Management of Insertional Tendinopathy of the Achilles Tendon
Section snippets
Semantics in Achilles tendon pain
Maffulli [3], [4], [5], [6] proposed a logical and easy-to-use nomenclature for describing Achilles tendon pathologies (Box 2). This has reduced the use of many confusing synonyms that were previously seen in the literature. The emphasis is upon tendon degeneration rather than inflammation. The clinical picture of pain, swelling, and impaired function is best referred to as Achilles tendinopathy [5]. This terminology may also be applied to the rotator cuff, patellar tendon, and other tendons
Local anatomy
To diagnose the cause of posterior heel pain or swelling arising in the region of the Achilles tendon insertion, a thorough understanding of the anatomy is essential (Fig. 1).
Multiple pathology
Posterior heel pain may be due to degenerative change in the insertional portion of the tendon itself, to enlargement of the retrocalcaneal bursa, or to both. The relevance of an associated Haglund deformity is less clear than previously believed [21]. Pump bumps are usually posterolateral and should not be confused with retrocalcaneal bursitis or insertional tendinopathy. Careful clinical assessment identifies the main pathology and thus guides treatment [22]. The same principle applies to the
Demographics
Achilles tendinopathy is common, but reliable epidemiological data is not available [26]. An association with athletic training is widely held to be evidence that overuse is the principal cause [10], [27]. Younger athletes have a lower incidence of Achilles pain than older individuals engaged in the same sport [28], [29]. Posterior heel pain can, however, affect sedentary individuals as well [12], [30]. Schepsis [30] reported that older athletes had a higher prevalence of insertional
Measuring Haglund deformity
The presence of a large bursal projection at the posterosuperior margin of the os calcis (Haglund deformity) has been associated with posterior heel pain since its first description in 1928 [31]. Many radiographic measurements have been described in an attempt to define the point at which the posterosuperior margin of the bone becomes excessively prominent [32], [33], [34], [35], [36]. Of these measurements, the parallel pitch lines described by Pavlov and colleagues [33] and the superior
Assessment
As with noninsertional Achilles tendinopathy, most patients with insertional symptoms respond to nonoperative treatments [20], [22], [37], [38], [39], [40]. Tailoring the treatment and advice given to the individual patient is essential, and the physician must base treatments on a clear diagnosis as well as on assessment of relevant biomechanics.
Orthotics and shoes
Patients with pump bumps respond to education regarding the cause of the symptoms, modification of shoes, and occasionally an orthotic to lift the affected part of the heel away from the upper margin of the heel counter. To avoid recurrence of the problem, the patient must fully understand that he or she must continue to be careful with choice of shoes even after the swelling and tenderness resolve.
Retrocalcaneal bursitis can be managed along similar lines. There may be some benefit from
Authors' preferred treatment
The authors believe that an accurate assessment of the source of pain guides treatment. Nonoperative treatment is preferred initially. Steroid injection is avoided wherever possible and, if performed, ultrasound guidance is used. The patient is counseled regarding the risk of rupture. For recalcitrant cases, surgery has good results (Box 3). If an isolated gastrocnemius contracture cannot be corrected by physiotherapy, a gastrocnemius release is considered. As with eccentric physiotherapy
References (59)
- et al.
Insertional Achilles tendinopathy
Foot Ankle Clin
(2005) - et al.
Overuse tendon conditions: time to change a confusing terminology
Arthroscopy
(1998) - et al.
Molecular events in tendinopathy: a role for metalloproteases
Foot Ankle Clin
(2005) The anatomy of the Achilles tendon
Foot Ankle Clin
(2005)- et al.
The anatomy of the calcaneus and surrounding structures
Foot Ankle Clin
(2005) Haglund's deformity and retrocalcaneal bursitis
Orthop Clin North Am
(1994)- et al.
Insertion tendopathy in athletes. A light microscopic, histochemical and electron microscopic examination
Pathol Res Pract
(1982) - et al.
Types and epidemiology of tendinopathy
Clin Sports Med
(2003) - et al.
Haglund's syndrome
J Foot Ankle Surg
(1998) - et al.
Imaging of the Achilles tendon
Foot Ankle Clin
(2005)