Background: Recalcitrant calcific insertional Achilles tendinopathy is difficult to treat.
Hypothesis: Bursectomy, excision of the distal paratenon, disinsertion of the tendon, removal of the calcific deposit, and reinsertion of the Achilles tendon with bone anchors is safe and effective.
Study Design: Longitudinal study.
Methods: Twenty-one patients (six women) (21 feet) (average age 46.9 ± 6.4 years) with recalcitrant calcific insertional Achilles tendinopathy were treated surgically with removal of the calcific deposit; the Achilles tendon was reinserted with bone anchors.
Results: At an average follow-up of 48.4 months, one patient necessitated a further operation. Eleven patients reported an excellent result, and five a good result. The remaining five patients could not return to their normal levels of sporting activity and kept fit by alternative means. The results of the VISA-A questionnaire were markedly improved in all patients, from an average of 62.4% to 88.1%.
Conclusions: We recommend disinsertion of the Achilles tendon to excise the calcific deposit fully and reinsertion of the Achilles tendon in the calcaneus with suture anchors. No patient experienced a traumatic disinsertion of the reattached tendon. However, five patients were not able to return to their original level of physical activity.
1. Alfredson H, Pietila T, Jonsson P, et al: Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med26:360–366, 1998
2.
2. Baker BE: Currrent concepts in the diagnosis and treatment of musculotendinous injuries. Med Sci Sports Exer16:323–327, 1984
3.
3. Benazzo F, Stennardo G, Valli M: Achilles and patellar tendinopathies in athletes: Pathogenesis and surgical treatment. Bull Hospital Joint Dis54:236–240, 1996
4.
4. Boberg JS, Anania MC: Retrocalcaneal exostosis: Anatomy and a new surgical approach. J Am Podiatr Med Assoc92:537–542, 2002
6. Capasso G, Maffulli N, Testa V, et al: Preliminary results with peritendinous protease inhibitor injections in the management of Achilles tendinitis. J Sports Traumatol Rel Res15:37–43, 1993
7.
7. Capasso G, Testa V, Maffulli N, et al: Aprotinin, corticosteroids and normosaline in the management of patellar tendinopathy in athletes: A prospective randomized study. Sports Exerc Inj3:111–115, 1997
8.
8. Clement DB, Taunton JE, Smart GW: Achilles tendinitis and peritendinitis: Aetiology and treatment. Am J Sports Med12:179–184, 1984
9.
9. DaCruz DJ, Geeson M, Allen MJ, et al: Achilles paratendinitis: An evaluation of steroid injection. Br J Sports Med22:64–65, 1988
13. Ireland D, Harrall R, Curry V, et al: Multiple changes in gene expression in chronic human Achilles tendinopathy. Matrix Biol20:159–169, 2001
14.
14. James SL, Bates BT, Osternig LR: Injuries to runners. Am J Sports Med6:40–45, 1978
15.
15. Khan KM, Maffulli N: Tendinopathy: An Achilles’ heel for athletes and clinicians. Clin J Sports Med8:151–154, 1998
16.
16. Khan KM, Tress BW, Hare WS, et al: Treat the patient, not the x-ray: Advances in diagnostic imaging do not replace the need for clinical interpretation. Clin J Sports Med8:1–4, 1998
17.
17. 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 Int20(7): 433–437, 1999
18.
18. Kvist H, Kvist M: The operative treatment of chronic calcaneal paratendonitis. J Bone J Surg62B:353–357, 1980
19.
19. Kvist M, Jarvinen M: Biological and biomechanical features in repair of muscle and tendon injuries. Int J Sports Med2:18–20, 1981
20.
20. Kvist M, Jozsa L, Jarvinen M, et al: Chronic Achilles paratendonitis in athletes: A histological and histochemical study. Pathology19:1–11, 1987
21.
21. Kvist M, Lehto MUK, Jozsa L, et al: Chronic Achilles paratendonitis: An immunohistological study of fibronectin and fibrinogen. Am J Sports Med16:616–623, 1988
22.
22. Kvist M: Achilles tendon injuries in athletes. Ann Chir Gynaecol80: 188–201, 1991
23.
23. Leach RE, Schepsis A, Takai H: Long-term results of surgical management of Achilles tendinitis in runners. Clin Orthop282:208–212, 1992
24.
24. Leadbetter WB, Mooar OA, Lane GJ, et al: The surgical treatment of tendinitis: Clinical rationale and biological basis. Clin Sports Med11: 679–712, 1992
25.
25. Leppilahti J, Karpakka J, Gorra A, et al: Surgical treatment of overuse injuries to the Achilles tendon. Clin J Sports Med4:100–107, 1994
26.
26. Maffulli N, Binfield PM, King JB: Tendon problems in athletic individuals. J Bone Joint Surg (Am)80-A:142–143, 1998
27.
27. Maffulli N, Binfield PM, Moore D, et al: Surgical decompression of chronic central core lesions of the Achilles tendon. Am J Sports Med27:747–752, 1999
28.
28. Maffulli N, Dymond NP, Regine R: Surgical repair of ruptured Achilles tendon in sportsmen and sedentary patients: A longitudinal ultrasound assessment. Int J Sports Med11:78–84, 1990
29.
29. Maffulli N, Ewen SWB, Waterston SW, et al: Tenocytes from ruptured and tendinopathic Achilles tendon produce greater quantities of collagen type III than tenocytes from normal Achilles tendon: An in vitro model of human tendon healing. Am J Sports Med28:499–505, 2000
30.
30. Maffulli N, Kader D: Tendinopathy of tendo Achillis. J Bone Joint Surg (Br)84:1–8, 2002
31.
31. Maffulli N, Khan KM, Puddu G: Overuse tendon conditions: Time to change a confusing terminology. Arthroscopy14:840–843, 1998
32.
32. Maffulli N, Regine R, Angelillo M, et al: Ultrasound diagnosis of Achilles tendon pathology in runners. Br J Sports Med21:158–162, 1987
33.
33. Maffulli N, Testa V, Capasso G, et al: Results of percutaneous longitudinal tenotomy in Achilles tendinopathy in middle- and long-distance runners. Am J Sports Med25:835–840, 1997
34.
34. Maffulli N, Testa V, Maffulli F, et al: Sporting activity and the Achilles tendon. Atleticastudi23:239–254, 1992
35.
35. McGarvey WC, Palumbo RC, Baxter DE, et al: BD insertional Achilles tendinosis: Surgical treatment through a central tendon splitting approach. Foot Ankle Int23:19–25, 2002
36.
36. Nelen G, Martin M, Burssens A: Surgical treatment of chronic Achilles tendinitis. Am J Sports Med17:754–759, 1989
37.
37. Novacheck TF: Running injuries: A biomechanical approach. J Bone Joint Surg (Am)80-A:1220–1233, 1998
38.
38. Puddu G, Ippolito I, Postacchini F: A classification of Achilles tendon disease. Am J Sports Med4:145–150, 1976
39.
39. Read MTF, Motto SG: Tendo Achilles pain: Steroids and outcome. Br J Sports Med26:15–21, 1992
40.
40. Renstrom P, Johnson RJ: Overuse injuries in sport. Sports Med2: 316–333, 1985
41.
41. 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 Med35:335–341, 2001
42.
42. Rolf C, Movin T: Etiology, histopathology, and outcome of surgery in achillodynia. Foot Ankle Int18:565–569, 1997
43.
43. Saillaint G, Thoreux P, Rodineau J, et al: Traitement chirurgical des tendinites d’Achille chez le sportif. Rev Chir Orthop73:580–585, 1987
44.
44. Schepsis AA, Leach RE: Surgical management of Achilles tendinitis. Am J Sports Med15:308–315, 1987
45.
45. Smart GW, Taunton JE, Clement DB: Achilles tendon disorders in runners: A review. Med Sci Sports Exerc12:231–239, 1980
46.
46. Subotnick S, Sisney P: Treatment of Achilles tendinopathy in the athlete. J Am Podiatr Med Assoc76:552–557, 1986
47.
47. Sundqvist H, Forsskhal B, Kvist MA: A promising novel therapy for Achilles peritendinitis: Double blind comparison of glycosaminoglycan polysulfate and high dose indomethacin. Int J Sports Med8: 298–303, 1987
48.
48. Tallon C, Maffulli N, Ewen SWB: Ruptured Achilles tendons are significantly more degenerated than tendinopathic tendons. Med Sci Sports Exerc33:1983–1990, 2001
49.
49. Testa V, Capasso G, Maffulli N, et al: Proteases and antiproteases in cartilage homeostasis: A brief review. Clin Orthop308:79–84, 1994
50.
50. Testa V, Maffulli N, Capasso G, et al: Percutaneous longitudinal tenotomy in chronic Achilles tendonitis. Bull Hosp Joint Dis54:241–244, 1996
51.
51. Watson AD, Anderson RB, Davis WH: Comparison of results of retrocalcaneal decompression for retrocalcaneal bursitis and insertional Achilles tendinosis with calcific spur. Foot Ankle Int21:638–642, 2000
52.
52. Williams JGP: Achilles tendon lesions in sport. Sports Med3: 114–135, 1986
53.
53. Yodlowski ML, Scheller AD Jr, Minos L: Surgical treatment of Achilles tendinitis by decompression of the retrocalcaneal bursa and the superior calcaneal tuberosity. Am J Sports Med30:318–321, 2002
