Chou: OKU: Foot and Ankle 7

Section 7: Tendon Disorders and Sports-Related Foot and Ankle Injuries

to have mild to moderate clinical benefit, but patients in placebo and control groups had similar improvements. In regard to platelet-rich plasma, a 2021 meta-analysis of four randomized controlled trials with 170 patients found no specific added benefit of platelet-rich plasma compared with saline injections when combined with an eccentric training program for the treatment of chronic midsubstance Achilles tendinopathy. 32 The effectiveness of extracorporeal shock wave ther apy was evaluated in a systematic meta-analysis of four randomized controlled studies and two pre-post stud ies. 33 The studies were inconsistent in participant char acteristics as well as dosages and impulses per session. Four studies found statistically significant improvement in functional outcomes, and the meta-analysis concluded that the evidence was satisfactory to show the effective ness of extracorporeal shock wave therapy for treating chronic Achilles tendinopathy. Surgical treatment may be indicated for refractory Achilles tendinosis after 6 months of unsuccessful non surgical treatment. The traditional surgical treatment consists of removing diseased portions of the tendon. Augmentation with FHL tendon transfer may be needed if more than 50% of the tendon is removed. A prospective study of 56 patients who had FHL transfer for insertional or noninsertional Achilles tendinopathy found significant improvement in functional outcome scores at 24-month follow-up, and 32 patients (57%) had no hallux weak ness. 34 Most of the patients in this study were described as sedentary. The study authors expressed concern that relatively young, active patients might notice functional deficits associated with great toe weakness. Minimally invasive paratenon release also has been suggested for treating Achilles tendinopathy. In a retro spective case study of 26 patients, percutaneous release of adhesions between the paratenon and tendon was followed by instillation of methylprednisolone and bupivacaine into the paratenon. 35 At an average 13-month follow-up, 73% of tendons were pain free or had significant improvement in pain. The study authors suggested that the release of adhesions in this procedure disrupts the neovascular ization process and allows tendon healing. A retrospec tive review of the outcomes of 39 runners found that 30 runners (77%) reported a good or excellent outcome an average 17 years after ultrasound-guided multiple per cutaneous tenotomies for Achilles tendinosis. 36 Several studies of isolated gastrocnemius lengthening for Achilles tendinopathy found clinical improvement in all patients without loss of plantar flexion strength. 37-39 Comparison with other studies is difficult, however, because of the lim ited characterization of the extent of tendon involvement. Insertional Achilles tendinopathy ranges from peri tendinitis to tendinosis. Isolated peritendinitis tends to

occur in relatively young and athletic individuals and can be caused by overuse, hill running, an interval training program, or a training error. Insertional tendinosis is more common in individuals older than 50 years with varying levels of activity. Patients often have concomi tant symptoms from retrocalcaneal bursitis and Haglund deformity. Inflammatory arthropathies may contribute to the etiology and especially should be considered in a younger patient with bilateral symptoms. The initial symptoms usually are morning stiffness, posterior heel pain, and swelling with activity, progressing to constant pain. Often the patient has swelling along the posterior heel. Active and passive limitation of dorsiflexion may be present. The location of the tenderness can help dis tinguish among retrocalcaneal bursitis, Haglund defor mity, and insertional tendinosis; all three sometimes are present. Radiographs may show calcification within the insertion of the tendon. Traditionally, a Haglund defor mity was considered to be most common in patients with insertional tendinopathy, but a recent retrospective radiographic study challenged this belief. 40 No significant difference was found in the radiographic parameters of Haglund deformity between patients with or without insertional Achilles tendinosis. Calcification of the ten don insertion was present in 73% of patients. The initial treatment, often including rest, NSAIDs, and activity modification, is effective in most patients. 30 Eccentric exercises are less effective for treating insertional tendinopathy than noninsertional tendinopathy. 33 A ran domized controlled study found a 28% improvement in patients treated with eccentric exercise, compared with a 64% improvement in those treated with extracorporeal shock wave therapy. 41 A prospective study of 103 patients treated using an ankle-foot orthosis and a home stretching program found improvement in 91 patients (88%). The average duration of treatment was 163 days. 42

Surgical treatment may be indicated if symptoms are not relieved after 6 to 12 months of nonsurgical manage ment. Surgical treatment is directed toward the underlying pathologic changes. The techniques include débridement of the Achilles tendon insertion, débridement of the ret rocalcaneal bursa, and posterosuperior calcaneal ostec tomy ( Figure 4 ). Several approaches have been described, including medial, lateral, combined medial and lateral, endoscopic, J-shaped, transverse, and central tendon split ting; there are insufficient data that suggest the superiority of one approach over another. A study reported on the results of dorsal closing wedge osteotomy in a group of recreational and professional athletes. 43 This was per formed on 52 patients who showed signs of a Haglund deformity and less than 50% degenerative tendinopathy at the Achilles tendon insertion on magnetic resonance images. All professional athletes returned to the same Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2023

Section 7: Tendon Disorders and Sports Related Foot and Ankle Injuries

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Orthopaedic Knowledge Update ® : Foot and Ankle 7