INSERTIONAL ACHILLES TENDINITIS - The Podiatry Institute

CHAPTER I9INSERTIONAL ACHILLES TENDINITIS: A DifferenrPerspective For Selected PatientsAlan S. Banks, D.P.M.There are probably a number of different sourcesfor pain at the Achilles tendon inserlion. Many ofthese patients will present with significant osseousspurring which may selve as a precursor to thesymptoms, and once present, may contribute tolocal irritation, inflammation, and pain. However,in some circumstances spurring may be absent, orof such a small degree that one may not be satisfiedthat this is a true component of the symptoms.\7hile certain biomechanical or structural faultsmay be identified in some patients, there ateothers with similar symptoms, where these findingsmay seem to be lacking. In other patients, theremay be some mechanical problem noted, but onewhich may not be traditionally associated with painat the Achilles insertion. It is this latter circumstancewhich has led the author to review the traditionalapproach to this condition in selected patients.NOMENCIATT]REPuddu et al. felt that the generic term "tendonitis"was inappropriate for pain associated with theAchilles tendon. They proposed that there werethree different forms of chronic Achilles tendonpathology: (A) Inflammation which involves thesurrounding tissue without involving the Achillestendon itself was termed peritendinif.zs. (B) Thetelrlr peritenclinitis uith tenclinoszs was preferredwhenever the surrounding tissues were inflamedand there was an associated degenerative processwithin the Achilles tendon. (C) The term tenclinosisdenoted a pure degenerative process within thetendon which was asymptomatic since thesurrounding tissues were not inflamed., Thecurrent author also prefers to use an additionalterm, insertional Achilles tend,initis, when referringto the pain and inflammatory changes which maybe seen at the posterior heel. This would seem alogical designation as the primary pain rypicallydoes not involve the more proximal aspects of theAchilles, and may or may not be associated withosseous spurring. Vhile some patients may presentwith concomitant symptoms, which extend into thedistal or central extent of the Achilles, the originof the pain is clearly noted to emanate from theinsertional component of the tendon.ETIOLOGYThe specific etiology of insertional tendinitis maybe the same or different from that of other inflammatoryconditions of the Achilles tendon. \(/hilethis paper is not intended to provide a completereview of Achilles tendinopathy, it would appearthat arthritides and biomechanical problems maybe consistent with symptoms in either anatomicarea. \7hen present, the insertional spurring mayprovide a unique potential means of instigatingpain. However, experienced clinicians will recallthat like patients with plantar heel spurs, thepresence of a posterior spur does not absolutelymean that symptoms will be present or necessarilydevelop at some later time. A11 of the factors thatlead to symptoms in patients with posterior heelspurs are not completely known, but it has beenthe author's experience in patients undergoingexcision of these fragments, that portions of thespurs are loosened or else freely moveable withinthe Achilles tendon. Excision of the spurring hasbeen the primary means of surgical treatmentfor the condition, with most patients sustainingsignificant relief.However, this again leads to the question as towhat initiates the symptoms of patients withoutposterior spurs and what is the most reasonableapproach for treatment when conselative optionsfall. Cefiainly, if the patient possesses either agastrocnemius or gastrosoleal equinus, then appropriatelengthening of the Achilles tendon mayalleviate the mechanical stress and associatedsymptoms. Yet in patients without spurring that theauthor has evaluated, good ankle motion has beenconsistently noted. Most of the patients have beenreasonably young and without any history or findingssuggestive of arthritic involvement. The only

CHAPTER 19l13significant structural or mechanical finding hasbeen a pes ca\ns of varying degree. Usually thismanifests as an anterior equinus deformity. Thisbeing the case, the author has attempted to reevaluatethe condition when contemplatingsurgical interuention in selected patients.PREOPERATTVE EVALUAIIONThe author will present the following case presentationof a palient who had been referred forchronic insertional Achilles pain of each heel. This39-year-old male had undergone extensive conservativecare consisting of oral anti-inflammatorymedications, physical therapy, padding, multiplechanges in shoes, and immobiiization. Clinicalevaluation revealed distinct pain over the posteriorcalcaneus in the atea of the Achilles tendoninsefiion. No swelling was noted and no tendernesswas present in the Achilles tendon proximally.The ankle joint demonstrated a good range ofmotion, and radiographs demonstrated no ovefiproblems at the posterior heel. The only significantfinding appeared to be a pes cavus condition,particularly an anterior equinus (Fig. 1A-1C). Therewas no history or other symptoms consistentwith afihritis.As noted, there was a distinct anterior equinusdeformity. Compensation would potentially createproblems at the posterior heel through twomeans. The first would be due to the change in theinclination of the calcaneus, possibly affecting theway in which pressure was applied to the posteriorheel. On the other hand, dorsiflexion at the anklewould be required to achieve balanced weightbearing between the forefoot and rearfoot, andcould thus create the pseudoequinus previouslydescribed by Green and \7hitney.'One might consider two different surgicalapproaches based upon individual philosophyand upon the patient's response to differentconseruative approaches. If convinced that thetuber of the calcaneus was in-itself a problem, thenthis might be addressed with a calcaneal osteotomysuch as described by Keck and Ke11y.3 Althoughthese authors have generally been credited withdescribing the procedure, the same technique hadbeen previously presented by Zadek.' Each ofthese authors appeared to develop the procedurewith the premise that Achilles tendinopathy andinflammation was due to impingement of theFigure 1A. Weight-bearing photographFigure 18. Non-weightbeadng photograph of the patientFigure 1C. Preoperative lateral racliograph. Note the absence of any{chilles inrenional sptrring.

I 14 CHAPTER 19superior corner of the calcaneus on the tendonitself. Therefore, its use in the treatment of insertionalAchilles pain would be extrapolated, asopposed to a primary historical indication.Nonetheless, the procedure has been used by someclinicians with the intent of reducing the prominenceof the posterior calcaneus.The author had employed this calcanealosteotomy in the past for insertional Achillestendinitis with less than satisfactory results. Uponcloser review, it would appear that the structuralchange effected via this osteotomy at the posteriorportion of the calcaneus was far less than expected.\7hile the prominence of the superior corner of thecalcaneus may be adequately addressed, the morecentral and distal aspects of the posterior calcanealsurface undergo little if any significant structuralrealignment. Furthermore, direct padding andprotection of the posterior heel provided no reliefin this particular patient, leading one to believethat primarily addressing the tuber with a similarprocedure wouid be of little benefit.It was also believed that the Keck and Kellyprocedure did little to alter the tension ofthe Achilles tendon at the calcaneal inseftion,particularly in someone with anterior equinus. Inthis patient, given the lack of spurring present, abasic premise of treatment was that the pseudoequinuscreated by the sagittal plane forefootdeformity would need to be addressed. Twomethods of Tocalizing the specific iocation or apexof the deformity have been described, Meary's andHibbs angles. In this patient, both methodsappeared to demonstrate the apex of deformity asthe naviculocuneiform area (Fig. 2). Appropriatecorrection of the anterior equinus would appear tobe accomplished via the Cole osteotomy.5 Thisprocedure would theoretically correct the anteriorequinus, thus alleviating the imposed weightbearingstress on the Achilles, but would also seemto exeft a more substantive change on the overallpressures of the calcaneal tuber than the Keck andKelly osteotomy.The author considered the Cole with somereticence, having cautioned against its use in thepast despite a lack of personal experience withthe technique.6 In addition, the procedure hadnot been viewed with wide approval by othermembers of the Podiatry Institute. However, morerecent favorable experiences with the Coleosteotomy by Downey had demonstrated that theprocedure could be performed with a minimum ofmorbidity and with good functional results.7'.Accordingly, the procedure was recommendedto the patient with the understanding that thiswould work in theory, but haci not been employedpreviously in actual practice.The patient underwent surgery and recovereduneventfully, sustaining complete relief of hissymptoms (Figs. 3A, 38, 4A-4C). The Coleosteotomy was performed on the contralateral footone year 7ater, again with complete resolution ofsymptoms. In the author's opinion, this was a realtest for this approach as no osseous spurringwas present at the posterior heel. Therefore, thereorientation of the forefoot had a pronouncedeffect on rearfoot symptoms.Since the success with this patient, the Coleosteotomy has been used in one other individualwho also underwent resection of significantspurring at the posterior heel. This patient notedthat a large dorsal prominence had posed aproblem with her shoe wear for a number ofyears. She similarly experienced a full resolution ofsymptoms, as well as an alleviation of shoepressure across the dorsum of the foot.DISCUSSIONFigure 2. Preoperative radiograph clemonstrating the convergence ofMeary's and Hibbs angles indicating the apex of deformity.Fiamengo et al. proposed three factors whichinteract to create a symptomatic posterior heel.As noted eadier, a prominence at the posteriorsuperior corner of the calcaneus can be an irritant.However, in most of these instances the specificdifference in the origin of the symptoms can beappreciated clinically. It was also proposed that

CHAPTER 19lt5Figure JR. Immediate postoperative radiograph.Figure JA. Immediate postoperative radiographsfbllowing the anterior tarszrl resection.Figure 4A. \Veight-bearing photograph of the patient at one yearfollou'ing surgery.Figr,rre 48. Non-weight bearing photograph at one year postoperativeFigure 4C. Postoperative radiograph at one year

I 16 CI]APTER 19patients with a longer horizontal axis or length ofthe calcaneus would place greater levels of stresson the Achilles tendon due to aL enhancedmechanical advantage associated with thisanatomic variation. Lastly, a posterior calcanealstep was found in a significant number of radiographsof symptomatic patients.eOther factors which may create symptomsinclude a large insertional Achilles spur, especiallyif part of the spur has fractured or loosened.Pseudoequinus is another factor which has notbeen discussed by most authors relative to thistopic. Vhitney and Green noted that this conditionwas most commonly associated with the anteriorca\-us foot type. If the forefoot is flexible, thencompensation for the deformity may occur throughdorsiflexion of the joints within the foot as the forefootis loaded during weight bearing. However,with more rigid feet, the dorsiflexion cannot beabsorbed in the foot, and any avallable dorsiflexionwithin the ankle is utilized.'Resection of the dorsal wedge of bone fromthe foot was originally described by Saunders. Hedescribed his results in 102 feet, having sustainedexcellent results in 28 patients, good results in J7,fair in 47, and poor in 2 feet, Of interest is that ofthe fair and poor results, most were not because ofuntoward consequences of the procedure itself, butdue to ankle equinus, heel varus deformity, orother coexistent deformities not addressed at thetime of the original surgery.'0 Cole proposed thesame procedure five years laler, but withoutproviding any discussion of his results.5This approach to posterior heel pain isproposed with some hesitation, especially consideringthe limited number of cases treated in thismanner. The Saunders (Cole) procedure shouldnot be used in every case of resistant posteriorheel pain, but may be considered in those patientswho possess distinct anterior cavlls deformitywhere it is felt that the coexistent pseudoequinuscondition is a primary force in the development ofheel symptoms.1234568.REFERENCESPuddu G, Ippolito E, Postacchini F: A classification of Achillestendon disease . Am J Spofis Mecl 4:1.45-1.50, 1976.Vhitney A, Green D: Pseudoequinus . J Am Podiahy Assoc 72:365-371. 1982.Keck S, Kelly P: Bursitis of the posterior part of tl're heel: evaluationof surgical treatment in 18 patients. J BoneJoint Surg 41 A:267-273, 1965.Zadek I: An operation for the cure of achillobursitis. AmJ Surg4J:542-546, 1939.Cole sfl: The treatment of claw foot. /Bone Joint Surg 22:895- 908,794C.).Banks A: Pes ca\.us deformity. In Marcinko D, ed. Medical andSurgical Therapeutics of tbe Foot and Ankle. Baltimore,Md:'Williams and \n'ilkins; I992:506-i11.Downey M; Cole osteotomy. In Camasta C, Yickers N, Ruch J, eds.ReconstructiDe Surgety of the Fctctt ancl Leg, Update '93, Tucker,GA: Podiatry Institlrte Publisl'ring; 1993 :204-208.Downey M: Cole osteotomy: a follow-up evaluation. In Vickers N.Mi11er S, Mahan K, Yu G, Camasta C, eds Reconstructiue Surgetyof the Foot and Leg, Upd.tte '97. Tucker, GA: Podiatry Institlrte;1997:192-196.Fiamengo S, \flarren R, Marshall J, Vigorita V, Hersh A: Posteriorheel pain associated w-ith a calcaneal step and Achilles tendoncalcification. Clin O?"tb op 1.57 :203-277, 7982.Saunders J: Etiology and treatment of clawfoot. Arcb Surg 30: 179-798, 19i5.