Chronic disorders of the Achilles tendon: results of conservative and surgical treatments

Does additional extracorporeal shock wave therapy improve the effect of isolated percutaneous radiofrequency coblation in patients with insertional Achilles tendinopathy? Study protocol for a randomized controlled clinical trial

BACKGROUND

No conclusive evidence recommends a prior treatment for insertional Achilles tendinopathy (IAT). It is theorized that both percutaneous radiofrequency coblation and extracorporeal shockwave therapy (ESWT) relieve pain within the insertion. However, no clinical evidence shows that either treatment promotes the regeneration of the tendon or if the combination of these 2 interventions offers better function and less pain than one therapy.

METHODS

The study is a randomized, controlled trial with patients allocated in a 1:1 ratio to one of two parallel groups. Patients with insertional Achilles tendinopathy who are not satisfied with the effect of conservative treatment will be screened. A minimum of 38 patients will be enrolled after deciding to participate in the trial on an informed basis. Then the intervention group and the control group perform radial ESWT and sham-ESWT respectively at 6 months after percutaneous radiofrequency coblation. The primary outcome will be the Victorian Institute of Sports Assessment Achilles (VISA-A) Score. Secondary outcome measures will be Foot and Ankle Outcome Score (FAOS) scale, visual analog scale (VAS), Tegner Score, and MRI ultra-short echo time (UTE) T2* value. The assessments will occur in 6 months, 1 year, and 2 years, post-operatively. The differences between the 2 groups will be conducted as intention-to-treat basis.

DISCUSSION

We aim to investigate if radiofrequency coblation associated with ESWT can provide more encouraging imaging findings as well as functional and clinical outcomes regarding the treatment of the IAT comparing to the single radiofrequency coblation treatment.

TRIAL REGISTRATION

ChiCTR1800017898; pre-results. Registered on 20 August 2018.

Recommended Musculoskeletal and Sports Ultrasound Terminology: A Delphi-Based Consensus Statement

OBJECTIVES

The current lack of agreement regarding standardized terminology in musculoskeletal and sports ultrasound presents challenges in education, clinical practice, and research. This consensus was developed to provide a reference to improve clarity and consistency in communication.

METHODS

A multidisciplinary expert panel was convened consisting of 18 members representing multiple specialty societies identified as key stakeholders in musculoskeletal and sports ultrasound. A Delphi process was used to reach consensus which was defined as group level agreement >80%.

RESULTS

Content was organized into seven general topics including: 1) General Definitions, 2) Equipment and Transducer Manipulation, 3) Anatomic and Descriptive Terminology, 4) Pathology, 5) Procedural Terminology, 6) Image Labeling, and 7) Documentation. Terms and definitions which reached consensus agreement are presented herein.

CONCLUSIONS

The historic use of multiple similar terms in the absence of precise definitions has led to confusion when conveying information between colleagues, patients, and third-party payers. This multidisciplinary expert consensus addresses multiple areas of variability in diagnostic ultrasound imaging and ultrasound-guided procedures related to musculoskeletal and sports medicine.

Failed Surgery for Achilles Tendinopathy

Treatments of Achilles tendinopathy continue to evolve. The body of literature is inadequate to provide a comprehensive guide to evaluation and treat failed surgeries. Issues related to failed surgical treatment may be divided into infection/wound issue, mechanical failure, and persistent pain. Awareness of the potential problems described in this article will allow surgeons to have a foundation in clinical assessment and making accurate diagnoses. Various surgical treatment options are available and should be executed carefully to treat individualized patient conditions.

Recommended musculoskeletal and sports ultrasound terminology: a Delphi-based consensus statement

The current lack of agreement regarding standardised terminology in musculoskeletal and sports ultrasound presents challenges in education, clinical practice and research. This consensus was developed to provide a reference to improve clarity and consistency in communication. A multidisciplinary expert panel was convened consisting of 18 members representing multiple specialty societies identified as key stakeholders in musculoskeletal and sports ultrasound. A Delphi process was used to reach consensus, which was defined as group level agreement of >80%. Content was organised into seven general topics including: (1) general definitions, (2) equipment and transducer manipulation, (3) anatomical and descriptive terminology, (4) pathology, (5) procedural terminology, (6) image labelling and (7) documentation. Terms and definitions which reached consensus agreement are presented herein. The historic use of multiple similar terms in the absence of precise definitions has led to confusion when conveying information between colleagues, patients and third-party payers. This multidisciplinary expert consensus addresses multiple areas of variability in diagnostic ultrasound imaging and ultrasound-guided procedures related to musculoskeletal and sports medicine.

Minimally Invasive and Endoscopic Approach for the Treatment of Noninsertional Achilles Tendinopathy

Minimally invasive treatment can offer an earlier recovery with less pain and scarring compared with traditional open surgeries. The goals of minimally invasive surgery are to debride degenerative tendon, stimulate healing, and, when appropriate, repair damaged tendon. Sclerotherapy and prolotherapy have been shown to reduce neovascularization and pain. Percutaneous stripping and endoscopic debridement are better options for diffuse tendinopathy. Plantaris release can be useful in diffuse disease in patients with primarily medial-sided Achilles pain. Overall, minimally invasive surgery provides similar benefits as open procedures with reduced complications and morbidity.

Flexor Hallucis Longus Transfer Improves Achilles Tendon Load to Failure in Surgery for Non-Insertional Tendinopathy: A Biomechanical Study

BACKGROUND

Non-insertional Achilles tendinopathy is a common disorder that may be treated with surgical debridement. A flexor hallucis longus (FHL) transfer is recommended if debridement of ≥50% is performed; however, there are no biomechanical data to support this. The purpose of this study was to assess the added biomechanical strength provided by an FHL transfer with incrementally sized non-insertional Achilles tendon defects.

METHODS

Thirty matched-pair below-the-knee cadaveric specimens (n = 60) (mean age at the time of donor death, 67 years; range, 36 to 74 years) were obtained and randomly divided into 3 groups according to whether the defect was 25%, 50%, or 75% of the tendon width. One specimen of each pair was then randomly selected to undergo FHL transfer using interference screw fixation. All specimens then underwent cyclic loading of 100 N, and elongation of the medial and lateral limbs of the tendon defect was recorded. The constructs were then loaded to failure to measure stiffness, ultimate strength, and peak elongation before failure.

RESULTS

The specimens with a 75% defect had significantly less elongation of the medial and lateral tendon-defect limbs when an FHL transfer had been done (p < 0.05). Ultimate load to failure was significantly increased in all groups (by 242 to 270 N depending on the defect size) following FHL transfer. Failures usually occurred through the tendon defect in the 75% and 50% defect groups, whereas all failures occurred at the Achilles tendon insertion when a 25% defect had been created. No significant differences were found in peak elongation with the addition of an FHL transfer. FHL augmentation resulted in significantly greater stiffness in the 25% and 75% defect groups (p < 0.05).

CONCLUSIONS

This study showed that an FHL transfer significantly increased load to failure of Achilles tendons with a non-insertional defect involving 25%, 50%, and 75% of the tendon width. The mechanism of failure was usually through the defect in the specimens with a 50% or 75% defect, supporting the use of FHL augmentation with debridement of ≥50%.

CLINICAL RELEVANCE

The present study supports the mechanical concept that FHL transfer is indicated when debridement of the Achilles tendon is ≥50%.

Achilles Tendinopathy and Associated Disorders

Degenerative disorders of the Achilles tendon are common, affecting up to 18% of the adult population. A thorough evaluation including a focused history, physical examination, and diagnostic studies helps in choosing the appropriate treatment. Initial treatment is usually nonoperative, consisting of activity modification, bracing, and physical therapy. Patents who fail nonoperative management may be treated operatively with a wide range of procedures from endoscopic surgery to open debridement and tendon transfer. Understanding a patient’s expectations and educating patients about potential treatments and their outcomes enables informed collaborative decision making. This article will review the evaluation and management Achilles tendinopathy and associated disorders.

Short-Term Results of Endoscopic Percutaneous Longitudinal Tenotomy for Noninsertional Achilles Tendinopathy and the Presentation of a Simplified Operative Method

PURPOSE

This study was aimed to review the short-term results of endoscopic percutaneous longitudinal tenotomy for noninsertional Achilles tendinopathy using the Centerline Endoscopic Carpal Tunnel Release instrument (Arthrex). This method simplifies the operation technique, allows a good endoscopic visualisation of the Achilles tendon with very promising results.

METHODS

We performed multiple percutaneous longitudinal tenotomies under local anesthesia in 24 patients (25 tendons) with Achilles tendinopathy or peritendinitis that had failed conservative treatment between January 2013 and September 2016. All ambulatory procedures consisted of paratenon release and longitudinal tenotomies. The results were reviewed in 22 patients (23 tendons) at an average follow-up period of 22.5 months (range 10-36 months). Patients' satisfaction and functional outcomes were evaluated using the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire, the pain visual analog scale (VAS), and the functional foot index.

RESULTS

Initial results are very promising with excellent results in 12 patients, good results in 9 patients, and fair result in 1 patient. One patient developed a postoperative thrombosis of the operated limb. Another patient developed a hypertrophic painful scar of the incision wound. The VAS for pain decreased drastically after the index procedure and averaged to 0.2 (SD 0.447). The VISA-A questionnaire score had improved from 42 ± 7.2 points preoperatively to 96.8 ± 14.3 points postoperatively (P = .004). The functional foot index decreased from 84 (SD 30.517) to 33.4 (SD 6.452) on the follow-up examination.

CONCLUSIONS

The endoscopic-assisted longitudinal tenotomies procedure of the Achilles tendon is easily feasible and can be performed on an outpatient basis, produces minimal complications and shows excellent results. The described technique is recommended for all surgeons especially for those familiar with endoscopy of the Achilles tendon.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case Series.

Noninsertional Tendinopathy of the Achilles

Noninsertional Achilles tendinosis is differentiated from insertional Achilles tendinosis based on anatomic location. Tendinosis, as opposed to tendonitis, is primarily a degenerative process and the role of inflammation is believed limited. The etiology of Achilles tendinopathy may include overuse leading to repetitive microtrauma, poor vascularity of the tissue, mechanical imbalances of the extremity, or combination of these elements. There is evidence to support eccentric exercise nonoperative management for patients with noninsertional Achilles tendinopathy. Operative treatment options include percutaneous longitudinal tenotomies, minimally invasive tendon scraping, open débridement and tubularization, and tendon augmentation with flexor hallucis longus.

Surgical treatment for midportion Achilles tendinopathy: a systematic review

PURPOSE

The aim of this study was to systematically evaluate the available literature on surgical treatment for midportion Achilles tendinopathy and to provide an overview of the different surgical techniques.

METHODS

A systematic review of the literature available in MEDLINE, EMBASE and the Cochrane database of controlled trials was performed. The primary outcome measure in terms of patient satisfaction and the secondary outcome measures that consisted of complication rate, pain score, functional outcome score and success rate were evaluated. The Downs & Black checklist and the Coleman methodology scale were used to assess the methodological quality of included articles.

RESULTS

Of 1090 reviewed articles, 23 met the inclusion criteria. The included studies reported on the results of 1285 procedures in 1177 patients. The surgical techniques were divided into five categories. Eleven studies evaluated open surgical debridement, seven studies described minimally invasive procedures, three studies evaluated endoscopic procedures, one study evaluated open gastrocnemius lengthening, and one study reported on open autologous tendon transfer. Results regarding patient satisfaction (69-100 %) and complication rate (0-85.7 %) varied widely.

CONCLUSIONS

This study demonstrates the large variation in surgical techniques available for treatment of midportion Achilles tendinopathy. None of the included studies compared surgical intervention with nonsurgical or placebo intervention. Minimally invasive and endoscopic procedures yield lower complication rates with similar patient satisfaction in comparison with open procedures. Minimally invasive and endoscopic procedures might therefore prove to be the future of surgical treatment of Achilles midportion tendinopathy.

LEVEL OF EVIDENCE

IV.

Follow-up of surgical and minimally invasive treatment of Achilles tendon pathology: a brief diagnostic imaging review

The follow-up of an operated tendon is primarily clinical, although clinical examination may not be sufficient in the presence of certain complications. The imaging techniques are of great value not only in the diagnosis of tendon pathologies, but also as an adjunct to clinical evaluation. This is particularly true in the follow-up of patients submitted to surgical tendon reconstruction, by monitoring morphological effects of different interventions and evaluating tendon healing processes. Interpretation of imaging findings requires knowledge of the imaging appearance of the operated tendon during the healing phase, to distinguish between normal postsurgical changes and real pathology, as well as knowledge of surgical technique, postoperative course (including type of prescribed therapy) and possible postoperative complications. The most important imaging modalities to examine the Achilles tendon are ultrasound and magnetic resonance imaging. This article gives a review of some of the most common treatment strategies for Achilles tendon pathology, expected postoperative imaging findings and postoperative complications.

Analysing the outcome of surgery for chronic Achilles tendinopathy over the last 50 years

AIM

To determine an association between when the study was performed, the robustness of the study and the outcomes for insertional and non-insertional Achilles tendinopathy surgery.

METHODS

We performed a systematic review in accordance with the PRISMA guidelines to assess the methodology of studies investigating the outcome of surgery in chronic Achilles tendinopathy over the last 50 years to identify any trends that would account for the variable results. The Coleman Methodology Scores were correlated with the reported percentage success rates and with the publication year to determine any trends using Pearson's correlation.

RESULTS

We identified 62 studies published between 1964 and 2014 reporting on a total of 2923 surgically treated Achilles tendinopathies. The average follow-up time was 40 mo (range 5-204 mo), and the mean reported success rate was 83.5% (range 36%-100%). The Coleman Methodology Scores were highly reproducible (r = 0.99, P < 0.01), with a mean of 40.1 (SD 18.9, range 2-79). We found a negative correlation between reported success rate and overall methodology scores (r = -0.40, P < 0.001), and a positive correlation between year of publication and overall methodology scores (r = 0.46, P < 0.001).

CONCLUSION

We conclude that although the success rate of surgery for chronic Acilles tendinopathy described in the literature has fallen over the last 50 years, this is probably due to a more rigorous methodology of the studies.

Achilles tendon disorders

Achilles tendon disorders include tendinosis, paratenonitis, insertional tendinitis, retrocalcaneal bursitis, and frank rupture. Patients present with pain and swelling in the posterior aspect of the ankle. Magnetic resonance imaging and ultrasound are helpful in confirming the diagnosis and guiding treatment. Nonsurgical management of Achilles tendon disorders includes nonsteroidal anti-inflammatory drugs, physical therapy, bracing, and footwear modification. Surgical treatment includes debridement of the diseased area of the tendon with direct repair. Tendon transfer may be necessary to augment the strength of the Achilles tendon.

Flexor hallucis longus tendon transfer in treatment of Achilles tendinosis

BACKGROUND

In patients with Achilles tendinosis, Achilles tendon debridement can be supplemented with flexor hallucis longus tendon transfer. Outcomes have not been studied prospectively in older, sedentary, and overweight patients.

METHODS

Fifty-eight consecutive limbs in fifty-six consecutive older, sedentary patients with insertional or midsubstance Achilles tendinosis were enrolled prospectively and underwent the procedure. Ten patients were lost to follow-up, leaving forty-eight limbs in forty-six patients available for evaluation after twenty-four months.

RESULTS

The forty-six patients who were included in the study had an average age of 54 ± 10 years with an average body mass index of 33.8 ± 6.8 kg/m². Significant improvement was observed between baseline and twenty-four months in terms of the visual analog scale for overall pain intensity (6.7 ± 2.3 versus 0.8 ± 2.0; p < 0.001), the Short Form-36 physical score (34.3 ± 8.0 versus 49.0 ± 9.3; p < 0.001), the Ankle Osteoarthritis Scale pain (54.4 ± 19.2 versus 1.9 ± 2.7; p < 0.001) and dysfunction (62.6 ± 21.4 versus 11.0 ± 24.2; p < 0.001) subscale scores, and performance of a single-leg heel rise (1.9 ± 3.0 versus 7.3 ± 2.7 cm; p < 0.001). Significant improvement compared with baseline was observed at three or six months except in the single-leg heel rise. Improvements in terms of pain and function occurred over twenty-four months, with the most improvement occurring in the first twelve months. At twenty-four months, maximum gastrocnemius circumference was significantly less in the involved compared with the uninvolved leg (40.2 ± 5.1 versus 41.2 ± 4.8 cm; p < 0.001). The mean passive range of motion of the first metatarsophalangeal joint decreased from 85.1° ± 25.3° preoperatively to 68.1° ± 36.7° (a 20% change) at six months (p = 0.03). Most patients reported no hallux weakness (57%; twenty-six of forty-six patients) and no loss of balance due to hallux weakness (76%; thirty-five of forty-six patients). Postoperative peroneal tendinitis was observed in seven patients. Complications included deep-vein thrombosis (two patients), superficial infection or delayed wound-healing (six), scar pain (four), and early disruption of the reconstruction due to a fall (one).

CONCLUSIONS

Surgical debridement of the Achilles tendon with flexor hallucis longus tendon transfer was associated with significant improvement in terms of Achilles tendon function, physical function, and pain intensity in a group of relatively inactive, older, overweight patients. When present, hallux weakness had minimal functional sequelae.

Clinical and magnetic resonance imaging outcomes following platelet rich plasma injection for chronic midsubstance Achilles tendinopathy

BACKGROUND

The successful treatment of chronic mid-substance Achilles tendinopathy remains elusive. Approximately 25% to 50% of patients fail conservative treatment modalities. Scientific evidence has supported the use of platelet rich plasma (PRP) in the tendon healing process, however despite initial promise there is a paucity of clinical data to validate a role for PRP in the treatment of tendon disorders including chronic midsubstance Achilles tendinopathy.

METHODS

As an alternative to operative treatment, our practice offers patients with chronic midsubstance Achilles tendinopathy intratendinous injection of PRP. We retrospectively reviewed all patients treated for Achilles tendinopathy with PRP injection over a 2-year period. Baseline and post injection functional scores including the Foot and Ankle Ability Measure (FAAM), Foot and Ankle Ability Measure - Sports (FAAMS), and the Short Form health survey (SF-8) were examined. Patients also underwent post-injection magnetic resonance imaging (MRI), which were compared to available pre-injection MRI data.

RESULTS

Ten patients were identified for this study. Pre- and postinjection functional outcome scores were available for eight of ten patients. The average SF-8 score improved from 24.9 to 30.0, the average FAAM score improved from 55.4 to 65.8, and the average FAAMS score improved from 14.8 to 17.4. Complete MRI data was available for six patients. Only one in six Achilles tendons demonstrated qualitative MRI improvement post-injection.

CONCLUSION

Patients who received PRP injection demonstrated modest improvement in functional outcome measures, however MRI appearance of diseased Achilles tendons remained largely unchanged following PRP injection.

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.

Extra-corporeal pulsed-activated therapy ("EPAT" sound wave) for Achilles tendinopathy: a prospective study

Achilles tendinopathy is common and extracorporeal shockwaves have become a popular treatment for this condition, even though previous research has not provided conclusive results regarding its efficacy in cases of Achilles tendinopathy. Our aim was to evaluate 3 weekly shockwave treatments in patients with Achilles tendinopathy, as quantified by the Roles and Maudsley score. A total of 74 tendons in 60 patients were assessed at baseline and at least 1 year posttreatment, including 32 (43.24%) paratendinoses, 23 (31.08%) proximal tendinoses, and 19 (25.68%) insertional tendinoses. The mean age of the participants was 48.6 ± 12.94 years, and patients with paratendinosis (41.44 ± 14.01 years) were statistically significantly younger than those with proximal (53 ± 8.9 years) and insertional (54.26 ± 9.74 years) tendinopathy, and these differences were statistically significant (P = .0012 and P = .0063, respectively). Overall, 58 (78.38%) tendons improved by at least 1 year posttreatment, including 75% in the paratendinosis, 78.26% in the proximal tendinosis, and 84.21% in the insertional tendinosis groups, and no adverse effects were observed. The Roles and Maudsley score improved from 3.22 ± 0.55 to 1.84 ± 1.05 (P < .0001) in the paratendinosis group, 3.39 ± 0.5 to 1.57 ± 0.66 (P < .0001) in the proximal tendinopathy group, and 3.32 ± 0.58 to 1.47 ± 0.7 (P = .0001) in the insertional tendinopathy group. Based on these results, we believe that shockwave therapy serves as a safe, viable, and effective option for the treatment of Achilles tendinopathy.

[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.

Radiofrequency coblation for chronic foot and ankle tendinosis

PURPOSE

To evaluate outcomes of radiofrequency coblation for chronic tendinosis of the foot and ankle tendons.

METHODS

Records of 7 men and 8 women (16 feet) aged 27 to 65 years who underwent radiofrequency coblation for chronic tendinosis (combined with other procedures for other pathology) of the Achilles, posterior tibial, and peroneal tendons were retrospectively reviewed. The visual analogue scale (VAS) for pain status, the Short Form (SF-36) questionnaire for quality of life, and the American Orthopaedic Foot and Ankle Society (AOFAS) scores for functional status of the patients were determined pre- and post-operatively.

RESULTS

All patients reported significant reduction in pain at 3 months, with more than 63% attaining VAS scores of 0 at 6 months. AOFAS scores were significantly improved at both 3 and 6 months. Most components of SF-36 scores improved at 6 months except those for general health and role emotional; only those for bodily pain improved significantly. At postoperative month 3 and 6 respectively, 93 and 100% of the patients had their expectations met, whereas 93 and 88% had good-to-excellent satisfaction. There were no major complications.

CONCLUSIONS

Radiofrequency coblation for chronic tendinosis of the foot and ankle achieves good short-term outcomes and pain relief. It may be combined with other procedures for maximal benefit.

Surgical treatment of non-insertional Achilles tendinitis

Noninsertional Achilles tendinitis is a distinct clinical entity, frequently characterized by swelling, pain, and lower limb dysfunction. This condition can be frustrating to treat, for the patient and the physician alike, as reflected in the various treatments, both conservative and surgical, that have been described. Although many patients with Achilles tendinitis can be successfully treated with nonoperative methods, persistent symptoms require surgical treatment, such as tenotomy, debridement, or repair.

Tendon disorders of the foot and ankle, part 2: achilles tendon disorders

Disorders of the Achilles tendon include both acute and chronic ruptures as well as a spectrum of chronic overuse injuries involving inflammatory and degenerative changes within the tendon and surrounding tissues. These injuries are relatively common in athletes as well as among the general population. There is no consensus on the optimal treatment of Achilles tendon disorders. The goals of this review are to develop a current understanding of the anatomy and diagnostic evaluation of the Achilles tendon, and to present current treatment options and the authors' preferred surgical techniques for operative management of Achilles tendon disorders.

Extracorporeal shockwave therapy for the treatment of Achilles tendinopathies: a prospective study

BACKGROUND

Extracorporeal shockwave therapy has been shown to be effective in the treatment of chronic tendon pathology in the elbow, shoulder, and plantar fascia. This prospective study examines the efficacy of extracorporeal shockwave therapy in the treatment of chronic Achilles tendon disorders.

METHODS

Twenty-three patients (23 feet) were treated with extracorporeal shockwave therapy for Achilles tendinosis, insertional tendonitis, or both. Indications for treatment were a minimum of 6 months of conservative care, and a visual analog pain score >5. The mean follow-up was 20 months (range, 4-35 months).

RESULTS

Ninety-one percent (14 patients) were satisfied or very satisfied (23 patients) with treatment. Eighty-seven percent (20 patients) stated that extracorporeal shockwave therapy improved their condition, 13% (3 patients) said it did not affect the condition, and none stated that it made them worse. Eighty-seven percent (20 patients) stated they would have the procedure again if given the choice. Four months after extracorporeal shockwave therapy, the mean visual analog score for morning pain decreased from 7.0 to 2.3, and activity pain decreased from 8.1 to 3.1.

CONCLUSION

High-power extracorporeal shockwave therapy is safe, noninvasive, and effective, and it has a role in the treatment of chronic Achilles tendinopathy.

Effect of bupivacaine on cultured tenocytes

Proliferation of cultured human fibroblasts and other types of cells has been shown to be hindered by exposure to local anesthetics, which are widely used in musculoskeletal medicine for their use in regional anesthesia, selective nerve blocks, bursography, and brisement. We hypothesized that bupivacaine would decrease cell proliferation and production of extracellular matrix components collagen and proteoglycan in healthy human tenocytes in culture. Primary human tenocyte cultures were prepared from samples of normal tendons obtained from healthy tissue that would otherwise have been discarded during lower extremity tendon transfer surgery. Samples were obtained from 6 patients, 5 women and 1 man with an average age of 69 years (range, 17-73 years). Five flexor digitorum longus tendon samples and 1 peroneus longus tendon sample were used. Harvested tendon tissues (5 mm(3)) were used as explants for primary cell cultures. To measure the proliferative response to bupivacaine, seeded cells were exposed to saline control or to various concentrations of bupivacaine in 1% fetal bovine serum DMEM/F12 or 10% fetal bovine serum DMEM/F12. The 1% fetal bovine serum medium demonstrated the pure bupivacaine effect, and 10% fetal bovine serum more closely approximated the in vivo environment. Seeded cells were starved of fetal bovine serum for 12 hours before exposure to phosphate-buffered saline (control group) and 500 microM bupivacaine (experimental group). This concentration of bupivacaine was selected because it was found to significantly hinder proliferation in both the 1% and 10% fetal bovine serum groups in our proliferation assay. Tenocyte proliferation and extracellular matrix component production were significantly lower (P<or=.05) at >or=1 time points up to 6 days in bupivacaine-treated groups as compared with controls.

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.

Flexor hallucis tendon transfer with an interference screw for chronic Achilles tendinosis: a report of 62 cases

Chronic disorders of the Achilles tendon are frequently treated by foot and ankle surgeons. A number of surgical techniques have been described for treating chronic degenerative Achilles tendinosis. This is the largest reported series evaluating a method of transferring the flexor hallucis longus (FHL) tendon and securing it with an Arthrex interference screw into the calcaneus. Sixty-two patients with Achilles tendinosis underwent Achilles debridement and transfer of the FHL tendon for chronic conditions when greater than 50% of the tendon was involved. All 62 patients were followed for an average of 26.97 months. A modified American Orthopaedic Foot and Ankle Society score was evaluated both preoperatively and postoperatively and demonstrated significant improvement. Because of the anatomical relationship of the FHL tendon to the Achilles tendon and the fact that both tendons act in the same phase, transfer of this tendon in chronic Achilles tendinosis or rupture is a reasonable option. The described technique is advantageous in that it is simple to perform and is less time-consuming than other reported methods. The authors have had no revisions to date.

Noninsertional Achilles tendinopathy

The treatment of noninsertional Achilles tendinopathy remains, to a large extent, empirical. Neither different operative techniques nor nonoperative regimes have been subjected to controlled trials. Rather, the condition is still treated on the basis of anecdotal evidence combined with personal experience. However, increased knowledge of the basic science of tendinopathy and tendon healing has directed therapeutic regimens and will continue to do so. Manipulation of proteolytic enzymes and control of neovascularization are probably the two areas that show most promise.

Tendon healing

An understanding of the processes of tendon healing and tendon-to-bone healing is important for the intraoperative and postoperative management of patients with tendon ruptures or of patients requiring tendon transfers in foot and ankle surgery. Knowledge of the normal process allows clinicians to develop strategies when normal healing fails. This article reviews the important work behind the identification of the normal phases and control of tendon healing. It outlines the failed response in tendinopathy and describes tendon-to-bone healing in view of its importance in foot and ankle surgery.

Prediction of the success of nonoperative treatment of insertional Achilles tendinosis based on MRI

BACKGROUND

Insertional Achilles tendinosis is a common clinical diagnosis for posterior heel pain. Nonoperative treatments often are unsuccessful. The purpose of this paper was to review a series of patients with insertional tendinopathy to determine whether MRI stratification could predictably identify patients in whom nonoperative treatment would fail.

METHODS

Review of records identified 157 patients (176 tendons) who were treated for insertional posterior heel pain. All patients who required surgery had MRI and their tendinosis was classified based on tendon size and degree of involvement (type I, II, or III). Patients who required surgery had standard two-incision decompression and debridement.

RESULTS

Of the 157 patients (176 tendons) with insertional heel pain, 83 (53%) responded to nonoperative treatment (96 tendons). Most of these patients who had MRI evaluation had type I involvement. The remaining 74 patients (47%) required operative intervention after an average of 12 months of conservative treatment (80 tendons). Most of these tendons were types II and III. Overall, two of the 16 type I tendons (12.5%) required surgery, 59 of the 65 type II tendons (90.8%) needed surgery, and 19 (70.4%) of the 27 type III tendons required surgery.

CONCLUSIONS

Patients with tenderness of the Achilles tendon insertion without obvious signs of inflammation who demonstrate confluent areas of intrasubstance signal changes on MRI (types II and III) are not likely to respond to nonoperative treatment. Early identification of these patients and operative intervention may lead to earlier return to function.

Tendinopathy of the main body of the Achilles tendon

Although Achilles tendinopathy has been extensively studied, there is a clear lack of properly conducted scientific research to clarify its etiology, pathology and optimal management. Emerging non-operative management and heavy load eccentric strengthening protocols based on these theories have yielded encouraging early results. Operative management traditionally produced good to excellent results, but randomized controlled studies comparing different surgical procedures and prospective evaluation of patient outcomes are necessary to truly establish the efficacy of these procedures. As the biology of tendinopathy is being clarified, more effective management regimens may come to light, improving the success rate of both conservative and operative management.

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.

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

Twenty-seven track athletes/runners with chronic Achilles tendinopathy underwent a retrospective review of 37 surgical Achilles procedures performed between 1990 and 1999. There were 22 males and 5 females. Average age of the group was 36.6 years (range, 16-75 years). The mean "return to activity" (RTA) was 10.6 +/- 6.3 weeks. For elite athletes, RTA was 7.9 = 4.8 weeks. For nonelite athletes, RTA was 15.0 +/- 6.2 weeks, and was statistically higher (p = .003). There was no significant difference between males' and females' RTA. Average follow-up for the group was 4.7 years (range, 1-10 years). Runners on average ran more than 60 miles a week. There were 14 elite and 13 nonelite athletes, including four Olympians, five sub-4-minute milers, and four National Champions. Return to competition and "100%" were 25.0 and 25.4 weeks, respectively, for the elite group. Return to competition for the nonelite group was 27.0 +/- 11.0 weeks. Eighteen patients underwent peritenolysis with a mean RTA of 7.7 weeks. Of this group, four patients with concomitant bony procedures had significantly slower RTA as opposed to the 14 patients who had peritenolysis only (mean, 4.5 weeks). Four patients had Achilles debridement for mucoid degeneration, and a mean RTA of 12.8 weeks. Eleven patients had Haglund-type procedure (retrocalcaneal exostectomy) had a mean RTA of 15.1 weeks. Six Achilles tendocalcinosis repair patients had a mean RTA of 12.0 weeks. There were three reoperations, two of which were performed by the author. Using the Testa Achilles tendon surgery rating scale, this group of patients had 34 "excellent" and 3 "good" results. The patients who underwent a reoperation were able to achieve "good" or better results.

Achilles tendons: clinical relevance of neovascularization diagnosed with power Doppler US

PURPOSE

To evaluate the clinical relevance of neovascularization diagnosed with power Doppler ultrasonography (US) in Achilles tendons in patients with chronic achillodynia.

MATERIALS AND METHODS

Forty consecutive patients (mean age, 52 years; age range, 30-72 years) were examined. US was performed bilaterally and repeated after 3 months. Shape and echogenicity were assessed with gray-scale US and vascularization with power Doppler US. All patients were treated conservatively. Clinical assessment was performed after 0, 3, and 6 months by using visual analogue scale (VAS) scores (0, no pain; 100, unbearable pain). The VAS scores were compared with the initial US findings, and analysis of variance was used for repeated measurements.

RESULTS

Neovascularization was present in 30 of 55 painful tendons and in one of 25 asymptomatic tendons. The mean VAS scores at 0, 3, and 6 months, respectively, for tendons with neovascularization were 52, 26, and 20; those for tendons without neovascularization were 39, 19, and 18 (P =.15). Forty-eight painful and nine asymptomatic tendons were spindle shaped. The mean VAS scores at 0, 3, and 6 months, respectively, for the spindle-shaped tendons were 48, 25, and 20; those for normally shaped tendons were 33, 10, and 16 (P =.17). Thirty-five painful and four asymptomatic tendons were inhomogeneous. The mean VAS scores at 0, 3, and 6 months, respectively, for symptomatic inhomogeneous tendons were 54, 29, and 25; those for symptomatic homogeneous tendons were 32, 12, and 9 (P <.001).

CONCLUSION

Although neovascularization is a specific sign for pain, it does not indicate an unfavorable outcome. Conversely, tendon inhomogeneity seems to be associated with an unfavorable outcome.

Surgical treatment for chronic Achilles tendinopathy: a prospective seven month follow up study

OBJECTIVE

To prospectively assess the early results of surgical treatment of chronic Achilles tendinopathy.

METHODS

This seven month prospective follow up study assessed the short term results of surgical treatment of chronic Achilles tendinopathy and compared the subjective and functional outcome of patients with Achilles tendinopathy without a local intratendinous lesion (group A) with that of similar patients with such a lesion (group B). Forty two of the initial 50 patients were examined before surgery and after the seven month follow up. Evaluation included an interview, subjective evaluation, clinical tests, and a performance test.

RESULTS

At the follow up, physical activity was fully restored in 28 of the 42 patients (67%), and 35 patients (83%) were asymptomatic or had only mild pain during strenuous exercise. In clinical tests, significant improvements were observed in climbing up and down stairs and the rising on the toes test. Surgical treatment also seemed to be successful from the total test score, which was excellent or good in 35 patients, compared with before surgery when it was excellent or good in one patient only. Patients in group A fared better than those in group B, whether evaluated by recovery of physical activity after surgery (88% v 54%) or the complication rate (6% v 27%).

CONCLUSIONS

Surgical treatment of chronic Achilles tendinopathy gives good and acceptable short term results. A lower complication rate and a trend to better recovery was observed in patients with peritendinous adhesions only than in those with peritendinous adhesions combined with an intratendinous lesion.

Surgical treatment of Achilles tendinitis by decompression of the retrocalcaneal bursa and the superior calcaneal tuberosity

BACKGROUND

Initial nonoperative treatment of pain at the Achilles tendon, often referred to as "tendinitis," is not always successful.

HYPOTHESIS

Surgical treatment is effective for patients with insertional tendinitis unrelieved by nonoperative measures.

STUDY DESIGN

Retrospective cohort study.

METHODS

Thirty-five patients (41 feet) who had painful Achilles tendon syndrome unrelieved by 6 months of nonoperative measures were treated surgically. The technique consisted of a single incision along the lateral border of the Achilles tendon. The dissection exposed the retrocalcaneal bursa and fat pad, which were completely excised along with any scarred and thickened paratenon. A partial calcaneal exostectomy of the tubercle was performed.

RESULTS

At a minimum follow-up of 20 months (average, 39), the patients' pain scores (rated from 0 to 6) improved from 4.7 (SD, 1.1) preoperatively to 1.5 (SD, 1.3); 90% had complete or significant relief of symptoms, 10% felt improved, and none felt unchanged or worse.

CONCLUSIONS

Surgical treatment of chronic Achilles tendon pain with resection of the prominent tuberosity, complete debridement of the bursa, excision of thickened, scarred paratenon, and removal of accessible calcific deposits within the tendon is an effective treatment.

Achilles tendon disorders in athletes

Achilles tendon disorders are among the more common maladies seen by sports medicine physicians. Understanding the anatomy and biomechanics of the Achilles tendon and contiguous structures is essential to the diagnosis and treatment of Achilles tendon overuse injuries. Posterior heel pain is multifactorial and includes paratenonitis, tendinosis, tendinosis with partial rupture, insertional tendinitis, retrocalcaneal bursitis, and subcutaneous tendo-Achilles bursitis. Each of these entities is distinct, but they often occur in combination. Although most cases of this disorder are successfully treated nonoperatively, a small subgroup of recalcitrant cases may benefit from surgical intervention. Complete ruptures in active, athletic persons should be treated operatively in most cases and result in predictably good outcomes. There may be some cases that escape early recognition and require a reconstructive procedure to salvage a potentially severe functional deficit.

Insertional Achilles tendinosis: surgical treatment through a central tendon splitting approach

Twenty-two heels in 21 patients treated surgically for a primary diagnosis of insertional Achilles tendinosis were reviewed on the basis of preoperative and postoperative examinations, office records, and a comprehensive questionnaire administered to each subject. Each patient underwent surgical treatment using a midline-posterior skin incision combined with a central tendon splitting approach for debridement, retrocalcaneal bursectomy, and removal of the calcaneal bursal projection as necessary. The findings at surgery revealed involvement of the middle third of the insertion in 21 of 22 cases with only one patient manifesting isolated lateral involvement. Thirteen of 22 had an associated prominent calcaneal bursal projection and four of 22 a superficially inflamed bursa. Three patients required reinsertion of the tendo Achilles via drill holes and one underwent augmentation with a plantaris tendon. Operative findings and complications were reported. Eight male and 13 female patients underwent 22 procedures (one case bilaterally) with an average follow-up of 33 months. Preoperative symptoms include presence of symptoms over a range of three months to two years and pain associated with activities of daily living (17 of 22), limitation of regular activities (six of 22), and pain present at rest in six of 22. Postoperatively, 20 of 22 patients were able to return to work or routine activities by three months; only 13 of 22 were completely pain free. Only 13 of 22 also claimed that they were able to return to unlimited activities. Overall, there was an 82% (18 of 22) satisfaction rate with surgery and 77% (17 of 22) stated they would have the surgery again.

Outcome of surgery for chronic Achilles tendinopathy. A critical review

Achilles tendinopathy is often treated surgically after failure of nonoperative management, but results are not uniformly excellent. We critically assessed the methods of 26 studies that reported surgical outcomes of patients with this condition. Using 10 previously published criteria, and blinded to study outcomes, we derived a "methodology score" (0 to 100) for each study. This score was highly reproducible (r = 0.99, P < 0.01). Scores were generally low concerning the type of study, subject selection process, and outcome measures, which indicates methods deficiency in the way the study was designed, performed, and analyzed. We found a negative correlation between reported success rate and overall methods scores (r = -0.53, P < 0.01), and a positive correlation between year of publication and overall methods score (r = 0.70, P < 0.01). Study methods may influence reported surgical outcome, and we suggest guidelines for improving study design in this area of clinical research. We acknowledge that study methods have improved over the course of the past 20 years.

Treatment of chronic achilles tendon disorders with flexor hallucis longus tendon transfer/augmentation

Chronic disorders of the Achilles tendon are commonly seen by the orthopaedic surgeon. In cases that are resistant to conservative treatment, a variety of surgical procedures have been utilized in the past. The indications for a previously described technique of flexor hallucis longus tendon transfer for reconstruction of chronic Achilles tendon rupture have been expanded to include further subsets of chronic Achilles tendinopathy, including rupture and tendinosis. We evaluated 20 patients (mean age 61) who underwent flexor hallucis longus transfer for treatment of chronic Achilles tendinopathy at a mean of 14 months following surgery. Our results were measured with the SF-36 survey, AOFAS Ankle-Hindfoot Scale, and Cybex strength and range of motion testing. Wound complications, tip-toe stance, and calf circumference were also assessed. There were no postoperative reruptures, tendinopathy recurrences, or wound complications. Despite a small loss of calf circumference, range of motion, and plantarflexion strength, 90% of patients scored 70 or higher on the AOFAS scale. SF-36 testing revealed significantly lower scores in the physical function category when compared with United States norms. Flexor hallucis longus tendon transfer/augmentation is a reasonable option for treatment of chronic Achilles tendinosis and rupture.

Long-term prognosis of patients with achilles tendinopathy. An observational 8-year follow-up study

To determine the long-term outcome of patients treated nonoperatively for acute or subchronic (duration of the symptoms before initiation of the treatment less than 6 months) Achilles tendinopathy, we performed a follow-up analysis on 83 of 107 patients an average 8 +/- 2 (SD) years after the initial contact. The analysis included a questionnaire, clinical examination, performance tests, muscle strength measurement, and ultrasonographic examination. Twenty-four of the 83 patients (29%) had to be operated on during the follow-up period. Seventy patients (84%) had full recovery of their activity level, and at 8 years' follow-up 78 patients (94%) were asymptomatic or had only mild pain with strenuous exercise. However, a clear side-to-side difference between the involved and the uninvolved sides was observed on the performance test, clinical examination, and ultrasonography. Also, 34 patients (41%) started to suffer from overuse symptoms in the initially uninvolved Achilles tendon. The results of our 8-year follow-up showed that the long-term prognosis of patients with acute-to-subchronic Achilles tendinopathy is favorable as determined by subjective and functional assessments. In the clinical and ultrasonographic examinations, mild-to-moderate changes were observed rather frequently in both the involved and initially uninvolved Achilles tendons, but the occurrence of these changes was not clearly related to the patients' symptoms.

Chronic Achilles tendinopathy in athletic individuals: results of nonsurgical treatment

We report the results of nonsurgical treatment of chronic Achilles tendinopathy in 22 patients with a follow-up of 33 to 72 months. Immediately after the treatment period, 70% of the patients were either improved or cured. At follow-up, 65% were improved or cured, and 35% failed treatment or had a poor long-term result. In these patients, early surgery might have been considered, but only one patient received a peritendinitis operation in the follow-up period. In athletic individuals with chronic Achilles tendinopathy, nonsurgical treatment with emphasis on active training is recommended. Surgery should be considered if the athlete has been treated for 3 to 6 months without progress.