Essential Insights In Diagnosing And Treating Chronic Achilles Tendinosis
- Volume 24 - Issue 5 - May 2011
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In moderate to severe cases, we usually attempt PRP therapy. However, if there is severe scar tissue formation, these types of treatments may not work. Platelet rich plasma works to bring the healing growth factors associated with blood products to the area of scar tissue to fool the body into believing there is a local injury and sending more blood for healing. The additional needling during PRP injection also breaks up the scar formation in the Achilles and increases blood supply to the scar region.
In cases of severe scar formation that is localized, one may attempt Topaz therapy. I prefer to perform a percutaneous approach rather than an open approach. I only perform an open Topaz procedure when I think the posterior Achilles retinaculum may be tight and I want to free it.
Salient Tips On Surgical Approaches
Approximately 80 to 85 percent of Achilles tendinosis cases we see in our offices improve with conservative or complex conservative approaches. The other 15 to 20 percent will require more advanced surgical approaches. In such cases, one should map the affected region and amount of scar tissue with either ultrasound or magnetic resonance imaging. If there is greater than 40 percent tendon damage in a given region of Achilles tendon, attempts at simple scar tissue debridement and tendon repair have a lower rate of success. Remember, the tendon is coiled on itself and if you remove a large portion of the tendon during debridement, you will find weakness and even a non-functioning Achilles tendon.
In cases of severe scar formation and greater than 40 percent tendon scar formation requiring debridement, I highly recommend a flexor hallucis longus tendon transfer to the calcaneus. This tendon transfer is so strong that it can act to replace the entire function of the Achilles. However, in tendinosis cases, one debrides the Achilles of all scar tissue and damaged tendon and performs the flexor tendon transfer to the calcaneus. In the old days, a large amount of flexor tendon was required for tendon transfer and this necessitated an incision in the arch for tendon harvest.
With the advent of the Bio-Tenodesis Screw (Arthrex) fixation, one can harvest the flexor tendon from a posterior approach just deep to the Achilles tendon and transfer it to the calcaneus. The additional support and stability of a Bio-Tenodesis Screw also allows for a more rapid ambulatory program and early physical therapy.
We have found that three weeks in a non-weightbearing cast followed by a plantarflexed position, short leg boot with partial weightbearing for an additional three weeks is ideal. Physical therapy starts four weeks after surgery and continues for two months. At six weeks, the patient may wear tennis shoes with a heel lift and progresses to full activity over the course of an additional six weeks.
Be confident and aggressive with Achilles tendonitis and tendinosis cases. If a case of tendonitis presents, use anti-inflammation approaches and rest to calm the problem. Also consider identifying the underlying cause or mechanical stress resulting in the problem. If a tendinosis case is present, check the level of damage and the level of blood supply to the area, and treat accordingly.
Increasing the blood supply and breaking up scar tissue will improve the problem in early cases but not in severe cases. If the scar tissue is not resolving, increase trauma in order to increase blood supply with shockwave, PRP or Topaz procedures. If a debridement is necessary, consider a flexor hallucis longus tendon transfer for additional strength and function.
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.