Results of chronic Achilles tendinopathy surgery on elite and nonelite track athletes

Achilles tendon debridement, calcaneoplasty and double-row tendon footprint reconstruction improve ankle function and athletic performance in patients with insertional Achilles tendinopathy

BACKGROUND

Insertional Achilles tendinopathy is a frequent condition among physically active individuals. Extensive intratendinous pathologies may require partial tendon detachment, debridement and reconstruction of the tendon footprint. Positive functional outcomes are reported after the procedure, but literature on postoperative sport function is limited.

METHODS

Pre- and postoperative sports capability and ankle function were assessed in 25 patients undergoing Achilles tendon debridement and double-row footprint reconstruction.

RESULTS

The mean VAS score for pain during sport decreased significantly from 7.4 (SD, 2.5) to 1.2 (SD, 2.0) postoperatively (p < 0.001). Sports ability and subjective fitness levels increased significantly from 3.6 (SD 3.0) and 3.5 (2.2) to 8.8 (2.4) and 8.8 (2.2), respectively (p < 0.001). A trend from high-impact sports to low-impact sports was observed postoperatively. The subjective surgical outcome was good or excellent in 96 %.

CONCLUSION

Our study shows improvement in postoperative sports ability and high patient satisfaction after insertional Achilles tendon debridement, and double-row tendon footprint reconstruction.

LEVEL OF EVIDENCE

Level IV - retrospective case series.

ICON 2020-International Scientific Tendinopathy Symposium Consensus: A Systematic Review of Outcome Measures Reported in Clinical Trials of Achilles Tendinopathy

BACKGROUND

Nine core domains for tendinopathy have been identified. For Achilles tendinopathy there is large variation in outcome measures used, and how these fit into the core domains has not been investigated.

OBJECTIVE

To identify all available outcome measures outcome measures used to assess the clinical phenotype of Achilles tendinopathy in prospective studies and to map the outcomes measures into predefined health-related core domains.

DESIGN

Systematic review.

DATA SOURCES

Embase, MEDLINE (Ovid), Web of Science, CINAHL, The Cochrane Library, SPORTDiscus and Google Scholar.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Clinical diagnosis of Achilles tendinopathy, sample size ≥ ten participants, age ≥ 16 years, and the study design was a randomized or non-randomized clinical trial, observational cohort, single-arm intervention, or case series.

RESULTS

9376 studies were initially screened and 307 studies were finally included, totaling 13,248 participants. There were 233 (177 core domain) different outcome measures identified across all domains. For each core domain outcome measures were identified, with a range between 8 and 35 unique outcome measures utilized for each domain. The proportion of studies that included outcomes for predefined core domains ranged from 4% for the psychological factors domain to 72% for the disability domain.

CONCLUSION

233 unique outcome measures for Achilles tendinopathy were identified. Most frequently, outcome measures were used within the disability domain. Outcome measures assessing psychological factors were scarcely used. The next step in developing a core outcome set for Achilles tendinopathy is to engage patients, clinicians and researchers to reach consensus on key outcomes measures.

PROSPERO REGISTRATION

CRD42020156763.

Clinical results of the Keck and Kelly Wedge Osteotomy approach in Haglund's deformity: Minimum 3-year follow-up

BACKGROUND AND PURPOSE

The Haglund's deformity, which may be difficult to treat non-surgically, is caused by a prominent bone hump in the posterosuperior region of the calcaneus and may be associated with bursitis and foot pain. Many surgical treatments for resistant Haglund deformities have been described. Here, we evaluate the AOFAS scores, pain and other characteristics of patients undergoing removal of the dorsally based wedge from the posterior calcaneus with the Keck and Kelly procedure.

MATERIALS AND METHODS

The study included 20 patients who had undergone the Keck and Kelly procedure at our center, from 2011 to 2019, and had attended follow-up for at least three years. Analyses were performed retrospectively. Preoperative (immediately before surgery) and postoperative (at last assessment) American Orthopedic Foot and Ankle Society (AOFAS) and visual analog pain scale scores (VAS) were determined, and calcaneal inclination angles were radiologically measured. Additionally, calcaneal pitch angle (CPA), Fowler and Philip angle (FPA), and Bohler angle were recorded.

RESULTS

Fourteen patients were female, and six were male, mean age was 45.8 ± 8.1 years. AOFAS scores were significantly increased, whereas VAS scores were significantly decreased after surgery. Postoperative AOFAS scores were correlated with preoperative VAS, CPA, and FPA values. Preoperative VAS scores were correlated with CPA, FPA, and Bohler angle values. FPA and CPA values were correlated positively.

CONCLUSIONS

It was found that ankle functions improved, and pain levels decreased after Keck and Kelly Wedge Osteotomy was applied for the treatment of Haglund's deformity. CPA and FPA were associated with both pain levels and ankle function. The Keck and Kelly Wedge Osteotomy procedure appears to be a preferable approach for the surgical treatment of Haglund's deformity.

The Zadek calcaneal osteotomy in Haglund's syndrome of the heel: Clinical results and a radiographic analysis to explain its efficacy

Local debridement or decompression of the posterior heel in Haglund's syndrome yields variable results. This condition is sometimes due to an excessively long calcaneus rather than simply a large posterosuperior bony prominence. Failure to address this abnormality may explain the poor results in some series. We recently published a new measurement (the X/Y ratio) which, combined with the calcaneal pitch angle, assesses the abnormality of the shape of the calcaneus. The Zadek osteotomy strongly modifies that shape. We retrospectively reviewed 50 patients treated by a Zadek osteotomy at a mean 7 years follow-up using the AOFAS ankle-hindfoot score, the VISA-A score and Tegner scale. We measured only the X/Y ratio and the calcaneal inclination angle, as the classically described radiographic measurements in Haglund's syndrome are unreliable. We then assessed the condition of the distal end of the Achilles tendon with an MRI. Our results demonstrate excellent outcomes(40/50, 80%) following Zadek osteotomy and correspond to the change in pre- and post-operative measurements, especially the X/Y ratio. An algorithm using those geometrical measurements of the calcaneus is proposed for decision making in Haglund's syndrome. Level of clinical evidence: Level 3.

Calcaneal Bone Bruise After Surgery for Insertional Achilles Tendinopathy

OBJECTIVE

Excision of the posterosuperior corner of the calcaneus (EPCC) is routinely undertaken in athletes after failure of conservative management of insertional Achilles tendinopathy. Some patients can experience sharp calcaneal pain during postoperative rehabilitation, a sign of a calcaneal bone bruise (CBB).

DESIGN

Case series, level of evidence IV.

SETTING

University teaching hospital.

PATIENTS

This study reports 8 patients who developed postoperative CBB after having started impact training too early.

INTERVENTION

Patients in whom a diagnosis of CBB had been formulated were followed to return-to-play and resolution of bone edema by MRI.

MAIN OUTCOME MEASURES

Detection of CBB after EPCC.

RESULTS

After routine EPCC for insertional Achilles tendinopathy, 8 patients presented with sharp pain for a mean 7.1 weeks (median 6 weeks, range 5-11 weeks) before clinical suspicion of CBB. At that stage, MRI showed clear evidence of a bone bruise, with a diagnosis of CBB formulated at an average of 10.8 postoperative weeks (range 6-16 weeks). Calcaneal bone bruise resolved with modified symptom-free loading. Patients returned to play at average on 5.6 months (range 2-9 months) after the diagnosis of postoperative CBB.

CONCLUSIONS

We describe 8 athletes who developed painful CBB following routine EPCC for insertional Achilles tendinopathy after having increased their level of activities too soon after the index procedure. In these patients, the diagnosis of postoperative CBB can be formulated by MRI and more cautious rehabilitation implemented.

Retrocalcaneal Enthesophyte Resection With Functional Lengthening of the Achilles Tendon and Buried Knot Technique: A Case Series

Retrocalcaneal exostosis can be debilitating and in severe cases, surgical resection is indicated. Complications can arise from surgical resection of the exostosis and reattachment of the Achilles tendon, including irritation of the suture knot, recurrence of the bony prominence, and dehiscence. The use of a buried knot technique with functional lengthening of the Achilles tendon and gastroc-soleal muscle complex can minimize these complications. Complete detachment of the Achilles tendon allows for aggressive and thorough resection of the exostosis and functional lengthening with reattachment. The buried cruciate knot technique allows for firm reattachment with buried knots to prevent soft tissue irritation. A total of fourteen patients (14 limbs) underwent retrocalcaneal enthesophyte resection with functional Achilles tendon lengthening, (8/14) of which had difficultly wearing shoe gear, (10/14) had edema, and (2/14) had erythema preoperatively. Postoperatively, (11/14) of patients returned to full activities and sports, and (11/14) returned to normal shoe gear. Complications included (1/14) of patients with Achilles tendon avulsion and (3/14) of patients with surgical site dehiscence requiring revisional surgery. Overall, this technique helps prevent short-term complications and long-term recurrence due to the functional lengthening mitigating insertional forces on the Achilles tendon.

Insertional Achilles Tendinopathy: Analysis of 166 Procedures and Return to Activity

The surgical procedure for Insertional Achilles tendinopathy (IAT) varies widely with no consensus as to approach and documenting return to activity (RTA). This study presents outcomes of surgery for IAT by a single surgeon, documenting activity level and return to activity. From January 2001 through January 2018, 166 procedures were reviewed. Surgery included debridement of the Achilles insertion, resection of the superior calcaneus and bursa, and re-attachment with suture anchors. There were 110 males and 56 females. The majority of patients in the entire cohort were runners (n = 54). The average age of the cohort was 50.3 ± 12.1 years (range 20-80). Average follow-up was 114.0 ± 63.5 months (range 6-222 months). Average RTA for males and females were 6.43 months and 7.22 months, (p = .2), respectively. There was no difference in RTA between patients who had calcific tendinosis (n = 84) and noncalcific tendinosis (n = 82). Complications were 2 infections, 2 DVTs, and 17 deep suture reactions with a total complication rate of 12.6%; there were no re-ruptures postoperatively. There was no significant difference in number of complications between absorbable and nonabsorbable suture in the anchors (p = .41). The average RM score was 1.5 ± 0.7. The RM scores were better for males (p = .002), but there were no differences in RTA or complications between sexes. Overall, 95.8% of the procedures resulted in improved outcome and ability to return to activity including sports. This retrospective investigation shows surgical intervention for IAT yields good results with an average return to activity including sports in approximately 7 months.

Mid-term results of open debridement and reattachment surgery for insertional Achilles tendinopathy: A retrospective clinical study

OBJECTIVE

The aim of this study was to determine the effects of age and body mass index (BMI) on the functional outcomes, satisfaction rates, and recovery time after open debridement and reattachment surgery in non-athletic patients with insertional Achilles tendinopathy (IAT).

METHODS

In this retrospective study, 33 non-athletic patients (34 ankles) in whom open debridement and reattachment surgery was performed for IAT from 2006 to 2016 were included. Change in pain intensity was assessed using a Visual Analogue Scale (VAS) preoperatively and at the final follow-up. Functional assessment was done by preoperative and postoperative American Orthopaedics Foot and Ankle Score (AOFAS) and final follow-up Victorian Institute of Sport Tendon Study Group-Achilles Tendinopathy score (VISA-A). Patient satisfaction was evaluated by Roles - Maudsley score (RMS). The recovery time was defined as the time interval from the first appearance to postoperative relief of symptoms and recording. In addition, the recurrent Haglund's deformity was determined by postoperative control radiographs.

RESULTS

The mean age at the time of the operation was 51.19 years. The mean follow-up was 61.75±8.49 months. According to BMI, 5 patients were determined as morbid obese, 19 as obese, 3 as overweight, and 6 as normal. The mean VAS score significantly decreased from 8.5 preoperatively to 1.3 postoperatively (p<0.001). The mean AOFAS score significantly improved from 55.8 preoperatively to 92 postoperatively (p<0.001). Postoperative VISA-A score was 86% (range=32%-100%). According to RMS, 22 patients reported the result as excellent, 8 as good, 2 as fair, and 1 as poor. The mean recovery time was 11.8 (range=2-60) months, but one patient did not reach a symptom free status and thus was not included in the recovery time analysis. Postoperative control radiographs revealed signs of recurrence deformity in four patients. Recovery time showed a negative correlation with the age of the patients (r=-0.65). Postoperative scores and BMI showed no significant correlations with the recovery time on the basis of Spearman's rho test (p=0.196).

CONCLUSION

The results of this study have shown that open debridement and reattachment surgery may be an effective surgical method in relieving pain and improving functional status with high satisfaction rate and acceptable recovery time in the management of non-athletic patients with IAT.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

Peritenolysis and Debridement for Main Body (Mid-Portion) Achilles Tendinopathy in Athletic Patients: Results of 107 Procedures

Achilles tendinopathy in the main body (mid-portion) of the tendon is a common pathologic finding among active and athletic populations and can be debilitating without proper and adequate treatment. Numerous surgical approaches for this common pathologic finding have been reported, with variable outcomes. We evaluated the surgical outcomes of peritenolysis and debridement of main body Achilles tendinopathy among athletic populations using the return to activity (RTA) and decreased desired activity (DDA) as our primary outcome measures. A total of 100 patients underwent 107 procedures by the senior author (A.S.) from January 2001 through December 2015 met the inclusion criteria, 65 (65%) of whom were runners. The mean follow-up duration was 106.6 ± 55.5 months from the index procedure, and the mean interval necessary to RTA for the entire group was 10.9 ± 5.3 weeks. The average RTA after debridement was 14.1 ± 5.2 weeks and after peritenolysis was 7.3 ± 2.0 weeks (p = .00001). Of the 100 patients, 3 (3%) had experienced a DDA at the last follow-up visit. With >97% of the patients able to return to their desired activities, we have concluded that peritenolysis and debridement are favorable surgical techniques for main body Achilles tendinopathy.

Treatment of Insertional Achilles Pathology With Dorsal Wedge Calcaneal Osteotomy in Athletes

BACKGROUND

Insertional Achilles tendinopathy and retrocalcaneal bursitis is difficult to treat, and several operative techniques have been used after failure of conservative management. Dorsal wedge calcaneal osteotomy has been described for the treatment of insertional Achilles pathology. It was hypothesized that dorsal wedge calcaneal osteotomy would be an effective and safe method for the treatment of athletes with insertional Achilles pathology unrelieved by nonoperative measures.

METHODS

Fifty-two athletes (64 feet) who had painful Achilles tendon syndrome unrelieved by 6 months of nonoperative measures were treated surgically. Dorsally based wedge calcaneal osteotomy was performed through a lateral approach, and 2 staples were used for fixation. Patients were scored pre- and postoperatively with the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot and Victorian Institute of Sports of Australia-Achilles (VISA-A) scores.

RESULTS

At a minimum follow-up of 3 years, the patients' AOFAS and VISA-A scores improved from 59.5 ± 15.0 and 65.9 ± 11.1 preoperatively to 95.7 ± 6.2 and 90.2 ± 8.4 postoperatively, respectively. Clinical results were considered excellent in 38 patients, good in 12 patients, and fair in 2 patients. Return to previous sports activity time was 21 (SD, 8.0) weeks. One patient necessitated a revision operation.

CONCLUSION

Operative treatment of insertional Achilles pathology in athletes with dorsal closing wedge calcaneal osteotomy was a safe and effective method that allowed for a quicker return to previous level of sports activities compared with other techniques.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Results of surgical treatment of calcaneus insertional tendinopathy in middle- and long-distance runners

PURPOSE

Calcaneus insertional tendinopathy in runners is common and involves important therapeutic controversies. The object of this study was to determine the delay and level of return to sport after insertional surgery in runners, with and without tendon damage.

METHODS

Eighteen runners underwent surgery for insertional calcaneus tendinopathy. Nine required an exostosectomy/bursectomy, and nine others required a tendon reinsertion/autograft. All patients were clinically assessed pre- and post-operatively with AOFAS scores and post-operatively with ATRS. This series included analysis of "pure conflicts" and "severe insertional lesion" scores. If the insertional tendon was free or the lesion was smaller than 50 %, the group was classified as "pure conflict/minor tendon damage". In the situation in which a loss of tendon occurred or the tendon lesion was greater than 50 %, the group was classified as "major tendon damage". Pre-operatively, the AOFAS "overall", "pure conflicts/minor tendon damage" and "major tendon damage" groups' scores were 58.5 ± 15, 68.2 ± 8.8 and 48.9 ± 13.9/100, respectively.

RESULTS

Post-operatively, the AOFAS "overall", "pure conflicts/minor tendon" and "major tendon damage" groups' scores were 93.7 ± 8.2, 93.2 ± 10.2 and 95.2 ± 5.7/100, respectively. The AOFAS score gain for each group was, respectively, 35.2 ± 19, 24 ± 17 and 46.3 ± 14.1. The ATRS "overall", "pure conflicts/minor tendon damage" and "major tendon damage" groups' scores were 81.5 ± 14.9, 78.3 ± 20.1 and 84.7 ± 6.7/100, respectively. The global sport recovery delay was 9.3 ± 4.1 months; it was 6 ± 3.3 months for the pure conflict/minor tendon damage subgroup and 10 ± 4.6 months for the severe tendon damages subgroup.

CONCLUSION

Achilles insertional tendinopathy surgery on this population results in few complications with good functional results if the surgical technique is adapted to the type of tendon injury. The clinical relevance of this study is that it highlights the various forms of calcaneus insertional tendinopathy and various treatment options. The authors show that in the case of major tendon damage, time to return to sport is longer.

Haglund Deformity - Surgical Resection by the Lateral Approach

The aim of this study was to analyse the outcome of surgical Haglund deformity is a prominence in the postero superolateral aspect of the calcaneum. Haglund deformity is a prominence in the postero superolateral aspect of the calcaneum, causing a painful bursitis, which may be difficult to treat by non-operative measures alone. Various surgical methods are available for effective treatment of refractory Haglund’s deformity. This study is to evaluate whether adequate resection of Haglund deformity by a lateral approach provides good to excellent results. During the period from 2009 to 2012, 40 patients with 46 feet had undergone resection of Haglund deformity using lateral approach and the outcome was analysed using AOFAS Ankle-Hind Foot Scale. The mean AOFAS score at the follow up was 86/100, with the majority of patients reporting alleviation of pain at one year follow up. The lateral approach to calcaneal ostectomy can be an effective treatment for those suffering from refractory Haglund deformity. However, the patient must be made aware of theduration of recovery being long.

Use of an anti-gravity treadmill in the rehabilitation of the operated achilles tendon: a pilot study

Achilles surgical patients were evaluated using an "anti-gravity" Alter-G (AG) treadmill that allows for reduction of weightbearing pressure on the lower extremity. We studied our hypothesis, which was based on our prior clinical findings, that being able to run on the AG treadmill at 85% of body weight is sufficient to clear patients to run with full body weight outside. Patients undergoing Achilles tendon rupture or insertional repair surgery were prospectively studied. They were compared with a control group that had similar surgeries and a similar rehabilitation program during the same time period: the variable was not using the AG treadmill. The criteria for the study group to be allowed to run outside was being able to run for at least 10 minutes on the AG at 85% of body weight. Each group had 8 patients who underwent surgery for 2 complete tendon ruptures and 6 insertional repairs. There was no significant difference between the AG and control group as to age and postoperative follow-up. AG patients began their initial run on the treadmill at 70% of their body weight at 13.9 ± 3.4 weeks, 85% at 17.6 ± 3.9 weeks, and outside running at 18.1 ± 3.9 weeks. The control group's return to running outside time was 20.4 ± 4.1 weeks. This was not significantly different (p = .27). We confirmed our hypothesis that being able to run at 85% of body weight after Achilles surgery was sufficient to clear patients to run outside.

[Surgical treatment for pain syndromes of the Achilles tendon]

Pain syndromes of the Achilles tendon (AT) include both insertional and non-insertional tendinopathy, two distinct disorders with different underlying pathophysiologies and management options, characterized by pain, impaired performance and swelling in and around the tendon. This article gives an overview of the operative treatment of pain syndromes of the Achilles tendon, including both insertional tendinopathy of the AT and tendinopathy of the main body of the AT. New minimally invasive techniques for the management of this condition, including endoscopy are also reported.

Rehabilitation of the operated achilles tendon: parameters for predicting return to activity

Return to activity (RTA) following Achilles tendon surgery assessment criteria has not been generally adopted. A well-defined postsurgical rehabilitation regimen with 3 distinct criteria, yet easy to measure, can be used to assess the ability of patients undergoing Achilles tendon surgery to return to activity. We studied whether if patients were able to meet all 3 criteria, would this show significance in predicting the ability to RTA within a normal range. A total of 219 patients undergoing surgery on the Achilles tendon from 1990 to 2005 were retrospectively studied to evaluate for the ability to perform 5 sets of 25 single-legged concentric heel raises, along with symmetry of calf girth and ankle range of motion. Time of RTA and the ability to meet all 3 parameters was studied. If patients could meet all 3 criteria, they were allowed to RTA. This time postsurgery was recorded in weeks. Of the 219 surgeries reviewed, 149 were on males and 70 on females. Fourteen patients were unable to meet all 3 parameters evaluated above within the proposed time frames. The inability to meet all 3 criteria resulted in a delay to RTA (P = .03). Eleven females had a delay in RTA as compared with 2 males (P < .0001). RTA was different based on procedure. Meeting all 3 criteria was helpful in assessing if patients were able to RTA in the normal range. Patients who were unable to meet all 3 had a delay in RTA. Females were more likely to have a delay in RTA.

Effect of ultrasound-guided, peritendinous injections of adalimumab and anakinra in chronic Achilles tendinopathy: a pilot study

A new review suggested that an inflammatory process may be related to the development of tendinopathy and that the inflammation may also play a role in chronic tendinopathy. Hitherto, peritendinous injections of glucocorticosteroids have been used to reduce the inflammation. In an attempt to reduce the possible side effects and the high frequency of relapse of symptoms after local treatments with glucocorticosteroids, new anti-inflammatory treatments were tested. Ultrasound-guided, peritendinous injections of adalimumab (tumor necrosis factor -alpha blocker) and anakinra (interleukin-1 receptor antagonist) were evaluated with regard to reducing pain, tendon thickness, and the blood flow in chronic Achilles tendinopathy. We found in this small pilot study that peritendinous injections of adalimumab had a significant effect on pain sensation at rest in chronic Achilles tendinopathy. Adalimumab had no effect on tendon thickness and contrary to all expectation, the tendon thickness in the anakinra-treated patients increased significantly after 12 weeks. Adalimumab showed a significant tendency to reduce the blood flow in the tendon over 12 weeks, whereas anakinra had no effect on the blood flow.

Surgical treatment for chronic disease and disorders of the achilles tendon

Chronic Achilles tendon disorders range from overuse syndromes to frank ruptures. Numerous forms of treatment have been used, depending on the nature of the disorder or injury. Ultrasonography and magnetic resonance imaging are commonly used for evaluation. The spectrum of disease comprises paratenonitis, tendinosis, paratenonitis with tendinosis, retrocalcaneal bursitis, insertional tendinosis, and chronic rupture. However, there is no clear consensus on what defines a chronic Achilles disorder. Nonsurgical therapy is the mainstay of treatment for most patients with overuse syndromes. Surgical techniques for overuse syndromes or chronic rupture include débridement, local tissue transfer, augmentation, and synthetic grafts. Local tissue transfer most commonly employs either the flexor hallucis longus or flexor digitorum longus tendon to treat a chronic rupture. Reports on long-term outcomes are needed before useful generalizations can be made regarding treatment.

Surgery for retrocalcaneal bursitis: a tendon-splitting versus a lateral approach

For patients with refractory retrocalcaneal bursitis (Haglund's syndrome), the most effective surgical approach has not been defined. We asked whether patients undergoing the tendon-splitting approach and the lateral approach would have comparably effective relief of pain for both types of calcaneal ostectomies. We retrospectively reviewed 30 patients (31 feet) who underwent the tendon-splitting approach and compared their results with 32 previous patients (35 feet) who had a lateral incision. Minimum followup was 12 months (mean, 16 months; range, 12-23 months) for the tendon-splitting group and 15 months (mean, 51 months; range, 15-109 months) for the lateral group. The mean American Orthopaedic Foot and Ankle Society score improved from 43 points preoperatively to 81 points (range, 8-100 points) postoperatively in the tendon-splitting group and from 54 points to 86 points (range, 55-100 points) in the lateral group. The mean physical component score of the Short Form-36, version 2, at followup was 52 (range, 22-61) in the tendon-splitting group and 49 (range, 34-63) in the lateral group. The median return to normal function was 4.1 months (range, 3-13 months) in the tendon-splitting group and 6.4 months (range, 4-20 months) in the lateral group. Both approaches to calcaneal ostectomy provided symptomatic pain relief. However, patients in the tendon-splitting group returned to normal function quicker than patients in the lateral group.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Management of common running injuries

Runners are susceptible to a variety of potential injuries because of the considerable stress of this activity. This can create a challenge for the treating practitioner; however, many of the common ailments occur in a reasonably predictable pattern. A careful history and physical examination are necessary for accurate diagnosis. Having a good understanding of these injuries as well of the role of biomechanical factors and common training errors can assist with appropriate care. Further development in the knowledge of soft tissue trauma, gait, and diagnostic and therapeutic modalities should lead to improved management of the injuries facing these athletes.

Posterior heel pain (retrocalcaneal bursitis, insertional and noninsertional Achilles tendinopathy)

The majority of patients with Achilles tendinopathy respond to nonoperative treatment. In patients with refractory symptoms, surgery can be considered. If paratenonitis is present, the paratenon is partially excised, and adhesions are released. Areas of symptomatic tendinosis are excised with repair of the residual defect in the Achilles tendon. An alternative for patients with tendinosis who are at increased risk for wound problems or who do not want a large open incision is percutaneous or endoscopic tenotomy. A symptomatic Haglund's deformity or inflamed retrocalcaneal bursa is excised. Augmentation of the Achilles tendon may be considered if debridement threatens the structural integrity of the tendon, in older patients, and in revision surgery.

Change in plantarflexion strength after complete detachment and reconstruction of the Achilles tendon

BACKGROUND

Chronic insertional tendinitis of the Achilles tendon is an overuse injury seen with increasing frequency because of an aging population and an increased interest in sports. We evaluated the change in plantarflexion strength in patients after our surgical technique for chronic insertional Achilles tendinitis.

METHODS

From our previous clinical series of detachment and reconstruction of the Achilles tendon for the treatment of insertional tendinitis, ten patients were evaluated with an average followup of 32.1 (range 18 to 52) months. The average age was 65.7 years. We developed a mathematical model to predict the difference in plantarflexion strength between a reconstructed ankle and a healthy contralateral one. Isokinetic testing at 60 degrees/second was performed, measuring plantarflexion peak torque, dorsiflexion peak torque, and total work.

RESULTS

Our mathematical model predicted a decrease of 4% in plantarflexion torque after the surgery. Isokinetic testing found no significant differences in plantarflexion torque, dorsiflexion torque, or total work between the operated and nonoperated ankles.

CONCLUSIONS

Complete detachment and reconstruction of the Achilles tendon do not decrease the working capacity of the gastrocsoleus muscle.