Achilles tendinopathy is prevalent and potentially incapacitating in athletes involved in running sports. It is a degenerative, not an inflammatory, condition. Most patients respond to conservative measures if the condition is recognised early. Surgery usually involves removal of adhesions and degenerated areas and decompression of the tendon by tenotomy or measures that influence the local circulation.

https://bjsm.bmj.com/content/bjsports/36/4/239.full.pdf

Patellar tendinopathy: some aspects of basic science and clinical management.

study, however, 31% of 58 patients with this condition did not participate in vigorous physical activity. 3 In this article, we have concentrated on tendinopathy of the main body of tendo Achillis. We have not dealt with Haglund's condition, insertional tendinopathy, or with lesions of the myotendinous junction. Anatomy. The gastrocnemius muscle merges with the soleus to form tendo Achillis. 4 It has a round upper part and is relatively flat in its distal 4 cm. Its fibres spiral through 90°, increasing the release of stored energy during locomotion. 5 Tendo Achillis is enveloped by a paratenon, originating from the deep fascia of the leg, the fascia cruris. Blood flow in the tendon increases considerably with exercise, probably due to the marked rise in the negative tissue pressure

Tendinopathy of tendo achillis.

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.

Insertional Achilles Tendinosis: Surgical Treatment Through a Central Tendon Splitting Approach:

Chronic ruptures of Achilles tendons are those that present four to six weeks after the original injury. They have become more common as acute Achilles tendon injuries have become more frequent, and they are associated with considerable functional morbidity. Most surgeons agree that chronic ruptures should be managed operatively. Diagnosis is based predominantly on history and clinical examination. Real-time, high-resolution ultrasound and magnetic resonance imaging are helpful in preoperative planning or as a diagnostic aid. Local tissue, local tendons, and allografts can be used to reconstruct the tendon, and end-to-end repair is possible if the gap is <2.5 cm. Compared with acute injuries, chronic injuries are associated with a higher rate of postoperative infection and more prolonged recovery.

Management of chronic ruptures of the Achilles tendon.

CURRENT CONCEPTS REVIEW: Management of Chronic Ruptures of the Achilles Tendon

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.

Treatment of Chronic Achilles Tendon Disorders with Flexor Hallucis Longus Tendon Transfer/Augmentation

Degeneration of the ankle and hindfoot joints is most commonly due to posttraumatic or rheumatoid arthritis. The first step in the successful management of ankle and hindfoot arthritis is making the correct diagnosis. This requires knowledge of the regional anatomy and biomechanics, a thorough history and physical examination, and the use of appropriate imaging studies. Treatment options for these complex problems, including a variety of nonsurgical modalities and surgical procedures, continue to evolve. Providing pain relief and improving a patient's function may involve shoe modifications, orthotic inserts, or antiinflammatory medications. Should these methods fail, surgical treatment may be beneficial. The mainstays of surgical treatment remain arthrodesis and arthroplasty. The goals of surgical treatment are pain relief, correction (or prevention) of deformity, and restoration (or preservation) of function. The literature from the last year has focused on ankle, subtalar, and triple arthrodeses, along with ankle arthroplasty.

Daniel K. Wilcox

Papers

Treatment of Chronic Achilles Tendon Disorders with Flexor Hallucis Longus Tendon Transfer/Augmentation

Advances in the surgical treatment of ankle and hindfoot arthritis