Emerging Insights On Treating The Painful Achilles
Achilles tendon problems have become more widespread with the increase in the number of adult athletes and an increase in the overall body mass index of patients. There have been many advances in the treatment of Achilles tendon problems with several improvements in conservative care, several so-called “overlap procedures” and multiple new surgical techniques.
In order to understand Achilles issues, we first need to discuss the make-up of the Achilles tendon and the terminology of associated problems. The Achilles complex is made up of several sections. On the outer surface is a lubricating sheath called the peritenon. This thin sheath acts to lubricate the tendon and improve its gliding mechanism. The actual tendon has an outer thicker layer and an internal fibrous layer made up of multiple fibrous strands. Together, these layers comprise the Achilles tendon proper.
In regard to inflammation of the peritenon, clinicians call this peritenonitis while inflammation of the Achilles tendon is called Achilles tendonitis. If there is fibrous scar tissue in the actual Achilles tendon, the proper term for such a problem is Achilles tendinosis.
Finally, if there is a spur in the posterior Achilles insertion site, physicians refer to it as a Haglund’s deformity for a dorsal lateral enlargement of the calcaneus. When there is an outgrowth of spur in the Achilles insertion site on the posterior calcaneus, it is called a retrocalcaneal exostosis.
In most cases of Achilles insertional problems, there is associated calcaneal bursitis or the presence of a bursal sack between the calcaneus and the Achilles tendon. There is also fibrous scar tissue in the Achilles tendon insertion which results in associated Achilles tendinosis.
Treatment of Achilles problems is often difficult because of the shotgun efforts to treat the tendon without a true understanding of the underlying cause of problems or even the actual problem such as tendonitis versus tendinosis. Diagnosis of the problem and the actual cause is essential prior to treatment.
In cases of peritenon problems, there is pain with soft rubbing of the medial and lateral tendons. One may also note possible crepitus of the tendon with squeeze and range of motion. There is also no thickening of the tendon.
In Achilles tendonitis cases, the tendon is painful. While this finding is similar to peritenon cases, there is no crepitus and there is pain with squeeze of the tendon, and mild to moderate swelling.
In tendinosis cases, there is bulbous enlargement of the tendon and scar in the region of tendinosis. There is pain to squeeze. Moderate to severe swelling may be present depending on the duration of the problem.
Essential Diagnostic Tips
When it comes to Achilles problems, usual diagnostic testing may include standard radiographs for foot alignment and checking for retrocalcaneal spurring. In the case of retrocalcaneal problems, a calcaneal axial image can provide a better view of the calcaneal posterior surface and show the actual region of spur formation.
Ultrasound is one of the best tools in the diagnosis of Achilles problems. The dynamic test can actually allow movement of the Achilles while one obtains the ultrasound images. Peritenon problems will show thickening of the peritenon with normal fibrillation and echogenecity of the Achilles proper.
With Achilles tendonitis issues, there is thickening of the Achilles tendon with no signs of tear. In Achilles tendinosis cases, one may see partial tears with scar formation. Using ultrasound can allow one to check the amount of tear and the amount of healthy viable tissue.
A power Doppler ultrasound enables physicians to check the level of blood flow to the tendinosis region to see if conservative care may help or not. In cases of poor blood supply, fibrous scar tissue in the tendon will respond less to conservative care in comparison to vascular regions. While magnetic resonance imaging (MRI) can also provide excellent imaging of the Achilles, it cannot reveal signs of vascular supply like power Doppler ultrasound.
A Guide To ‘Overlap Procedures’ For The Achilles
After making a diagnosis, I suggest a course of conservative care. Common conservative measures include rest, orthotics (to prevent the strain and possible overuse type injury to the Achilles), stretching and massage.
Practitioners have found that treatments such as acupuncture and medications such as Arnica and Traumeel (Heel, Inc.) have excellent potential in the conservative care of Achilles inflammation. One may also attempt a period of rest in a boot or cast in the conservative care of Achilles problems.
The area of treatment with the greatest advances in the treatment of Achilles problems is in the “overlap procedure” group. This term refers to minimally invasive injection or surgical procedures that one may perform in the office setting with little to no downtime following treatment.
Three new treatments attempt to increase blood supply to the Achilles complex and may possibly break up the scar tissue in the region as well.
The first is the injection of Traumeel and Arnica into the Achilles tendon and peritenon region. This has shown great promise in Achilles tendonitis and Achilles peritenon inflammation. A period of two to three weeks of rest in a boot is suggested after injection. Two to three injections at a week to two-week intervals may be needed for improvement.
The second treatment is the use of platelet rich plasma injections. Platelet rich plasma is the rich nutrient portion of a patient’s own blood that is drawn and spun down.
Subsequently, one may use the nutrient portion for injection therapy. Physicians may place the injection between the Achilles and peritenon, or the intrasubstance in the actual Achilles in cases of fibrous tendinosis. A period of rest in a boot is suggested. I prefer to do both of these procedures under ultrasound guidance for better accuracy with the injection placement.
The final overlap procedure is the use of radiofrequency Coblation (Arthrocare) to break up the fibrous cross-linked bonds in cases of Achilles tendinosis and increase blood supply to the area. Both platelet rich plasma and Coblation techniques seem to increase growth hormones and restart the inflammatory process for healing. Coblation also seems to decrease the normal sensory nerve pain associated with Achilles pain.
Pertinent Pointers On Surgical Options
Advances in surgical care include open scar resection of the Achilles complex with advances in flexor hallucis tendon transfer to the calcaneus in cases of severe tendinosis. Instead of having to harvest the flexor from the arch, one can harvest the tendon from the posterior heel region and place the tendon in the calcaneus with a biotenodesis screw. This results in early range of motion and rigid fixation.
Physicians have been giving more attention to the peritenon and potential problems with severe scar formation of the peritenon. In such cases, a release of the peritenon may be necessary and is often helpful.
The posterior Achilles retinaculum, which one can best visualize with ultrasound, may also be tight and cause pain in the central Achilles region. Resection of the retinaculum alone has been helpful in several cases we have done for elite athletes. Advances in tendon reattachment of the Achilles in cases of Haglund’s or retrocalcaneal problems have also allowed for early range of motion and less risk of tendon insertion pain.
Finally, orthobiologics have facilitated improved strength to the tendon in cases of tears or scar tissue with surgeons using the tissue material as a wrapping around the tendon.
Also bear in mind that some cases of Achilles tendon pain, especially at the insertion site, may be due to an equinus deformity. In such cases, the gastrocnemius tendon may be tight and restrict motion. We have found endoscopic gastrocnemius procedures to be a safe and effective way to reduce equinus pain and problems.
With careful workup and attention to detail, Achilles tendon problems are often very fulfilling to treat and have an excellent outcome potential. Zeroing in on the actual cause of pain and selecting appropriate treatment options is essential for improved outcomes.
Dr. Baravarian is an Assistant Clinical Professor at the UCLA School of Medicine. He is the Chief of Foot and Ankle Surgery at the Santa Monica UCLA Medical Center and Orthopedic Hospital, and is the Director of the University Foot and Ankle Institute in Los Angeles.
For further reading, see “Achilles Tendinopathy: What Are The Best Treatment Options?” in the October 2006 issue of Podiatry Today. Also check out the archives at www.podiatrytoday.com.