingoccurs over the next 4 weeks. Physical therapy (ultra­sound, contrast baths, range of motion exercises, elec­trical stimulation, and cryotherapy) is started at 8 to 10

296 THE JOURNAL OF FOOT AND ANKLE SURGERY

B

Figure 7. Radiograph of Achilles tendocalcinosis to be ex­cised (A) and area of tendocalcinosis to be excised (B).(Note: the posterior superior aspect of the calcaneus may beresected.)

weeks postoperatively and resumption of running sportsoccurs at 12 to 16 weeks postoperatively.

Procedure III. Tendocalcinosis and AchillesTenodesis

A modified lazy S incision is used to visualize theposterior, superior, lateral aspect of the calcaneus, andthe Achilles tendon insertion (Fig. 6). The incision

Figure 8. Insertion of Mitek G II Quick Anchors for Achillestenodesis.

courses proximal-lateral above the heel, crosses over themidline, and extends inferiorly to the junction of thecalcaneal fat-pad. For those patients whose tendocalci­nosis involves little to no portion of the Achilles tendoninsertion, a simple midline incision can be made toextract the exostosis and associated bursa. This proce­dure can also be performed with the lazy S incision. Inaddition, the proximal lateral portion of the incisionallows removal of any Haglund's deformity or retrocal­caneal bursae. The Achilles fibers are reflected from theexostosis (Fig. 7). To aid in tenodesis, Mitek G II QuickAnchors/ are placed in the calcaneus (Figs. 8, 9). Thetendon is repaired side-to-side with a modified Bunnell'ssuture.' using #2 nonabsorbable braided polyester su­ture (Fig. 10). Subcutaneous tissue and skin are reap­proximated as previously discussed.

Postoperative care involves 4 weeks of nonweight­bearing in an equinus nonweightbearing below-the-kneecast, followed by 4 to 6 weeks of partial weightbearing tofull weightbearing in a below-the-knee cast walker boot.A physical therapy regimen similar to that previouslydescribed is started at 10 to 12 weeks postoperativelyand resumption of running sports is allowed at 12 to 20weeks, depending on the degree of tenodesis requiredand the patient's symptoms.

2 Mitek Surgical Products, Inc., Norwood, MA.3 The traditional Bunnell's suture is a method of end-to-end repair

of tendons. The modified Bunnell's technique is an adaptation of thistechnique for side-to-side repair of longitudinal tendon tears. Braidedpolyester suture is used to repair the tendon spanning beyond thelength of the torn (or linearly incised) tendon, as in Figure 10.

VOLUME 34, NUMBER 3, 1995 297

Figure 9. Radiographs of inserted Mitek G II Quick Anchors ,laterally (A) and axially (B) .

Results

Nineteen patients (16 males and 3 females) under­went 21 procedures for Achilles tendon and relatedpathologies. The average patient age was 46.5 years.(The average age of patient s undergoing perit enolysiswas 30.2 years.) The average duration of symptoms andconservative treatment was 4.3 and 2.6 years, respec ­tively. Five procedures involved peritenolysis, and four

Figure 10. Repair of the Achilles tendon after insertion ofMitek G II Quick Anchors.

others consisted of mucoid degeneration of the Achillestendon excision. In addition, 12 patients had treatmentfor tendocalcinosis, and 9 patient s' procedures necessi­tated tenodesis. Among this group of 19 patients werethree sub-four-minute mile runn ers and one eight-timenational cross-country champion . The remaining pa­tients were all athletically active in either running,tennis , basketball, or exercise walking.

All of the patients returned to performing daily activ­ities without pain. Eighteen of the 19 returned to theirdesired level of athletic activities. The peri tenolysisgroup was able to resume running activities an averageof 4 weeks postoperatively. This differs significantlyfrom the remaining patients, who had more involvedprocedures. These patient s returned to their desiredactivity an average of 14 weeks postoperatively.

One patient who had excision of tendocalcinosis andbursa redeveloped retrocalcaneal bursitis 1 year later.Recommendation was made for excision of the posteri­or/superior calcaneal prom inence and bursa. Only twoother minor complications were noted. The se includedirritation from a knot of braided polyester suture and asuperficial wound infection that led to a hypertrophicscar on a patient who could not be completely non­weightbearing because of scoliosis.

Discussion

Authors have noticed varying degrees of success insurgery for chronic Achilles problems (2-4, 6, 11, 13,15). The patients in this series healed well. The advent of

298 THE JOURNAL OF FOOT AND ANKLE SURGERY

TABLE 1. Profile of patients undergoing Achilles tendon surgerY

Patient Agel PostoperativeReturn to Desired

Diagnosis Procedure Fool Type Athletic Act ivityNo. Sex Complications

(weeks)

1 271M L paratendonos is Peritenolysis FF varus None 32 251M L paratendonos is Peritenolysis PFFR, 2-5 varus None 53 311M R paratendonosis Peritenolysis & tendonitis Neutral & small focal None 64 351M B paratendonos is Defect excision peritenoloys is FF varus None 3.55 391M B tendonos is Excision of mucoid FF varus None 12

degeneration6 65/M R tendonosis & Excision of mucoid RF varus & equinus None 20

partial rupture degeneration &repair of rupture

7 59/M R tendonos is Excision of mucoid Equinus None 20degeneration

8 311M L tendoca lcinosis Excision of tendocalcinosis FF valgus None 129 51/M R tendocalci nosis Excision of tendocalcinosis FF valgus None 10

10 48/M L tendocalcinosis Excision of tendocalcinosis FF valgus Recurrence 10myositis ossificans of bursitis

11 63/M R tendocalcinosis Excision of tendocalcinosisl FF varus None 14tenodesis

12 341M R tendocalcinosis Excision of tendocalcinosisl FF varus Suture knot 12tenodesis irritation

13 47/M R tendocalcinosis Excision of tendoca lcinosisl FF varus/Hallux None 12tenodesis rigidus

14 51/M R tendocalcinosis Excision of tendocal cinosisl FF valgus None 14tenodesis

15 70/M L tendocalcinosis Excision of tendocalcinosisl FF valgus None 16tenodesis

16 63/F R tendocalcinosis Excision of tendocalcinosisl FF varus Superficial 16tenodesis wound infection

17 66/F R tendocalcinosis Excision of tendocalcinosisl FF varus None 14tenodesis

18 44/F R tendocalcinosis Excision of tendoca lcinosisl FF varus None 12tenodesis

19 53/M L Achilles avulsion Tenodesis FF varus None 24

a Abbreviations: R, right; L, left; B, bilateral; RF, rearfoot ; FF, forefoot; PFFR, plantarflexed first ray.

soft tissue anchors appears to decrease the morbiditypreviously associated with tenodesis; the proceduresperformed on this series of patients allowed them toreturn to athletic activities faste r, when compared toother series (16). In addition, soft tissue anchors causeless tissue disruption than other tenodesis meth ods suchas screw/washer, treph ine/plug, and monofilament/wire(15). One patient in the tenodesis group previously hada stero id injection for ret rocalcaneal bursitis, and subse­quently suffered an avulsion-type rupture of the Achillesinsertion. In a recently published manuscript, Schepsis etal. noted similar results and findings with their 79 casesover a I3-year period. They divided these cases into thefollowing surgical subgro ups: paratendonosis (23), ten­donos is (15), retrocalcaneal bursitis (24), insertionaltendonitis (7), and combined abnormalities (10). Thestudy report ed 51% excellent, 28% good, 17% fair, and4% poor results. Of the cases with more than 5 years'follow-up, 16% necessitated reo peration over time (16).

Previous studies have atte mpted to implicate foot typewith Achilles tendonopathies. However, in this study,

there is no predominance of a pronated nor supinatedfoot (1, 2, 5, 7). All patients had decreased ankle jointdorsiflexion, which was measured with the foot in asupinated position. This decrease in ankle dorsiflexionmay not be the cause of the pathology, but rather theresult. The reader is refe rred to Table 1 for the findingswith each part icular patient.

Conclusion

Surgical treatment for Achilles peritendonosis, mu­coid-degenerated Achilles tendons, and tend ocalcinosiscan be undertaken with the surgical techniques de­scribed above. The modified lazy S incision offers betterexposure to the surgical pathology associated with Achil­les tendocalcinosis. Adherence to the postoperat ive pro­tocols allows pat ient s to return to their desired activitylevel. Prior to undergoing surgery, patients should beadministered adequate conservative treatment. Oneshould note that in this series, patients averaged 2.6

VOLUME 34, NUMBER 3, 1995 299

years of conservative treatment. When indicated, sur­gery performed for chronic Achilles tendonopathies canbe successful.

Acknowledgments

The author acknowledges Susan Keller for providingillustrations, and Drs. Donald Bunce, Gordon Campbell,and Stephen Osborn for assistance and incorporation ofvarious cases presented.

References

1. Williams, J. G. Achilles tendon lesions in sports. Sports Med.3:114-135, 1986.

2. Clement, D. B., Taunton, J. E., Smart, G. W. Achilles tendonitisand peritendonitis: etiology and treatment. Am. J. Sports Med.12:179-184,1984.

3. Saxena, A Achilles peritendonosis: an unusual case due to frost­bite in an elite athlete. J. Foot Ankle Surg. 33:87-90, 1994.

4. Leach, R. E., James, S., Wasilewski, S. Achilles tendonitis. Am. J.Sports Med. 9:93-98, 1981.

5. Galloway, M. T., JokI, P" Dayton, D. W. Achilles tendon overuseinjuries. In Clinics in Sports Medicine, pp. 771-782, edited by P.Renstrom and W. Leadbetter, W. B. Saunders Co., Philadelphia,1992.

6. Nelen, G., Martens, M., Burssens, A. Surgical treatment of chronicAchilles tendonitis. Am. J. Sports Med. 17:754-759, 1989.

7. Lemm, M., Blake, R. L., Colson, J. P., Ferguson, H. F. Achillesperitendonitis. A literature review with case report. J. A P. M. A.82:482-490, 1992.

8. Hume, E. L. Traumatic disorders of the ankle or overuse syn­dromes, ch. 5. In Traumatic Disorders of the Ankle, pp. 56-58,edited by W. C. Hamilton, Springer Verlag, New York, 1984.

9. Kvist, M., Jarvinen, M. Clinical histochemical and biomechanicalfeatures in repair of muscle and tendon injuries. Int. J. SportsMed.3 (Suppl):12-14, 1982.

10. Kvist, M., Jozsa, L., Jarvinen, M. J., Kvist, H. Chronic Achillesparatendonitis in athletes: a histological and histochemical study.Pathology 19:1-11, 1987.

11. Schepsis, A A, Leach, R. E. Surgical management of Achillestendonitis. Am. J. Sports Med. 15:308-315, 1987.

12. Postacchini, F., DiCastro, A Subtotal ossification of the Achillestendon: case report. Ita\. J. Orthop. Traumato\. 4:529-532, 1983.

13. Kleiger, B. The posterior calcaneal tubercle impingement syn­drome. Orthop. Rev. 5:487-493, 1988.

14. Raynor, K. J., McDonald, R. J., Edelman, R. D., Parkinson, D. E.Ossification of the Achilles tendon. J.A P. M. A 12:688-690,1986.

15. Marczak, L., Gelsomino, S., Lusk, D. Calcified tendo-achillesinsertion: a new surgical approach. J. Foot Surg. 5:457-459, 1991.

16. Schepsis, A., Wagner, C., Leach, R. Surgical management ofAchilles tendon overuse injuries. Am. J. Sports Med. 5:611-619,1994.

300 THE JOURNAL OF FOOT AND ANKLE SURGERY