Dr. Chandrashekhar Sonawane -Dept. Of Orthopaedics
47 years old male with left heel pain since15 dayspain more in the morning, aggravated byweight bearing, relieved with medicationsand rest.no H/O trauma, swelling, fever, any otherjoint pain,no H/O DM , koch’s
O/E - tenderness over posterior part of left heel and painful dorsiflexion of foot
conservative treatment anti-inflammatory drugs along with heel support No improvement after 6 monthsSurgery haglund bump excision by a central tendon splitting method
Total no. of cases in last year - 24Conservative management - 22Oprative management - 02
The largest and strongest tendon in the human body Formed from the tendninous contributions of the gastrocnemius and soleus musclesThe tendons converge appr. 15 cm proximal to the insertion at the posterior calcaneus
The right Achilles tendon appears to spiral counterclockwise 30‐150º toward its insertion at the calcaneusThe spiraling allows for elongation and elastic recoil within the tendon, facilitating storage and release of energy during movement
posterior tibial artery and its contributionsto the musculotendinous junction, as well asvessels which cross the paratenon. The watershed zone is an area 2‐6 cmproximal to the calcaneus, in which the bloodsupply is less abundant and becomes even sparserwith age
The osteotendinous junction of theAchillestendon is made up of1) Bone,2) Fibrocartilage, and3) Tendon.
-Complex interlocking between calcified fibrocartilage and bone at the insertion site-Interlocking is of fundamental importance in anchoring the tendon to the bone.
The triad ofPain,Swelling (diffuse or localized),and Impaired Performance constitutestendinopathy.
Insertional tendinopathy could beconsidered an overuse injury, but withpredisposition caused by preexistingweakening of the tendon.
Repetitive Traction Forces flat foot, pes cavus, obesity, overuse, poor trainingDegeneration , attrition , mechanical and chemical irritation chronic inflammatory response spur formation and calcification
Edema, mucoid degeneration, disruptionof collagen bundles, necrosis, smallhemorrhages, and calcification are notedAlso,areas with proliferating blood vessels withlymphocytes and histiocytes suggesting areparative process
-Increased activity of NADP-diaphorase, LDH, β-glucuronidase, and alkaline phosphatase.-Submicroscopic calcification and fibrillar degeneration.-Increased levels of type II and III collagen and decreased levels of type I collagen
Early morning stiffness,Pain that deteriorates after exerciseThickening or nodularity at the insertion.Range of motion of the ankle may or maynot be limited
Insertional tendinopathy of the Achillestendon seems to present moreoftenas a triadrather than as a solitary pathology.
Insertional tendinopathy of the Achilles tendon,Retrocalcaneal bursitis,Haglund’s deformity, the prominentposterosuperior calcaneal process
Haglund’s deformity,Retrocalcaneal bursitis,Os trigonum,Posterior talar process fracture,Flexor hallucis longus tendinopathy,Peroneal tendinopathy,Tibialis posterior tendinopathy,Osteochondral lesions of talus
-Blood investigations to rule out systemic conditions-(MRI scan and US scan) can help to confirm the diagnosis-Radiographs help identify ossification of insertion of the Achilles tendon or a spur (fishhookosteophyte) on the superior portion of thecalcaneum
Radiopacities of the Achilles tendonwere classified into three types byMorris et al.
Type I - Radiopacities at the Achilles insertion orsuperior pole of the calcaneus.Bony changes to the calcaneus are often seen intype I lesions.Insertional tendinopathy of Achilles tendoncauses type I abnormality
Type II -Radiopacities are intratendinous and areLocated 1–3 cm proximal to the Achillesinsertion, and are separated from calcanealsurface
Type III. Radiopacities are located proximal tothe insertion zone, upward to 12 cm above theinsertion zone.Type III is subdivided intoIIIA (partial tendon calcification) andIIIB (complete tendon calcification).
Classification based on ultrasonographicchanges at the Achilles tendoninsertion was introduced byPaavola et al.
Classification Insertional ChangesNo alteration No calcification. Homogeneous fiber structure in the insertional area.Mild abnormality Insertional calcification, length 10 mm or less and thickness less than 2 mm. Homogeneous fiber structure in the insertional area.Moderate Insertional calcification, length more than 10 mmabnormality and thickness less than 2 mm. Slight alterations in the echo structure of tendon in the insertional area.Severe abnormality Insertional calcification, length more than 10 mm or thickness more than 2 mm. Moderate to severe variety in the echo structure of tendon in the insertional area.
-Success rates of 85% to 95% have been reported with simple measures like rest, ice, modification of training, heel lift, and orthoses-stretching and strengthening exercises can also be effective.-Tendon loading stimulates collagen fiber repair and remodeling. Therefore, complete rest of the injured tendon is not advisable
Surgical options are considered after 3 to 6monthsof conservative management-Debridement of the calcific or diseased portion, Excision of the retrocalcaneal bursa, and Resection of the Haglund’s deformity, if present.
Various surgical procedures have beendescribedWe prefer to reattach the Achillestendon using bone anchors if one-third or moreof the insertion is disinserted.
A midline posteriorskin incision combined with a centraltendon-splitting approach for debridement,retrocalcaneal bursectomy, and removal ofthe calcaneal bursal projection as describedby McGarvey
Haglund’s bump excised after splitting tendo achilles
First two weeks- Protected weight bearingalong with leg elevation as much as possible
2 weeks to 4 weeks- A synthetic anteriorbelow-knee slab is applied, with the ankle inneutral and secured to the leg with three or fourremovable Velcro straps for 4 weeks
After 6 weeks- the anterior slab is removed.-Stationary cycling and swimming from 8th week-gentle training-Gradual progression to full sports activity at 20 to 24 weeks
Follow-up - Patients are reviewed at 3, 6, and9 months from the operation, and at 6-monthintervals thereafter.
Insertional tendinopathy of the Achilles tendonis a degenerative rather than an inflammatorylesion, though the accompanying bursitis maypaint an inflammatory picture
Type I collagen contributes to the tensilestrength in tendons, allowing them to resistforce and tension and to stretch. Therefore,tendons with an increased type III and areduced type I collagen content are lessresistant to tensile stresses
The diagnosis is mainly clinical, and radiographshelp in confirming the diagnosis as doultrasound scan or MRI scan