Insertional achilles tendinopathy: The central approach
Insertional Achilles tendinopathy is a painful, frequently disabling condition of the posterior foot and ankle. Discomfort and irritation typically arise along the posterior aspect of the heel. As with most tendinopathies, pain begins intermittently and gradually becomes constant as the disease progresses. A common sign of this insertional tendon disease is the patient's difficulty in wearing closed-back shoes. Athletically inclined patients may report more pain after exercise. Despite advances in basic science tendon research, the pathophysiology of insertional Achilles tendinopathy is still not well understood. Traditionally, the disease has been viewed as an overuse phenomenon. Shear forces between collagen fascicles as well as biomechanical problems at the osseotendinous junction have been cited as causative factors in the disease. Recently, molecular collagen studies have hinted at the role of tenocytic chondral metaplasia as a causative factor. Other studies have focused on the role of increased microcirculation at the point of pain in insertional tendinopathy. It is not clear whether these findings represent etiologic or secondary factors. Insertional Achilles tendinopathy manifests in two very different patient populations: young active athletes and older sedentary patients. In the former group, pain is related to athletic activity and overuse. Running, dancing, tennis, and basketball are associated sports that tend to involve repetitive jumping and vigorous push-off activities. Pain seldom affects activities of daily living in this patient population. Pain usually presents at the initiation of sports activities and again just following activities. These patients' symptoms may be aggravated by running on hard surfaces, uneven ground, or uphill. Patients almost invariably present in open-backed shoes or sandals. Generally, this group appears to do well with conservative treatment. The latter group of patients is typically older than 45 years of age, sedentary, overweight, frequently female (although men can also be affected), and frequently have numerous medical comorbidities. Pain in these patients appears to be caused by degenerative changes rather than overuse. They, too, find open-backed shoes or sandals most comfortable. This group appears to do poorly with conservative treatment. On physical exam, an inflamed retrocalcaneal bursa or a posterolateral bony ridge may be noted. Tenderness is usually localized to the central lateral portion of the calcaneus at the tendon insertion. Pain is rarely found medially. The gastrocnemius-soleus complex may be tight with decreased ankle dorsiflexion when compared to the contralateral heel cord. Swelling and broadening of the heel is common. Crepitus and generalized erythema may also be observed. Pain is typically exacerbated by forced ankle dorsiflexion. Plain X-ray studies often demonstrate Haglund's deformity as well as intratendinous bone spurs wisping back from the bone-tendon junction (Fig. 19.1). Both magnetic resonance imaging (MRI) and ultrasonography may demonstrate lakes of tendinopathy within fibers of healthy tendon (Fig. 19.2). Both of these soft tissue imaging modalities may offer an advantage in the preoperative planning of tendon debridement. Ultrasound imaging, particularly with color Doppler imaging, has proven to be a quite helpful in the authors' hands. © Springer Science+Business Media, LLC 2009.
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