Achilles Paratenon Disorders

Fig. 62 This shows a relatively acute paratendinosis with adhesions to the skin
Fig. 63 This is a chronic fibrotic tendon sheath overlying a severe and chronic tendinotic tendon

SYMPTOMS There is gradual onset of diffuse exercise-induced pain or ache and swelling around the Achilles tendon, often around the mid-portion. It is common in runners and during pre-season training in soccer, rugby and similar sports. AETIOLOGY Para-tendinosis is defined from histopathological findings as a paratenon condition with an initial inflammation, changing into fibrosis, thickening of the tendon sheath and adhesions. This condition may or may not be symptomatic. It can be caused by increased friction from ill-fitting shoes, strapping or braces.

CLINICAL FINDINGS There is tenderness on palpation over the tendon, which may feel spongy and thicker, with or without inflammatory signs and with redness and increased temperature. Compare to the other side. This condition may occur simultaneously as tendinosis with or without a nodule (see Achilles tendinosis).

INVESTIGATIONS Ultrasound or MRI may show typical extra-tendinous findings and confirm or rule out intra-tendinous ailments. TREATMENT This often chronic ailment may respond to conservative treatment, including modification of training and calf muscle strengthening exercises that can be tried over three months. It is also important to reduce friction against the tendon by adjusting shoes or technique. If this regime is not successful, surgery may be necessary to release any constrictions and adhesions between the skin and paratendon, which in severe cases needs to be excised. Cortisone injections should be administered only in rare cases, due to the high risk of consequential tendon rupture. Surgery is followed by a few weeks' partial immobilisation and rehabilitation before resuming sport. Weight bearing is usually allowed early on.

REFERRALS Refer to orthopaedic surgeon for consideration of surgery. Refer to physiotherapist for planning of a one to two months' return programme.

EXERCISE PRESCRIPTION Cycling and swimming (when wound is healed) are good alternatives to keep up general fitness.


Monitor clinical symptoms and signs. Note that the tendon may remain thicker than normal. Calf muscle performance should be similar to the other side. Objective tests with maximal number of resisted toe raises are strongly suggested before resuming full sport.

DIFFERENTIAL DIAGNOSES Tendinosis, tendinitis, bursitis, para-tendinosis, para-tendonitis. PROGNOSIS Excellent-Good.

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