Cath Lab Digest

Patients with tendinopathies can undergo conservative care for months without resolution of the condition. Delayed presentation is often an issue as well. Accordingly, this author emphasizes the differences between tendinopathy and tendinosis, and offers salient insights on surgical modalities and procedures.

   At podiatric medical conferences, one will see rows and rows of vendors displaying a wide variety of products involving fixation of bone. However, there are very few vendors who display products that foot and ankle surgeons can use in the treatment of tendon-related problems. The majority of these products are conservative in nature. They include devices that immobilize, devices that utilize static and dynamic stretching, and topical therapies.

   The lack of emphasis on surgical products reflects the lack of clear understanding regarding the pathological process of tendinopathies and its treatment.

   This article is not meant to serve as a literature review or a comprehensive overview of tendon anatomy, physiology, pathology or treatment. It is also beyond the scope of this article to discuss each tendon and its specific issues. Instead, we will take a closer look at important aspects that are critical in the surgical treatment of tendinopathies.

   The exact number of those who suffer from tendinopathies in the foot and ankle is unknown. The majority of published studies focus on Achilles tendon disorders in athletes. These disorders reportedly occur in 7 to 9 percent of the athletic population.^1,2 However, there is a growing population of relatively sedentary individuals who suffer from tendinopathies as well. While the exact etiology for tendinopathies is unclear, training errors, biomechanical faults, muscle weakness and inflexibility have been implicated.^3-7

   Clinicians often refer to tendinopathies as “overuse” injuries. This implies that patients continue to aggravate the problem over time. The majority of patients who present with tendinopathy relate a long history of pain that may have lasted for several months to years. Patients often cannot identify a specific event that initiated this process. More often, patients report a history that progresses from occasional pain with increased activities to continuous pain and discomfort. Swelling may also be associated with this problem.

   Due to the insidious onset of tendinopathies, patients often do not seek medical care at the initial presentation of the problem. Patients will wait until the pain becomes so debilitating that they often present to our offices with an antalgic gait.

   Patients suffering from tendinopathies often undergo conservative treatment for many months with only minor or no resolution to their problem. The typical conservative treatments include: immobilization in a cast or Cam Walker; physical therapy including eccentric stretching; heel pads; nonsteroidal anti-inflammatories; or injectable or oral steroid therapy. Unfortunately, these therapies are nominally effective in the treatment of tendinopathies. ^8-11 The limited success of these conservative therapy modalities may be more indicative of the delay in treatment rather than the inefficacy of that treatment. ^12,13

   In the acute setting, conservative management may be effective. However, as previously stated, patients have been suffering from this problem for many months prior to their initial treatment by a clinician. Therefore, the problem has already progressed beyond the acute stage of tendinopathy and is accordingly chronic in nature. It is not surprising that conservative management is largely ineffectual at this point. One must consider surgical management to treat the tendinopathy effectively.