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Sports Medicine and Arthroscopic Surgery of the Foot and Ankle pp 167–186Cite as

Insertional and Midsubstance Achilles Tendinopathy

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Abstract

Achilles tendinopathy is characterized by pain, impaired performance, and swelling in and around the tendon.1 It can be categorized as insertional and noninsertional, two distinct disorders with different underlying pathophysiologies and management options.2 Other terms used as synonymous of noninsertional tendinopathy include tendinopathy of the main body of the Achilles tendon (AT) and mid-portion Achilles tendinopathy. In this chapter, we give a detailed overview of insertional tendinopathy of the AT and tendinopathy of the main body of the AT.

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References

  1. Longo UG, Ronga M, Maffulli N. Achilles tendinopathy. Sports Med Arthrosc. 2009;17:112–26.

    Article  PubMed  Google Scholar 

  2. Clain MR, Baxter DE. Achilles tendinitis. Foot Ankle. 1992;13:482–7.

    PubMed  CAS  Google Scholar 

  3. Bouché R, McInnes B. Posterior heel pain: Haglund’s deformity, pump bump deformity amd Achilles insertional calcific tendonitis (AITC). In: Chang T, editor. The foot and ankle. Philadelphia: Lippincott; 2005. p. 265–77.

    Google Scholar 

  4. Kolodziej P, Glisson RR, Nunley JA. Risk of avulsion of the Achilles tendon after partial excision for treatment of insertional tendonitis and Haglund’s deformity: a biomechanical study. Foot Ankle Int. 1999;20:433–7.

    PubMed  CAS  Google Scholar 

  5. Haglund P. Contribution to the diseased conditions of the tendo Achilles. Acta Chir Scand. 1928;63:292–4.

    Google Scholar 

  6. Carmont MR, Maffulli N. Management of insertional Achilles tendinopathy through a Cincinnati incision. BMC Musculoskelet Disord. 2007;8:82.

    Article  PubMed  Google Scholar 

  7. Leach RE, Schepsis AA, Takai H. Long-term results of ­surgical management of Achilles tendinitis in runners. Clin Orthop Relat Res. September 1992;282:208–12.

    Google Scholar 

  8. Maffulli N, Testa V, Capasso G, Sullo A. Calcific insertional Achilles tendinopathy: reattachment with bone anchors. Am J Sports Med. 2004;32:174–82.

    Article  PubMed  Google Scholar 

  9. Saxena A, Cheung S. Surgery for chronic Achilles tendinopathy. Review of 91 procedures over 10 years. J Am Podiatr Med Assoc. 2003;93:283–91.

    PubMed  Google Scholar 

  10. Sella EJ, Caminear DS, McLarney EA. Haglund’s syndrome. J Foot Ankle Surg. 1998;37:110–4. discussion 173.

    Article  PubMed  CAS  Google Scholar 

  11. Johnston E, Scranton P Jr, Pfeffer GB. Chronic disorders of the Achilles tendon: results of conservative and surgical treatments. Foot Ankle Int. 1997;18:570–4.

    PubMed  CAS  Google Scholar 

  12. Krishna Sayana M, Maffulli N. Insertional Achilles tendinopathy. Foot Ankle Clin. 2005;10:309–20.

    Article  PubMed  Google Scholar 

  13. Saxena A, Maffulli N, Nguyen A, Li A. Wound complications from surgeries pertaining to the Achilles tendon: an analysis of 219 surgeries. J Am Podiatr Med Assoc. 2008;98:95–101.

    PubMed  Google Scholar 

  14. Malay S, Duggar G. Heel surgery. In: Dalton McGlamry E, editor. Comprehensive textbook of foot surgery. Baltimore: Williams & Wilkins; 1987. p. 268–83.

    Google Scholar 

  15. Saxena A. Results of chronic Achilles tendinopathy surgery on elite and nonelite track athletes. Foot Ankle Int. 2003;24:712–20.

    PubMed  Google Scholar 

  16. Leitze Z, Sella EJ, Aversa JM. Endoscopic decompression of the retrocalcaneal space. J Bone Joint Surg Am. 2003;85-A:1488–96.

    PubMed  Google Scholar 

  17. Tozun R, Pinar H, Yesiller E, Hamzaoglu A. Indomethacin for prevention of heterotopic ossification after total hip arthroplasty. J Arthroplasty. 1992;7:57–61.

    Article  PubMed  CAS  Google Scholar 

  18. Saxena A. Return to athletic activity after foot and ankle surgery: a preliminary report on select procedures. J Foot Ankle Surg. 2000;39:114–9.

    Article  PubMed  CAS  Google Scholar 

  19. Maffulli N, Binfield PM, King JB. Tendon problems in athletic individuals. J Bone Joint Surg Am. 1998;80:142–4.

    PubMed  CAS  Google Scholar 

  20. McLauchlan GJ, Handoll HH. Interventions for treating acute and chronic Achilles tendinitis. Cochrane Database Syst Rev. 2001:CD000232.

    Google Scholar 

  21. Astrom M. Partial rupture in chronic Achilles tendinopathy. A retrospective analysis of 342 cases. Acta Orthop Scand. 1998;69:404–7.

    Article  PubMed  CAS  Google Scholar 

  22. Maffulli N, Khan KM, Puddu G. Overuse tendon conditions: time to change a confusing terminology. Arthroscopy. 1998;14:840–3.

    Article  PubMed  CAS  Google Scholar 

  23. Ames PR, Longo UG, Denaro V, Maffulli N. Achilles tendon problems: not just an orthopaedic issue. Disabil Rehabil. 2008;30:1646–50.

    Article  PubMed  Google Scholar 

  24. Maffulli N, Barrass V, Ewen SW. Light microscopic histology of Achilles tendon ruptures. A comparison with unruptured tendons. Am J Sports Med. 2000;28:857–63.

    PubMed  CAS  Google Scholar 

  25. Teitz CC, Garrett WE Jr, Miniaci A, Lee MH, Mann RA. Tendon problems in athletic individuals. Instr Course Lect. 1997;46:569–82.

    PubMed  CAS  Google Scholar 

  26. Maffulli N, Kenward MG, Testa V, Capasso G, Regine R, King JB. Clinical diagnosis of Achilles tendinopathy with tendinosis. Clin J Sport Med. 2003;13:11–5.

    Article  PubMed  Google Scholar 

  27. Robinson JM, Cook JL, Purdam C, et al. The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy. Br J Sports Med. 2001;35:335–41.

    Article  PubMed  CAS  Google Scholar 

  28. Silbernagel KG, Thomee R, Eriksson BI, Karlsson J. Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. Am J Sports Med. 2007;35:897–906.

    Article  PubMed  Google Scholar 

  29. Silbernagel KG, Thomee R, Karlsson J. Cross-cultural adaptation of the VISA-A questionnaire, an index of clinical severity for patients with Achilles tendinopathy, with reliability, validity and structure evaluations. BMC Musculoske­let Disord. 2005;6:12.

    Article  PubMed  Google Scholar 

  30. Maffulli N, Longo UG, Testa V, Oliva F, Capasso G, Denaro V. Italian translation of the VISA-A score for tendinopathy of the main body of the Achilles tendon. Disabil Rehabil. 2008;30:1635–9.

    Article  PubMed  Google Scholar 

  31. Dogramaci Y, Kalacy A, Kucukkubathorn N, Ynandy T, Esen E, Yanat AN, Khan K. Validation of the VISA-A questionnaire for Turkish language: the VISA-A-Tr study. Br J Sports Med. 2011;45(5):453–5.

    Google Scholar 

  32. Rolf C, Movin T. Etiology, histopathology, and outcome of surgery in achillodynia. Foot Ankle Int. 1997;18:565–9.

    PubMed  CAS  Google Scholar 

  33. Neuhold A, Stiskal M, Kainberger F, Schwaighofer B. Degenerative Achilles tendon disease: assessment by magnetic resonance and ultrasonography. Eur J Radiol. 1992;14:213–20.

    Article  PubMed  CAS  Google Scholar 

  34. Gibbon WW. Musculoskeletal ultrasound. Baillières Clin Rheumatol. 1996;10:561–88.

    Article  PubMed  CAS  Google Scholar 

  35. Khan KM, Maffulli N. Tendinopathy: an Achilles’ heel for athletes and clinicians. Clin J Sport Med. 1998;8:151–4.

    Article  PubMed  CAS  Google Scholar 

  36. Malliaras P, Richards PJ, Garau G, Maffulli N. Achilles ­tendon Doppler flow may be associated with mechanical load among active athletes. Am J Sports Med. 2008;36(11):2210–5.

    Article  PubMed  Google Scholar 

  37. Leadbetter WB. Cell-matrix response in tendon injury. Clin Sports Med. 1992;11:533–78.

    PubMed  CAS  Google Scholar 

  38. Kader D, Saxena A, Movin T, Maffulli N. Achilles tendinopathy: some aspects of basic science and clinical management. Br J Sports Med. 2002;36:239–49.

    Article  PubMed  CAS  Google Scholar 

  39. Maffulli N, Longo UG. Conservative management for tendinopathy: is there enough scientific evidence? Rheumatology (Oxford). 2008;47:390–1.

    Article  CAS  Google Scholar 

  40. Rompe JD, Furia JP, Maffulli N. Mid-portion achilles tendinopathy – current options for treatment. Disabil Rehabil. 2008;30(20–22):1666–76.

    Article  PubMed  Google Scholar 

  41. Leadbetter WB. Anti-inflammatory therapy and sports injury: the role of non-steroidal drugs and corticosteroid injection. Clin Sports Med. 1995;14:353–410.

    PubMed  CAS  Google Scholar 

  42. Vane JR. Introduction: mechanism of action of NSAIDs. Br J Rheumatol. 1996;35:1–3.

    Article  PubMed  CAS  Google Scholar 

  43. Almekinders LC. The efficacy of non-steroidal anti-inflammatory drugs in the treatment of ligament injuries. Sports Med. 1990;9:137–42.

    Article  PubMed  CAS  Google Scholar 

  44. Mafi N, Lorentzon R, Alfredson H. Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis. Knee Surg Sports Traumatol Arthrosc. 2001;9:42–7.

    Article  PubMed  CAS  Google Scholar 

  45. Kannus P, Jozsa L. Histopathological changes preceding spontaneous rupture of a tendon. A controlled study of 891 patients. J Bone Joint Surg Am. 1991;73-A:1507–25.

    Google Scholar 

  46. Manias P, Stasinopoulos D. A controlled clinical pilot trial to study the effectiveness of ice as a supplement to the exercise programme for the management of lateral elbow tendinopathy. Br J Sports Med. 2006;40:81–5.

    Article  PubMed  CAS  Google Scholar 

  47. Maffulli N, Longo UG. How do eccentric exercises work in tendinopathy? Rheumatology (Oxford). 2008;47:1444–5.

    Article  CAS  Google Scholar 

  48. Roos EM, Engstrom M, Lagerquist A, Soderberg B. Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathy – a randomized trial with 1-year follow-up. Scand J Med Sci Sports. 2004;14:286–95.

    Article  PubMed  Google Scholar 

  49. Sayana MK, Maffulli N. Eccentric calf muscle training in non-athletic patients with Achilles tendinopathy. J Sci Med Sport. 2007;10:52–8.

    Article  PubMed  Google Scholar 

  50. Murrell GA. Oxygen free radicals and tendon healing. J Shoulder Elbow Surg. 2007;16:S208–14.

    Article  PubMed  Google Scholar 

  51. Rompe JD, Nafe B, Furia JP, Maffulli N. Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial. Am J Sports Med. 2007;35:374–83.

    Article  PubMed  Google Scholar 

  52. Rompe JD, Furia J, Maffulli N. Eccentric loading versus eccentric loading plus shock-wave treatment for midportion Achilles tendinopathy: a randomized controlled trial. Am J Sports Med. 2009;37:463–70.

    Article  PubMed  Google Scholar 

  53. Longo UG, Olivia F, Denaro V, Maffulli N. Oxygen species and overuse tendinopathy in athletes. Disabil Rehabil. 2008;30:1563–71.

    Article  PubMed  Google Scholar 

  54. Paoloni JA, Appleyard RC, Nelson J, Murrell GA. Topical glyceryl trinitrate treatment of chronic noninsertional Achilles tendinopathy. A randomized, double-blind, placebo-controlled trial. J Bone Joint Surg Am. 2004;86-A:916–22.

    PubMed  Google Scholar 

  55. Paoloni JA, Murrell GA. Three-year followup study of topical glyceryl trinitrate treatment of chronic noninsertional Achilles tendinopathy. Foot Ankle Int. 2007;28:1064–8.

    Article  PubMed  Google Scholar 

  56. Kane TP, Ismail M, Calder JD. Topical glyceryl trinitrate and noninsertional Achilles tendinopathy: a clinical and cellular investigation. Am J Sports Med. 2008;36:1160–3.

    Article  PubMed  Google Scholar 

  57. Giombini A, Giovannini V, Di Cesare A, et al. Hyperthermia induced by microwave diathermy in the management of muscle and tendon injuries. Br Med Bull. 2007;83:379–96.

    Article  PubMed  CAS  Google Scholar 

  58. Warden SJ. A new direction for ultrasound therapy in sports medicine. Sports Med. 2003;33:95–107.

    Article  PubMed  Google Scholar 

  59. Hoksrud A, Ohberg L, Alfredson H, Bahr R. Ultrasound-guided sclerosis of neovessels in painful chronic patellar tendinopathy: a randomized controlled trial. Am J Sports Med. 2006;34:1738–46.

    Article  PubMed  Google Scholar 

  60. Maxwell NJ, Ryan MB, Taunton JE, Gillies JH, Wong AD. Sonographically guided intratendinous injection of hyperosmolar dextrose to treat chronic tendinosis of the Achilles tendon: a pilot study. AJR Am J Roentgenol. 2007;189:W215-20.

    Article  PubMed  Google Scholar 

  61. Knobloch K, Schreibmueller L, Longo UG, Vogt PM. Eccentric exercises for the management of tendinopathy of the main body of the achilles tendon with or without an airHeeltrade mark brace. A randomized controlled trial. B: effects of compliance. Disabil Rehabil. 2008;30(20-22):1692–6.

    Google Scholar 

  62. Knobloch K, Schreibmueller L, Longo UG, Vogt PM. Eccentric exercises for the management of tendinopathy of the main body of the achilles tendon with or without the airheeltrade mark brace. A randomized controlled trial. A: effects on pain and microcirculation. Disabil Rehabil. 2008;30(20–22):1685–91.

    Google Scholar 

  63. Chan O, O’Dowd D, Padhiar N, et al. High volume image guided injections in chronic Achilles tendinopathy. Disabil Rehabil. 2008;30:1697–708.

    Article  PubMed  Google Scholar 

  64. Maffulli N, Kader D. Tendinopathy of tendo achillis. J Bone Joint Surg Br. 2002;84:1–8.

    Article  PubMed  Google Scholar 

  65. Paavola M, Kannus P, Järvinen TAH, Khan K, Józsa L, Järvinen M. Achilles tendinopathy. J Bone Joint Surg Am. 2002;84-A:2062–76.

    PubMed  Google Scholar 

  66. Maffulli N, Testa V, Capasso G, Bifulco G, Binfield PM. Results of percutaneous longitudinal tenotomy for Achilles tendinopathy in middle- and long-distance runners. Am J Sports Med. 1997;25:835–40.

    Article  PubMed  CAS  Google Scholar 

  67. Testa V, Maffulli N, Capasso G, Bifulco G. Percutaneous longitudinal tenotomy in chronic Achilles tendonitis. Bull Hosp Jt Dis. 1996;54:241–4.

    PubMed  CAS  Google Scholar 

  68. Testa V, Capasso G, Benazzo F, Maffulli N. Management of Achilles tendinopathy by ultrasound-guided percutaneous tenotomy. Med Sci Sports Exerc. 2002;34:573–80.

    Article  PubMed  Google Scholar 

  69. Longo UG, Ramamurthy C, Denaro V, Maffulli N. Minimally invasive stripping for chronic Achilles tendinopathy. Disabil Rehabil. 2008;30:1709–13.

    Article  PubMed  Google Scholar 

  70. Maffulli N. Re: etiologic factors associated with symptomatic Achilles tendinopathy. Foot Ankle Int. 2007;28:660, author reply 660–1.

    Article  PubMed  Google Scholar 

  71. Tallon C, Coleman BD, Khan KM, Maffulli N. Outcome of surgery for chronic Achilles tendinopathy. A critical review. Am J Sports Med. 2001;29:315–20.

    PubMed  CAS  Google Scholar 

  72. Glaser T, Poddar S, Tweed B, Webb CW. Clinical inquiries. What’s the best way to treat Achilles tendonopathy? J Fam Pract. 2008;57:261–3.

    PubMed  Google Scholar 

  73. Maffulli N, Testa V, Capasso G, et al. Surgery for chronic Achilles tendinopathy yields worse results in nonathletic patients. Clin J Sport Med. 2006;16:123–8.

    Article  PubMed  Google Scholar 

  74. Maffulli N, Testa V, Capasso G, et al. Surgery for chronic Achilles tendinopathy produces worse results in women. Disabil Rehabil. 2008;30:1714–20.

    Article  PubMed  Google Scholar 

  75. Hamilton B, Remedios D, Loosemore M, Maffulli N. Achilles tendon rupture in an elite athlete following multiple injection therapies. J Sci Med Sport. 2008;11(6):566–8.

    Article  PubMed  Google Scholar 

  76. Movin T, Ryberg A, McBride DJ, Maffulli N. Acute ­rupture of the Achilles tendon. Foot Ankle Clin. 2005;10:331–56.

    Article  PubMed  Google Scholar 

  77. Sharma P, Maffulli N. Basic biology of tendon injury and healing. Surgeon. 2005;3:309–16.

    Article  PubMed  CAS  Google Scholar 

  78. Sharma P, Maffulli N. The future: rehabilitation, gene ­therapy, optimization of healing. Foot Ankle Clin. 2005;10:383–97.

    Article  PubMed  Google Scholar 

  79. Sharma P, Maffulli N. Biology of tendon injury: healing, modeling and remodeling. J Musculoskelet Neuronal Interact. 2006;6:181–90.

    PubMed  CAS  Google Scholar 

  80. Sharma P, Maffulli N. Tendinopathy and tendon injury: the future. Disabil Rehabil. 2008;30(20-22):1733–45.

    Google Scholar 

  81. Sharma P, Maffulli N. Tendon injury and tendinopathy: healing and repair. J Bone Joint Surg Am. 2005;87:187–202.

    Article  PubMed  Google Scholar 

  82. Sharma P, Maffulli N. Understanding and managing Achilles tendinopathy. Br J Hosp Med (Lond). 2006;67:64–7.

    Google Scholar 

  83. Rompe JD, Nafe B, Furia J, Maffulli N. Eccentric loading, shock-wave treatment or a wait-and-see policy for tendinopathy of the main body of tendo-Achillis: a randomized controlled trial. Am J Sports Med. 2007;35:374–83.

    Article  PubMed  Google Scholar 

  84. Saxena A, Ramdath S, O’Halloran P, Gerdesmeyer L, Gollwitzer H. Extra-corporeal pulsed-activated Therapy (“EPAT” Sound Wave) for Achilles tendinopathy: a prospective study. J Foot Ankle Surg. 2011; 50(3):315–19.

    Google Scholar 

  85. de Vos RJ, Weir A, Tol JL, Verhaar JA, Weinans H, van Schie HT. http://pubmed/21047840. No effects of PRP on ultrasonographic tendon structure and neovascularisation in chronic midportion Achilles tendinopathy. Br J Sports Med. 2011;45(5):387–92.

    Article  Google Scholar 

  86. de Vos RJ, Weir A, van Schie HT, Bierma-Zeinstra SM, Verhaar JA, Weinans H, Tol JL. http://pubmed/20068208. Platelet-rich plasma injection for chronic Achilles tendinopathy: a randomized controlled trial. JAMA. 2010;303(2):144–9.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Sports Medicine, PAFMG-Palo Alto Division, Clark Bldg., 3rd Flr, 795 El Camino Real, Palo Alto, CA, 94301, USA

    Amol Saxena D.P.M.

  2. Department of Trauma and Orthopaedic Surgery, University Campus Bio-Medico of Rome, Rome, Italy

    Umile Giuseppe Longo M.D. & Vincenzo Denaro M.D.

  3. Barts and The London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary University of London, London, E1 4DG, UK

    Nicola Maffulli M.D., M.S., Ph.D., F.R.C.S (Orth).

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  1. Amol Saxena D.P.M.
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  2. Umile Giuseppe Longo M.D.
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  3. Vincenzo Denaro M.D.
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  4. Nicola Maffulli M.D., M.S., Ph.D., F.R.C.S (Orth).
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Correspondence to Amol Saxena D.P.M. .

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  1. Sports & Surgical Podiatry, Dept. Sports Medicine, Palo Alto Medical Foundation, El Camino Real 795, Palo Alto, 94301, California, USA

    Amol Saxena

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Saxena, A., Longo, U.G., Denaro, V., Maffulli, N. (2013). Insertional and Midsubstance Achilles Tendinopathy. In: Saxena, A. (eds) Sports Medicine and Arthroscopic Surgery of the Foot and Ankle. Springer, London. https://doi.org/10.1007/978-1-4471-4106-8_14

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