A Closer Look At Platelet-Rich Plasma For Achilles Tendon Pathology

David Soomekh, DPM, Sydney K. Yau, DPM, and Bob Baravarian, DPM, FACFAS

   Achilles tendon injuries may occur due to a number of intrinsic or extrinsic factors. Age, body type, gender, tendon vascularity, gastrocnemius-soleus dysfunction, overpronation, lateral heel strike, pes cavus, lateral ankle instability, poor training technique and/or improper footwear can predispose someone to an Achilles tendon injury.2-5 Repetitive microtrauma or overload can also predispose the tendon to inflammation of its sheath and intratendinous degeneration.2-5 Pain may be indicative of a partial rupture in the degenerate tendon in this area and will ultimately lead to thickening and nodularity of the tendon.5

Essential Diagnostic Keys

Paratenonitis of the Achilles tendon may present with pain and swelling to the area. This inflammatory condition develops acutely and can cause discomfort throughout the tendon. Inflammation of the paratenon may be associated with degeneration of the associated tendon. If the paratenon is chronically inflamed, it may thicken and cause adhesions to the Achilles tendon.2-6

   Tendinosis or tendinopathy is the preferred term to describe the degenerative noninflammatory process of a tendon. Do not use the term tendonitis as the condition is not associated with any inflammatory cells and researchers have shown that inflammation of the tendon does not occur at any stage during the degeneration of the Achilles tendon.7 This noninflammatory process begins with mucoid or fatty material accumulating throughout the affected portion of the Achilles tendon. The fibers then thin and disorient, causing fibril ruptures. These tears can coalesce and form larger tears within the tendon. This ultimately results in thickening of the tendon that can be diffuse, nodular or fusiform.2,5,6

   One can often establish a clinical diagnosis with a clinical examination. Focal or generalized swelling and pain on palpation to the Achilles tendon are indicative of a pathologic tendon. If a clinical diagnosis is not clear, one may assess the Achilles tendon with the use of plain radiography, ultrasound or magnetic resonance imaging (MRI).2,8

   A lateral radiograph of the foot can somewhat show the thickness and continuity of the tendon. It can also be useful in evaluating a Haglund’s deformity, tendon calcification, calcaneal spurring or insertional tendinopathy.2,3

   A MRI is very sensitive in showing changes such as intratendinous lesions and tears within the Achilles tendon. It will also show any thickening of the tendon that may be indicative of a degenerative tendon. The normal thickness of the Achilles tendon is approximately 4 to 6.7 mm. Normally on a MRI, the Achilles tendon shows homogeneously low signal intensity with a concave or flattened anterior border and a convex posterior border.2

   Ultrasound examination allows for dynamic evaluation of the Achilles tendon. It allows for evaluation of normal tendon movement and glide during ankle motion. A normal Achilles tendon on ultrasound in the sagittal plane will show a homogenous and tightly packed fibrillary structure that broadens toward the calcaneal insertion. The fascicles are arranged in a regular honeycomb pattern in the axial plane. On the axial plane, the normal Achilles tendon has a concave anterior border and a convex posterior border. Ultrasound also allows for the assessment of vascularity of the tendon with the color Doppler. Pathological tendon conditions are associated with hypervascularity of the region secondary to angiogenesis.2

A Primer On Treatment Options For Achilles Paratenonitis And Tendinosis

When it comes to Achilles paratenonitis and tendinosis, one can usually treat these conditions successfully with non-operative measures such as rest, activity modifications, correction of training errors, physical therapy, and shoe modifications such as a slight heel lift to the affected extremity.

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