Achilles Tendinosis

Fig. 59 This MRI shows serious tendinopathy, with a thick tendon (normally black] with grey and white areas of fibrotic in-growth, neo-vascularisation, and a rupture in the proximal end

Fig. 60 This is the same tendinotic tendon seen by ultrasound

Fig. 59 This MRI shows serious tendinopathy, with a thick tendon (normally black] with grey and white areas of fibrotic in-growth, neo-vascularisation, and a rupture in the proximal end

SYMPTOMS Gradual onset of diffuse exercise-induced pain or ache around the Achilles tendon. Often the athlete has noted a tender nodule at the mid-portion of the Achilles tendon. It is most common in middle-aged runners and recreational athletes.

AETIOLOGY 'Tendinosis' is defined from histopathological findings as a free tendon condition with an altered collagen structure, thickening of the tendon, re-vascularisation and increased cellularity. It can be looked upon as a 'blocked' early healing stage and is a continuing process, not a degenerative condition. This condition may or may not be symptomatic. A majority of complete Achilles tendon ruptures have these changes in the tendon. CLINICAL FINDINGS There is tenderness on palpation over the tendon, which often is thicker, with or without localised nodules. Occasionally there are inflammatory signs with redness and increased temperature. Compare to the other side.

Fig. 60 This is the same tendinotic tendon seen by ultrasound

Fig. 61 This demonstrates the hypervascularity of tendinosis, contrary to common beliefs that there is poor blood supply in the tendon. A healthy tendon does not bleed like this

INVESTIGATIONS Ultrasound or MRI will show typical intra-tendinous findings. TREATMENT This often chronic ailment may respond to conservative treatment in early stages, including modification of training and calf muscle strengthening exercises that can be tried over three months. If this regime is not successful surgery may be necessary to release any constrictions and adhe sions between the skin and excise abnormal parts of the tendon. Cortisone injections should be administered only in rare cases, due to the high risk of later tendon rupture. Indeed, cortisone injection and frequent use of NSAID are possible causes of this ailment. Surgery is followed by a few weeks' partial immobilisation and rehabilitation before resuming sport. Weight bearing is usually allowed soon after surgery, if the injury is protected by an ankle brace. REFERRALS Refer to orthopaedic surgeon for consideration of surgery. Refer to physiotherapist for planning of a three to six months' return programme. EXERCISE PRESCRIPTION Cycling and swimming (when the wound is healed) and closed chain training are good alternatives to keep up general fitness.

EVALUATION OF TREATMENT OUTCOMES

Monitor clinical symptoms and signs. Note that the tendon will remain thicker than the non-injured side. Calf muscle performance should be similar to the other side. Objective tests with, for example, maximum numbers of resisted toe raises are strongly suggested.

DIFFERENTIAL DIAGNOSES Tendinosis, tendinitis, bursitis, para-tendinosis, para-tendonitis (see tendinopathy).

PROGNOSIS Good-Poor; in some cases this condition can be the beginning of the end for an elite athlete's care.

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