Key Insights For Diagnosing And Treating Tendinosis

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Here one can see a typical example of mild/moderate Achilles tendinosis with mild fibrous enlargement.
With chronic insertional Achilles tendonitis, one will see calcification or spurring at the bone/tendon junction that extends into the tendon. (Photo courtesy of Patrick DeHeer, DPM, and Stephen M. Offutt, DPM)
Key Insights For Diagnosing And Treating Tendinosis
By Babak Baravarian, DPM

   Tendinosis is one of those diagnostic terms that took me a while to truly understand. People most often use this term in relation to the Achilles complex but tendinosis can be related to any tendon of the foot or ankle. In most cases, tendinosis is associated with the tendons about the ankle and the most commonly affected tendons are the Achilles, posterior tibial and peroneals.

   While tendinosis is a very simple concept to explain, it is a far more difficult concept to truly understand and treat. Essentially, tendinosis involves the fraying or scarring of the fibers of the associated tendon and the replacement of a small or extended region of the tendon with scar tissue or fibrous tissue. The level of scar may be palpable to pressure on the associated region or may be microscopic in nature. There may be a bulbous region of damage or very small, scattered regions of damage.

   When tendinosis involves the posterior tibial or peroneal tendons, there is no associated peritenon and accordingly no peritenonitis or peritenosis. The most common regions of tendinosis are at stretch areas such as the associated malleolar bends, the navicular insertion for the posterior tibial tendon and the fifth metatarsal base for the peroneus brevis tendon. There are also far less visible signs of problems and one may define the major pathology with an ultrasound or an MRI of the region. The Achilles is a totally different animal and may have many different pathology findings due to the fact that there is a tendon, a prominent insertion site and a paratenon.

Understanding And Addressing Achilles Tendon Pathology

   The overall result with the Achilles tendon pathology is that one can have a peritenonitis, a peritenosis, a tendonitis, a tendinosis, a partial tear, an exostosis or any combination. For the sake of this article, we will only address the tendinosis concept and leave the treatment of Achilles tendon pathology for a subsequent article.

   That said, we now understand that tendinosis is a fibrotic replacement of the true substance of a tendon with possible microscopic or small partial tears. When it comes to mild internal pathology, we know it is best to visualize this with an MRI or ultrasound.

   How does this pathology occur? The truth is it is not well understood in detail. The general concept is there is tension along the line of pull of the tendon, resulting in microscopic or macroscopic trauma to the tendon and a resulting partial tear of the tendon. The tearing may also be microscopic or macroscopic in nature. As there is minimal pain and discomfort on a daily basis at first, patients will continue to perform their regular activity and continue the microscopic damage to the region. Over time, the accumulation of trauma causes a replacement of the fibrils of tendon with scar tissue.

   The result is a tendon that is less flexible and stiffer with possible internal bulbous or linear tears, and degeneration of the tendon. One can best note this in a large tendon such as the Achilles. On a microscopic level, clinicians may see small linear tears and scar formation, mild thickening of the tendon and mild internal cystic changes. Over time, the scarring and cystic changes increase, and there may be thickening and bulbous enlargement of the tendon, which one can easily see through the skin and palpate with pressure along the tendon. With further neglect, there may be frank tears of the tendon or even complete replacement of a section of tendon with either bone or complete scar formation.

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