current concepts review: insertional achilles … of the achilles tendon is a common source of...

FOOT & ANKLE INTERNATIONAL

Copyright 2010 by the American Orthopaedic Foot & Ankle SocietyDOI: 10.3113/FAI.2010.0933

Current Concepts Review: Insertional Achilles Tendinopathy

Todd A. Irwin, MDAnn Arbor, MI

INTRODUCTION

Pathology of the Achilles tendon is a common sourceof posterior ankle and heel pain. A variety of terms havebeen used to describe similar but clinically distinct condi-tions involving this tendon including tendinosis, tendinitis,paratenonitis, and peritendinitis. The latter are misleadingbecause their suffixes imply an inflammatory process.However, inflammatory cells are rarely present in biopsiesfrom involved tendons.3 The most common histopathologicfinding is a degenerative process characterized by disorga-nized collagen, abnormal neovascularization, necrosis andmucoid degeneration.34,58 Based on these findings, Maffulliand colleagues advocated for the term tendinopathy todescribe the syndrome characterized by pain, swelling andimpaired performance.39

While runners comprise the largest group of patientswith chronic pain in the Achilles tendon, individuals ofall activity levels and ages present with similar complaints.The location of the pain is an important discriminatingfactor, as insertional (tendon-bone junction) pain is oftentreated differently than noninsertional (2 to 6 cm proximalto the insertion) pain. This review will focus on insertionaltendinopathy and will discuss related disorders includingretrocalcaneal bursitis and Haglund’s deformity.

Recently, much has been learned regarding the patho-physiology of Achilles tendinopathy and this knowledge haslead to the development of new treatment options. However,the evidence to support these innovative approaches has notbeen appraised. This current concepts review will presentthe etiology, pathophysiology, and evaluate the merits of

No benefits in any form have been received or will be received from a commercialparty related directly or indirectly to the subject of this article.

Corresponding Author:Todd A. Irwin, MDClinical Assistant ProfessorDepartment of Orthopaedic SurgeryUniversity of Michigan2098 S. Main St.Ann Arbor, MI 48103-5827E-mail: [email protected] information on pricings and availability of reprints, call 410-494-4994, x232.

currently available treatment options for the management ofinsertional Achilles tendinopathy.

BACKGROUND

The etiology of Achilles tendinopathy is likely multifacto-rial. Numerous factors including pes cavus, hyperpronation,advancing age, hypertension, diabetes, obesity, steroid use,use of estrogen and fluoroquinolone antibiotics have beenassociated with Achilles tendon disorders.6,23,34,52 Overuseand genetic predisposition are also believed to contribute tothe onset of disease.6,34,42 Shoewear may also play a role.Insufficient heel height, poor shock absorption, and wedgingfrom uneven wear, are factors that may affect the stressapplied to the tendon. Poor training habits including exces-sive training, training on hard or sloping surfaces, and abruptchanges in scheduling have been shown to contribute to theonset of tendinopathy.6,34,52

Pain and swelling posterolaterally or anterior to thetendon, usually signifies retrocalcaneal bursitis. Meanwhile,a bony prominence present on the superolateral aspect of thecalcaneal tuberosity is referred to as a Haglund’s deformity(also called a pump bump). Pain and a tender subcutaneousadventitial bursa may occur over this prominence due torubbing against the heel counter. While these two conditionsare clinically distinct, both are often seen together and inconjunction with insertional Achilles tendinopathy.

Most studies examining the epidemiology of Achillestendinopathy have focused on the athletic population,specifically runners. One large retrospective study ofcompetitive and recreational athletes with Achilles tendonproblems reported that 66% had noninsertional tendinopathyand 23% had either retrocalcaneal bursitis or insertionaltendinopathy.33 Kujala and colleagues compared malerunners to matched controls and found 29% of runnersreported an overuse injury of the Achilles compared to 4% ofa control group.32 After following 60 elite runners, Lysholmand Wiklander reported an annual incidence of Achillestendon disorders of 7% to 9%.38

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PATHOPHYSIOLOGY

While advancing age, decreased vascularity and increasedmechanical strain are frequently postulated as causativefactors, the true pathogenesis of Achilles tendinopathyremains unknown. Lyman et al. investigated the distribu-tion of tensile strain at the insertion of the Achilles tendonduring functional range of motion. Based on the usual site oftendinopathy, they hypothesized that the location of higheststrain would be anterior. Interestingly, their cadaveric biome-chanical study showed increasing strain in the posteriorportion of the tendon, with a trend toward decreasing strainin the anterior portion, thus describing a stress-shieldingeffect within the tendon.37 A review of the biomechan-ical literature echoes this finding that the site affected withtendinopathy is generally “stress shielded”.41 Rufai et al.described the tendency for cartilage-like changes to developwithin the tendon on the stress-shielded side of the enthesisleading to intratendinous bone formation through endochon-dral ossification.58 The work of Benjamin et al. suggeststhat that calcification and spur formation at the insertion isnot dependent on inflammation or preceding microtears ofthe Achilles. These authors claim that spur formation wasan adaptive process that increases the surface area at thebone-tendon junction, thereby protecting this area in the faceof increased mechanical loads.4 These findings suggest thatthe role of repetitive tensile loading in insertional Achillestendinopathy is more complex than originally thought.

Another common hypothesis maintains that decreasedvascularity associated with advancing age contributes tooveruse injury of the Achilles tendon. However, a recentstudy utilizing power Doppler ultrasound showed neovas-cularization in 55% of painful tendons compared to 4% ofasymptomatic controls.72 Knobloch et al. used laser Dopplerflowmetry to reveal a significant elevation in microcircula-tory blood flow within tendons with insertional and midsub-stance disease compared to their uninvolved contralateraltendon and compared to a normal athletic control group.31

These studies suggest the presence of a relationship betweenneovascularization and pain in tendinopathy, a reaction to ahypoxic, degenerative lesion within the tendon.

CLINICAL PRESENTATION

Patients will complain of pain, swelling, burning, andstiffness. They will frequently localize symptoms to theposterior midline of the tuberosity, but may identify a medialor lateral focus. Exercise, stair climbing, and running on hardsurfaces are activities that exacerbate their symptoms. In theearly stages, patients will report that their symptoms occuronly after strenuous activity, but as the disease progressesand becomes chronic, any activity may cause symptoms,including walking. Patients may even experience symptomsat rest.

Physical examination commonly reveals tenderness andswelling at the posterior aspect of the calcaneal tuberositywith a midline or posterolateral bony prominence. If thelocation of these findings is anterior, lateral, or less frequentlymedial to the tendon, then retrocalcaneal bursitis is morelikely to be the diagnosis.

IMAGING

Weightbearing radiographs of the foot should be the initialimaging study. The anteroposterior view can identify a pesplanovalgus or cavovarus foot. The width of the Achillesshadow and maintenance of Kager’s triangle should beevaluated on the lateral view. The presence of intratendinouscalcification and a bony spur is best seen on this view,but may also be appreciated on an axial view of thecalcaneus.

Magnetic resonance imaging (MRI) can provide additionalinformation regarding the Achilles tendon. Most studies haveevaluated MRI in the setting of chronic tendinopathy, bothinsertional and noninsertional. Karjalainen et al. evaluated118 painful tendons and found that 15% had intrasubstanceabnormalities within 2 cm of the insertion, 8% had increasedsignal in the calcaneus, and 19% had an enlarged retro-calcaneal bursa.28 Haims et al. reviewed “abnormal” MRimages in 94 feet and found only 64 were clinically symp-tomatic. The authors noted a significant overlap in findingsbetween symptomatic and asymptomatic tendons, however,calcaneal edema was found almost exclusively in symp-tomatic patients.19 Nicholson et al. retrospectively reviewed157 patients with insertional Achilles tendinopathy, classi-fied the degree of degeneration based on MRI findings, andpredicted the success of nonoperative treatment based on thefindings. They concluded that tendons with confluent areas ofintrasubstance signal abnormalities are unlikely to respond tononoperative treatment.47 Shalabi proposed that serial studiescould be used to monitor the effects of treatment for chronicAchilles tendinopathy.59

The role of diagnostic ultrasound has increased in recentyears. It is a less expensive alternative to MRI, and permitsdynamic examination of the tendon. A case-control studyshowed enlargement of the mid and distal portions of thetendon, disruption of the fibrillar pattern, and an increase invascularity in patients with chronic Achilles tendinopathycompared to normal controls.36 Astrom et al. comparedthe images from ultrasound and MRI with surgical find-ings in 27 patients with chronic Achilles tendinopathy.They concluded both modalities gave similar informationand may best be utilized as a prognostic instrument.2

Overall, while neither ultrasound nor MRI is requiredto diagnose tendinopathy, both can assist in preoperativeplanning.

Copyright 2010 by the American Orthopaedic Foot & Ankle Society

Foot & Ankle International/Vol. 31, No. 10/October 2010 INSERTIONAL ACHILLES TENDINOPATHY 935

NONOPERATIVE TREATMENT

Activity and shoewear modification

A period of rest or cessation of activities that incitesymptoms is often the initial treatment for noninsertionaltendinopathy. Often, the use of orthoses, heel lifts, bracesand immobilization with a cast or pneumatic walking bootis combined with this period of modified activity. It is agenerally held consensus that one or more of these optionsshould be pursued prior to initiating any invasive treatments(Level V evidence), and there are no published studiesdocumenting the efficacy of these options for insertionalAchilles tendinopathy. Given this lack of data, insufficientevidence exists to recommend for or against the use ofrest, activity and shoewear modification as treatment for thisdisorder (Grade I recommendation).

Eccentric training

Eccentric training, during which the tendon unit is length-ened during simultaneous muscle contraction, has showngood results in the treatment of noninsertional Achillestendinopathy.12,70 However, consistent results have not beenobserved with insertional tendinopathy. In one study, only32% of patients with insertional Achilles tendinopathydemonstrated satisfactory results compared to 89% ofpatients with noninsertional pain.12 Jonsson et al. eval-uated a new protocol for eccentric training that elimi-nated ankle dorsiflexion to avoid impingement between theAchilles tendon, retrocalcaneal bursa and calcaneus whichwas the presumed source of prior poor results for insertionaltendinopathy. This short-term pilot study (Level III evidence)showed improved clinical results in 67% of patients.27

Knobloch et al. investigated the physiologic effects ofeccentric training on diseased Achilles tendons comparedto controls for 12 weeks (Level I evidence). Pain levelsin the study group decreased by 48%; though this groupcontained patients with both insertional tendinopathy (nineof 15) and noninsertional tendinopathy (six of 15). All studygroup patients showed evidence for preserved paratendonoxygen saturation. Paratendinous postcapillary venous fillingpressure, which can decrease the venous congestion seen ininflammation, was reduced in the Achilles midportion anddeep insertional areas, but was increased at the superficialinsertional region.30 Eccentric training has been comparedto extracorporeal shock wave therapy, in a randomized,controlled trial of patients with chronic insertional Achillestendinopathy (Level I evidence). This study showed thatthe results for eccentric training were inferior, although theprotocol for eccentric training utilized maximum dorsiflexionof the ankle.57 Based on the limited data available evaluatingthe effects of eccentric training on insertional Achillestendinopathy, there is insufficient evidence to support the useof this modality for this condition (Grade I recommendation).

Extracorporeal shock wave therapy (ESWT)

Extracorporeal shock wave therapy has been used to treatmultiple orthopaedic disorders including plantar fasciitis,shoulder calcific tendinitis and lateral epicondylitis.14,15,48

ESWT is hypothesized to improve symptoms by promotingneovascularization and angiogenesis at the tendon-bone junc-tion and inducing degeneration of epidermal nerve fiberswith subsequent reinnervation.50,64 Randomized controlledtrials comparing ESWT to placebo in noninsertional Achillestendinopathy have shown conflicting results.8,55

Two studies specifically evaluating the effect of ESWTon insertional Achilles tendinopathy have been reported. ALevel III case-control study comparing high-energy ESWTto nonoperative therapy showed significant improvement inpain scores in the ESWT group.13 This study also suggesteda local anesthesia field block done prior to the applicationof the shock waves may decrease the effectiveness. Rompeet al. performed a randomized controlled trial comparingthe effectiveness of eccentric loading therapy to low-energyESWT (Level I evidence). While on average the outcomemeasures and pain scores improved for both groups, thelow-energy ESWT group had significantly more favorableresults than the eccentric loading group.57 This study did notinclude a sham treatment group. Therefore, the contributionof a placebo effect to the shockwave results was not assessed.

The limited number of studies in the literature and thevariation in the timing and dosing of shockwaves providesinsufficient evidence to support the use of ESWT in thetreatment of insertional Achilles tendinopathy (Grade Irecommendation).

Corticosteroid injections

Corticosteroid injections have been used to treat multipleorthopaedic conditions, including acute and chronic tendondisorders.53 No consensus exists regarding their efficacy andconcern for rupture after injection has limited their use inthe management of insertional Achilles tendinopathy.1,16,60

Animal studies have shown that collagen breakdown, celldeath, and adverse biomechanical properties occur whencorticosteroid is injected directly into a tendon.24,25,53

Metcalfe et al. performed a systematic review to evaluatethe effects of glucocorticoid injections into diseased Achillestendons. Only 5 studies met their inclusion criteria, includingone randomized controlled trial, three retrospective studiesand one prospective case series. No study looked exclusivelyat insertional Achilles tendinopathy. Four examined peri-tendinous injection and one study assessed an intratendinousinjection. The randomized controlled trial indicated there wasno value in the use of peritendinous corticosteroid injection,while the remaining studies showed variable pain relief andsafety.45 In addition, while one study demonstrated the effi-cacy of using ultrasound guidance for peritendinous injection,the adherent nature of the paratenon near the Achilles inser-tion especially in affected tendons would make this approach



difficult. Based on the lack of dedicated studies to the inser-tional region of the Achilles and the inherent risk of tendonrupture, there is insufficient evidence to support the use ofcorticosteroid injections for insertional Achilles tendinopathy(Grade I recommendation).

Sclerosing therapy

To test the theory that neovascularization contributes to thepain associated with tendinopathy, investigators have studiedthe effect of sclerosing therapy. Polidocanol is a sclerosingagent that destroys the neovessels and presumably, theadjacent nerves. Good results have been demonstrated for theuse of this agent in the treatment of midsubstance Achillestendinopathy.7 A subsequent pilot study evaluated sclerosingtherapy in chronic insertional tendinopathy. The short-termresults showed increased patient satisfaction and decreasedpain levels in eight of 11 patients.49 A report of a singlecase of tendon rupture in an elite athlete after sequentialinjections with sclerosing agents has been reported.20 Thepaucity of data lacks sufficient evidence to support the useof sclerosing therapy for insertional Achilles tendinopathy(Grade I recommendation).

OPERATIVE TREATMENT

Patients who do not respond to conservative treatmentmay become candidates for operative management. Noconsensus exists regarding the duration of conservativetreatment before surgery, though most clinicians consider3 to 6 months the minimum time necessary to assessits effect. The surgery typically includes excision of theretrocalcaneal bursa, resection of the prominent superiorcalcaneal tuberosity, and debridement of degenerative tendonincluding calcifications and, if necessary, reattachment of thetendon to bone.

Several studies have investigated open retrocalcanealdecompression and tendon debridement through a variety ofapproaches.29,62,66,71 Watson et al. compared the results of16 cases of retrocalcaneal bursitis and 22 cases of bursitiswith calcific insertional Achilles tendinopathy. Both groupswere treated with an open retrocalcaneal decompressionthrough a posterolateral approach and the latter group hada debridement of the Achilles with minimal detachment ofthe tendon. The patients with calcific insertional Achillestendinopathy reported a significantly lower rate of satisfac-tion, more pain, more shoewear restrictions, and nearly twiceas much time to reach symptomatic improvement66 (LevelII evidence). Yodlowski et al. retrospectively reviewed theresults of 35 patients treated with open retrocalcaneal decom-pression through a lateral incision (Level IV evidence). Inthis study, intratendinous calcifications were excised througha longitudinal incision. Ninety percent of patients reportedcomplete or significant relief of symptoms, and the remaining10% felt improved71 Another investigation evaluated the

results of open retrocalcaneal decompression through a medi-ally based J-shaped incision and compared partial or nodetachment of the Achilles insertion with complete detach-ment and proximal V-Y lengthening (Level III evidence).The tendons were reattached to bone with suture anchors.Both groups demonstrated high rates of satisfaction withno significant difference found in subjective measures ofclinical outcome.63 Maffulli et al. achieved good clinicalresults through a medial approach and a variable amount oftendon detachment that was based on the extent of calcifictendinopathy present at the insertion. The number of sutureanchors used for reattachment was based on the amount oftendon detached from its insertion40 (Level IV evidence).A central tendon splitting approach has also provided goodclinical results.26,44 In these studies, suture anchors wereused for reattachment when greater than 50% of the tendonwas detached from its insertion,. In one study, age greaterthan 55 years correlated with advanced disease found intra-operatively and a trend towards a poor clinical outcome.44

Interestingly, another study found no significant differencein outcome between patients older or younger than 50 yearsusing a similar surgical technique26 (Level IV studies).

Decompression of the retrocalcaneal space can be per-formed endoscopically. This technique can address bony andsoft tissue impingement, although its ability to debride thetendon and remove calcifications is limited. Leitze et al.compared the results of endoscopic and open decompression(Level II evidence). Both techniques had similar outcomescores and recovery times, however patients treated endo-scopically had fewer complications and a better cosmeticresult.35 Two separate case series have reported good clin-ical outcomes with endoscopic decompression, however oneof these studies reported an Achilles tendon rupture 3 weeksafter surgery51,61(Level IV evidence).

Many authors advocate for the addition of a tendon transferafter debridement and/or reattachment of the Achilles tendon.Transfer of the flexor hallucis longus (FHL) tendon is thepreferred reconstruction based on its excellent strength, in-phase contraction, and low-lying muscle belly to enhancethe perfusion and healing of the reconstruction.65 Severalstudies have investigated the use of FHL tendon transfer forchronic Achilles tendon ruptures and noninsertional Achillestendinosis.18,43,65,67,68 Wapner et al. initially described adouble-incision harvest technique using a medial midfootincision for distal release of the FHL.65 Hansen and morerecently Den Hartog have described a single-incision FHLharvest technique.10,21

Two studies have evaluated the use of an FHL tendontransfer in patients with insertional Achilles tendinopathytreated with partial calcaneal ostectomy, intratendinousdebridement with or without reattachment. Den Hartogreviewed his results with 29 cases in 26 patients (27 of29 cases were insertional Achilles tendinopathy) (Level IVevidence). He found significant improvement in AOFASankle-hindfoot scores and 88% rate of patient satisfaction.



The subgroup of patients greater than 50 years of age had atleast as good an outcome as those less than 50 years.10 Eliaset al. utilized the same single-incision technique describedby Den Hartog; however, in their study the FHL tendon wasfixated in the calcaneus using a bioabsorbable interferencescrew11 (Level IV evidence). In addition to excellent AOFASankle-hindfoot scores and significantly improved VAS painscore, there was no loss of plantarflexion strength or power,and only a four degree loss of active ankle range of motion.The rate of satisfaction in this study was 95%. A third studyreported similar functional outcome and pain scores withthe single incision technique. However, it was unclear if thepatients with chronic Achilles tendinopathy were insertionalor noninsertional69(Level IV evidence).

Overall, the operative management of insertional Achillestendinopathy is supported by the literature. The consistentlygood results from a spectrum of high and low quality inves-tigations constitute fair evidence to support the excisionof the superior calcaneal tuberosity, decompression of theretrocalcaneal bursa and debridement of insertional Achillestendinopathy through an open procedure utilizing a medial,lateral or central tendon-splitting approach (Grade B recom-mendation). The paucity of evidence from well-designedcomparative studies prevents a recommendation of one tech-nique over another regarding the method of debridement,reattachment or fixation of the Achilles tendon. Partial orcomplete detachment from the insertion may be necessary todebride and remove intrasubstance calcifications adequatelyfrom the Achilles tendon. The decision to reattach and securethe tendon to bone with fixation occurs at the discretion of thesurgeon. At this time, the evidence is insufficient to supportthe performance of these procedures endoscopically (Grade Irecommendation). Lastly, the favorable results reported withtransfer of the FHL tendon after debridement, reattachment,or both provides level IV evidence to support the use of thisprocedure (Grade B recommendation).

Operative complications

One series with a large cohort looked specifically at therate of complication after the surgical management of chronicAchilles tendinopathy and reported an overall complicationrate of 11%. In the insertional tendinopathy subgroup, a4.7% complication rate was observed, including one skinnecrosis, one superficial wound infection, two hematomas,and one fibrotic reaction or scar formation.54 Avulsion of theAchilles tendon has been reported, and is usually precipitatedby a fall that occurs in the early postoperative period.5,63,66

Major wound complications, although rare, are potentiallydevastating.63 Fortunately, the most common wound compli-cations reported are related to the scar, with hypersen-sitivity, hypertrophy, and numbness frequently mentioned.Other complications reported include delayed wound healing,superficial infection, sural neuritis, recurrence of pain, anddeep vein thrombosis.26,40,44,63,66,71

Complications specific to FHL tendon transfer have alsobeen reported. Medial plantar nerve transection and halluxcock-up deformity have been reported with the double-incision technique.18,22 A cadaver study showed injury toeither the medial plantar nerve or lateral plantar nerve in 33%of specimens after the medial midfoot harvest of the FHLin the double-incision technique.46 Decreased flexion powerat the hallux interphalangeal joint was shown after single-incision FHL tendon transfer, although patient function washigh.56 The effect of FHL transfer on forefoot loadingremains uncertain.9,17,56

SUMMARY

1. Achilles tendinopathy is a clinical syndrome character-ized by the combination of pain, swelling and impairedperformance. Insertional tendinopathy is located at thetendon-bone junction on the posterior calcaneus, andnoninsertional tendinopathy is usually located 2 to 6 cmproximal to the insertion.

2. The etiology of Achilles tendinopathy is multifactorialincluding anatomic factors such as hindfoot alignment,medical factors such as diabetes and fluoroquinolone use,mechanical factors such as shoewear and heel height, andtraining factors such as overuse. Genetic predispositionmay also play a role.

3. The true pathogenesis of insertional Achilles tendino-pathy is unknown. Studies suggest that there is a stress-shielding effect on the anterior portion of the Achillesinsertion, which may lead to calcification and spurformation. Neovascularization at the Achilles insertionhas also been demonstrated, with some evidence this isone source of pain. Studies also suggest a degenerativeprocess as opposed to an inflammatory process based onbiopsy specimens.

4. While eccentric exercise has shown good results inthe treatment of noninsertional Achilles tendinopathy,there is conflicting evidence and few quality studiesinvestigating the effect of this treatment on insertionalAchilles tendinopathy (Grade I recommendation).

5. Other conservative treatments such as extracorporealshockwave therapy, corticosteroid injections, and scle-rosing agents have been studied, though at this time thereis insufficient evidence to support the use of one modalityover another of these modalities (Grade I recommenda-tion).

6. Fair evidence exists to support the use of surgical decom-pression of insertional Achilles tendinopathy that hasfailed conservative treatment (Grade B recommenda-tion). Augmentation with a FHL transfer has gained inpopularity, though currently only fair evidence exists tosupport the use of this procedure (Grade B recommenda-tion).



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