Achilles Tendinopathy: What Are The Best Treatment Options?

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This patient is demonstrating heavy-load eccentric calf muscle training as part of a 12-week rehabilitation program.
Here one can see forceps grasping the flexor hallucis longus tendon anterior to the surgically repaired Achilles tendon.
Here one can see forceps grasping an adherent paratenon. The paratenon is capable of manifesting an inflammatory response and it can become adherent in conditions like peritendinitis and/or tendinosis.
This photo depicts debridement of the Achilles tendon with an elliptical incision.
Achilles Tendinopathy: What Are The Best Treatment Options?
Achilles Tendinopathy: What Are The Best Treatment Options?
70
Author(s): 
By Edward G. Blahous Jr., DPM

     It is important to keep in mind that the anatomy in the arch can be quite challenging. Further, the neurovascular structures are precariously at risk in this area of dissection. Suffice it to say, some review of cross-sectional anatomy as well as some extra preparation in the cadaver lab would be prudent before taking on some of the more involved cases. One can appropriately achieve the majority of transfers with the more straightforward one incision approach. The second case presentation below depicts a very complex case involving, among other things, an FHL tendon transfer.

How To Reduce The Risk Of Complications

     As with any other surgical procedure, complications do occur. In the case of any Achilles surgery, wound complications are most notable. Wound dehiscence and infection are always of concern. Gentle tissue dissection and meticulous paratenon closure are critical to safeguard against this occurrence. Interestingly, I have seen few, if any, long-term complaints with respect to postoperative hallux function after the transfer. The flexor hallucis brevis remains intact and the variable communication between the FHL and FDL tendons in the porta pedis presumably allows at least some residual power to the distal tendon stump. Perhaps the patient is so pleased to have a functional Achilles tendon that he or she has little concern for any decreased hallux flexion.

     That said, take care when preparing any athletic or active patient for a tendon debridement with FHL transfer. The majority of these types of cases involve patients who are functionally debilitated as opposed to high-caliber athletes. The exact morbidity of FHL transfer in an athlete has not yet been scrutinized.

     The following case studies demonstrate profoundly different clinical presentations and treatments of Achilles tendinopathy. Hopefully, they give some insights as to treatment options when dealing with these pathologies.

Case Study: When Eccentric Rehabilitation Makes An Impact

     A 55-year-old male presents with a chief complaint of a painful, thickened Achilles tendon. The exam demonstrates classic fusiform swelling and pain with palpation of the tendon. After a three-week period of relative rest (walking boot), the patient began a 12-week eccentric rehabilitation program.

     Photos of initial, six-week and 12-week presentations demonstrate a relative decrease in the tendon volume. The patient reports no pain despite some residual tendon thickening and returned to full activity (walking and running) 14 weeks after the initial presentation. The patient reports no pain at 17 weeks and has been asked to follow up on a prn basis.

Case Study: When Complex Achilles Tendinosis Requires Surgical Treatment

     A 50-year-old male presents after a hyper-dorsiflexion injury to his ankle. He relates a history of feeling a “pop” in the Achilles tendon/heel area. The exam reveals a positive Thompson test (indicating total rupture) and a palpable gap noted just superior to calcaneal insertion. Radiographs reveal significant insertional spurring as well as calcification superiorly. Magnetic resonance imaging reveals that the proximal calcification is actually an avulsed fragment from the posterior calcaneus.

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