· inflammation of Achilles tendon at or near insertion into calcaneus
· common in
· runners
· tennis players
· dancers
· noninsertional form due to repetitive loading associated with jumping
· occurs in area of decreased vascularity and fibre rotation
· insertional form may be associated with shoewear
· occurs at site of insertion
· involves tendon just proximal to insertion
· inflammation of peritendon and/or tendon
· associated with chronic overuse
Peritendinitis
· inflammation limited to peritendon
Tendinitis
· tendon thickened
· focal areas of degeneration
· may be partial tear
· inflamation of tendon associated with
· retrocalcaneal bursitis
· bony protruberance of os calcis (Haglund’s)
· associated with women’s shoewear
Bursitis
· retrocalcaneal bursa lies between tendon and posterior surface of calcaneum
· normal lubricating structure
· may become inflamed
Bony protruberance
· prominence of posterior superior tuberosity of calcaneus
· called Haglund’s deformity
· causes impingement and mechanical abrasion of tendo Achilles at insertion
Presentation
· pain 2-6 cm proximal to insertion
· usually worse in morning and after exercise
· may present with complete rupture of tendon
Findings
· localised tenderness and crepitus
· tendon may be thickened
· dorsiflexion may be limited
X-ray
· normal
· partial tear may be demonstrated by ultrasound
Presentation
· pain at bone-tendon interface
· worse after exercise
Findings
· localised tenderness and thickening
· bony lump
· dorsiflexion may be limited
X-ray
· shows Haglund’s deformity
· may be calcification of bone-tendon interface with spur
Nonoperative
· rest
· NSAIDs
· stretching programme
· heel lift with medial arch support
Operative
· indication
· if fails to setle in 3-6 mths
· technique
· peritendon resected
· tendon debrided
· tears in tendon repaired
· if tendon severely compromised, transfer required
Nonoperative
· as for noninsertional
Operative
· indication
· if fails to settle in 3-6 mths
· technique
· tendon split longitudinally
· bony lump resected
· retrocalcaneal bursa excised
· calcified tissue removed
· degenerate tendon debrided
· tendon repaired
· if tendon severely compromised, transfer required
· can augment tendo Achilles with
· peroneus brevis
· FDL (preferred)
· FHL
· tendon released distally and proximally
· tendon woven through tendo Achilles
· then secured through drill hole in calcaneus
· usually age > 40 yrs
· calf contraction with forced dorsiflexion
· in setting of tendon degeneration
· sudden pain in calf
· with audible snap
· on unaccustomed exercise
· esp. tennis or squash
· if neglected
· difficulty with push off
· running, jumping, stairs compromised
· palpable gap
· weak plantarflexion
· positive Simmond’s sign
· squeezing calf does not produce plantarflexion
· if neglected, gap fills with scar tissue
· Simmond’s sign negative
· gap not palpable
· excessive dorsiflexion possible
· proponents of operative and nonoperative treatment
· most surgeons prefer surgical repair in most patients
Technique
· walking cast in equinus for 8 weeks
· then heel raise for 4 weeks
· physiotherapy and stretching programme
Results
· 10% risk of repeat rupture
· no risk of infection or wound breakdown
Technique
· posteromedial approach
· tendon repaired with modified Kessler core stitch
· reinforced with circumferential interrupted sutures
· plantaris detached proximally
· woven through repair for reinforcement
Results
· 2% re-rupture rate
· 5% incidence of wound problems
· may be able to approximate ends when scar freed
· may need to use augmentation
Bosworth technique
· median raphe of gastrocnemius harvested
· 1/2” wide x 8” long
· left attached just proximal to rupture
· strip passed transversely through proximal tendon
· then passed through distal end of tendon
· passed again across gap
· reinforced with plantaris tendon