Achilles Tendinopathy: What Are The Best Treatment Options?

By Edward G. Blahous Jr., DPM

     When you perform a literature review on Achilles tendinopathy, be prepared to be inundated with a litany of citations. Literally hundreds of articles annually are dedicated to the investigation of this relatively enigmatic tendon. Some will focus on histological findings and others will feature anecdotal clinical investigations. A multitude of studies featuring newer, so-called “alternative” therapies are introduced and all the while, review-type articles of variable depth will litter your search.      Suffice it to say, filtering through this amount of information can be overwhelming to the practicing foot and ankle specialist. In spite of this, the diagnosis and treatment of various Achilles tendon disorders can and should be relatively straightforward. That is not to say that Achilles tendinopathy is a simple discussion. However, with a discriminating understanding of the current literature and a healthy dose of clinical experience, one can be quite adept at dealing with these pathologies.      Any discussion on the Achilles tendon should begin with an understanding of the currently accepted terminology. I prefer to separate proximal (“zone 1”) and distal (“zone 2”) pathologies. In the interest of clarity, “zone 2” or insertional disorders as well as ruptures (from zone 1) will be excluded from this discussion. However, the second case study below will discuss a complex surgical dilemma involving all aspects of Achilles tendinopathy.      Puddu is generally credited with the earliest, most appropriate classification of “zone 1” Achilles tendinopathy.1 The specific categories are peritendinitis, tendinosis, peritendinitis with tendinosis, and rupture. One should avoid the outdated terms “tendonitis” and “tenosynovitis” in any scientific discussion pertaining to this tendon. These terms are inappropriate given the lack of a true synovial sheath and the lack of evidence that the tendon manifests chemical inflammation.

A Guide To Key Anatomic Considerations

     In terms of general anatomic considerations, it is important to recall that the Achilles tendon is surrounded by a clear areolar tissue that allows movement between the tendon and the surrounding tissue. This paratenon is capable of manifesting an inflammatory response and can become adherent in conditions such as peritendinitis and/or tendinosis.      Another significant consideration is that of the rotation of fibers as the tendon courses distally. The fibers externally rotate beginning approximately 12 to 15 cm from the insertion and reaching a maximum of 2 to 5 cm proximal to it.2 This rotation may give insight as to why this area of the tendon is notoriously afflicted with pathology. It may also give credence to the use of orthoses in the context of an everted heel. Anecdotally speaking, I have had success with the use of orthoses in treating Achilles tendinopathy but only in cases involving a hyperpronated foot.      One final but significant anatomic consideration is the popular contention of a hypovascular or so-called “watershed” region of the Achilles tendon. The oft-cited Lagergren and Lindholm study from the 1950s is the primary basis of this notion.3 However, more recent studies and technological advances have questioned this decades-old scientific dogma.4 To this day, the debate about the vascular integrity of the Achilles tendon continues to evolve.

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