The Blackburn Foot and Ankle Hyperbook

Evidence based education in foot and ankle surgery

Achilles tendonopathy
Reviews Clain and Baxter (1992) published a review in Foot and Ankle which gave an excellent overview of Achilles tendonopathy and introduced the classification into insertional and non-insertional tendonopathy. Epidemiology Most epidemiological studies relate to non-insertional tendonopathy in runners. Studies by Bovens (1979), Krissoff(1979) and Clement (1981) found an incidence of between 6 and 18%. Clement found Achilles problems to be twice as common in men. Pathology Tallon et al (2001) carried out microscopic studies on samples obtained from patients with rupture(35), tendonopathy(13) and normal tendons(16). The normal tendons were from older persons. A semiquantitative scoring system was used, which was fairly reliable. They found waviness and separation of collagen fibres with hyalinisation, increased rounding of cell nuclei, marked varibility in cellularity with cell proliferation, random blood vessel formation,

decreased collagen stainabilityand increased glycosaminoglycan staining. These features were more marked in samples from ruptured than from painful tendons. Ohberg et al (2001) performed grey-scale ultrasound and colour Doppler examination on 21 patients with chronic non-insertional Achilles tendonopathy and 14 controls. All the patients, but none of the controls, demonstrated neovascularisation of the thickened portion of the tendon, particularly in the ventral portion. Alfredson et al (1999) demonstrated increased levels of glutamate, a neurotransmitter often associated with pain perception, in painful Achilles tendons compared with controls. Tallon et al (2001) carried out microscopic studies on samples obtained from patients with rupture(35), tendonopathy(13) and normal tendons(16). The normal tendons were from older persons. A semiquantitative scoring system was used, which was fairly reliable. They found waviness and separation of collagen fibres with hyalinisation, increased rounding of cell nuclei, marked varibility in cellularity with cell proliferation, random blood vessel formation, decreased collagen stainabilityand increased glycosaminoglycan with 79 abnormal tendons (from a cohort of 76 patients/92 tendons), Rufai et al (1995) described histological and pathological findings in the insertional region of the tendon. They used 50 cadaver tendons from 30 patients aged between 57 and 96. Normal tendons were attached to bone at an enthesis which contained a zone of fibrocartilage. Fibrocartilage lined the walls of most bursae. Pathological changes included bone spurs (16 specimens), which arose from the posteroinferior part of the insertion and contained traces of the calcified fibrocartilage present in the normal enthesis; longitudinal (19 specimens) and transverse (5 specimens) fissuring in the tendon; and degeneration of the bursal fibrocartilage (28 specimens). Scott and Winter (1990) demonstrated forces in excess of six times body mass in the Achilles tendon during running. Subtalar movement and the spiral arrangement of the Achilles tendon fibres produce torsional forces in the tendon in addition. James et al () suggest that overpronation of the foot increases the stresses in the Achilles tendon and predisposes to tendonopathy; however, no data have been offered to support this. Indeed, Angermann and Hovgaard (1999) found that 14% of their patient were overpronators and 27% had cavovarus feet. Natural history Paavola et al (2000) reviewed 83 of 107 patients treated nonsurgically for acute/subacute non-insertional Achilles tendonopathy with a variety of interventions. Follow-up was 8+/-2 years after the initial treatment; no information is given on independent review. 59% were asymptomatic at follow-up, 35% had mild exertional pain, 5% had severe pain on exercise and one had constant pain but continued to train. 84% had returned to their previous level of