Non Insertional Achilles Tendinopathy

 

Tendinopachilles

 

Definition

 

Inflammation and degeneration of the achilles tendon in the midsubstance 2 - 6 cm from insertion

 

Classification of Tendon Inflammation

 

1. Peritendonitis - inflammation of paratenon

 

2. Tendinopathy - combination of inflammation + tendinous degeneration

 

3. Combination

 

Anatomy

 

Triceps tendon

- medial and lateral gastrocnemius + soleus

- surrounded by paratenon which allows gliding and supplies nutrition

 

Insertion

- middle 1/3 calcaneal tuberosity

- 2 x 2 cm area

- 90o rotation distally

 

Retrocalcaneal bursa (x2)

- proper is between tendon and calcaneum

- superficial is between tendon and skin

 

Etiology

 

Elite and recreational athletes in running sports

 

Also seen in diabetics / obesity

 

Symptoms

 

Pain 2-6 cm proximal to insertion

Usually worse in morning and improves with exercise

- compared to insertional that worsens with activity

 

Examination

 

achillesachillesachilles

 

Localised tenderness mid tendon

Tendon may be palpably thickened

Pain with dorsiflexion and plantar flexion

Dorsiflexion may be limited

 

MRI

 

Achilles tendinopTendon thickeningAch tendinop

Tendon thickening

 

Tendinoptendinop

Thickening of the tendon with some intra-substance degeneration / partial tearing

 

Nonoperative Management

 

Eccentric exercises

 

Mainstay of treatment

 

Prudencio et al BMC Sports Sci 2023

- systematic review of eccentric exercises for midportion tendinopathy

- evidence for these exercises in reducing pain

 

Night splints

 

de Vos et al Br J Sports Med 2007

- RCT of eccentric exercises +/- night splints for non insertional tendinopathy

- no advantage with the addition of night splint

 

Extra-corporeal shockwave therapy

 

Feeney et al Cureus 2022

- systematic review of ECSW for non insertional achilles tendinopathy

- four RCTs

- consistent evidence that ECSW effective at reducing pain and improving function

 

Injections

 

Cortisone

 

Risk of tendon rupture

 

PRP

 

Nauwelaers et al Foot Ankle Surg 2021

- systematic review of PRP for non insertional achilles tendinopathy

- 4 RCTS

- no difference in clinical outcomes between PRP and placebo

 

Operative management

 

Options

 

Paratenon debridement

- open

- endoscopic

 

Vertical tenotomies

- open

- endoscopic

- ultrasound guided

 

Technique

 

Arthroscopy techniques endoscopic paratenon debridement

 

Results

 

Open versus minimally invasive

 

Lohrer et al BMC Musculoskeletal Disord 2016

- systematic review of surgical treatments

- 20 studies and 800 procedures

- open procedures: statisfaction rates 78%, complication rate 11%

- minimally invasive: satisfaction rates 79%, complication 5%

 

Ultrasound guided percutaneous tenotomy

 

Maffulli et al AJSM 2013

- ultrasound guided percutaneous tenotomy

- 39 runners with average 17 year follow up

- 77% good or excellent results

 

Endoscopic debridement and tenotomy

 

Maquirriain et al Foot Ankle Surg 2013

- endoscopic debridement and longitudinal tenotomies

- 27 procedures with 5 year follow up

- 85% excellent outcome