Tendinopathy is the term used for degeneration of a tendon, which is accompanied by new blood vessel formation into the tendon which is thought to contribute to the pain and the pathology.
Achilles tendinopathy can develop at two areas.
• Within the main body of the tendon: Non-Insertional Achilles Tendinopathy
• At its insertion into the heel bone: Insertional Achilles Tendinopathy
Non-Insertional Achilles tendinopathy
This condition presents with pain within the Achilles tendon in an area two to six centimetres above its insertion into the back of the heel. This area is susceptible to injury due to a reduced blood supply.
The exact causes of the condition are unclear but theories include:
• Excessive tendon loading during training
• The function and motion of the Achilles tendon: excessive heel motion, which can lead to whipping of the tendon
• Body weight
• Unstable ankle
• High arched foot
• Certain medications
• Recent discoveries have shown certain gene expressions can influence tendon cellular activity.
Investigations include ultrasound and MRI scans. An X-ray might be done to rule out any bony abnormality.
There can be good long-term outcomes with the following:
• Anti-inflammatory drugs
• Activity modification: reduction of speed, distance, time and the running surface
• Footwear alteration / review
• Eccentric stretching
• Extracorporeal shock wave therapy
• Transverse friction massage (across the tendon)
• Injections: High Volume Image Guided Injections
A high-volume image guided injection is performed under ultrasound guidance. The injection comprises of water and local anaesthetic. The aim of the injection is to separate the paratenon (a thin membranous covering over the main tendon) from the tendon itself thereby reducing the amount of new blood vessel infiltration into the tendon. The injection also reduces the pain and discomfort associated with the condition and allows for the eccentric exercises to be performed.
Surgical treatment is only considered after six months of conservative care.
The aim of surgery is to reduce the pain and improve your functional ability. There are many different types of surgical approaches including:
• Releasing any adhesions that may have formed between the tendon and the paratenon; paratenon stripping
• Removal of affected, degenerative areas of the tendon. If greater than fifty percent of the tendon is excised a tendon transfer would be required to maintain the strength and power of the ankle joint
The recovery time can vary depending on the procedures performed and may require a period of cast immobilisation.
Insertional Achilles tendinopathy
Insertional tendinopathy affects the Achilles tendon where it inserts into the back of the heel. This condition can be part of a triad of; Insertional Achilles Tendinopathy, inflammation of the bursa in front of the tendon; bursitis and enlargement of the bony prominence on the top of the heel (bursal projection; Haglund’s deformity) next to the bursa and the tendon. Bursitis (inflammation of the bursa), in isolation, is often responsive to steroid injections.
Like Non-insertional Achilles tendinopathy this condition causes pain during activity but also problems from foot wear due to swelling and increase prominence at the back of the heel bone.
The condition can be managed conservatively with footwear alteration, shock wave therapy, steroid injections, activity modification and heel raises but if this fails to alleviate the problem surgery may be required.
X-ray of the ankle showing calcification of the Achilles tendon
Enlargement of the back of the heel due to bony prominence.
Surgery can include:
• Resection of the bump on the top of the heel bone in relation to the bursa
• Resection of the bony outgrowth with re-attachment of the Achilles tendon to the heel. For this surgery, the Arthrex Achilles SpeedBridge™ is used. This allows for a faster return to weight bearing and recovery.
An animation of the technique can be viewed through the link: Here
In certain cases, there can be an increased pitch of the heel bone which can contribute to the pathology if this is the case a wedge of bone, from the heel, is resected, repositioned in a slightly upward position and fixed with screws to stabilize the bone whilst it heals.