Emerging Insights On Treating The Painful Achilles

By Bob Baravarian, DPM

   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.

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