Calcific Achilles Tendinitis

Jeffrey S. Boberg, D.P.M.

Retrocalcaneal exostosis with calcific Achilles Failure to respond to conservative care justifies tendinitis are often seen as incidental findings on surgical interuention. Because surgery involves the lateral radiographs. On occasion these become partial or complete detachment of the Achilles symptomatic and may require surgical interyention. tendon, it should be undertaken judiciously. This paper explores the porential etiology and surgical options for retrocalcaneodynia. PREOPERATIVE FINDINGS

CLN-ICAL DESCRIPTION The author reviewed ! surgical cases (3 males, 6 females) performed in the last three years. The Morris et a\. described three different patterns of average age of the patients was 43. the onset of calcifications in the posterior aspect of the heel., pain in all individuals was fairly acute, and all Type I is a true retrocalcaneal exostosis at the sought treatment within several weeks following insertion of the Achilles tendon. Type II are the initiation of symptoms. No direct trauma was calcifications within the body of the tendon, but reported by the patients. not attached to the calcaneus, typically .5 cm to 3 Radiographic analysis showed two patients with cm proximal to the inseftion. These usually involve exclusively a Type II calcification pattern. In both only a pafiial thickness of the tendon. Type III patients, the calcification appeared to be fractured. calcifications are more proximal in the tendon, The remaining seven patients all showed Type I sometimes approaching the myotendinous calcifications. Five of these seven also presented with junction. Black and Kanat described numerous Type II calcification. Type I calcifications were all etiologies for soft tissue calcifications., The majority well-formed, and clearly corticated with distinct of which can be attributed to constant and chronic trabeculation noted. The Type II calcifications were microtrauma to the posterior heel. generally ill-defined and very closely associated with Retrocalcaneal tendinitis is a distinct clinical the retrocalcaneal exostosis (Figs 1-3). entity that is not easily confused with Haglund's deformity. Palpatory tenderness is marked at the SURGICAL TECHNIQUE AND FINIDINGS posterior heel at its most prominent point. Some tenderness is also evident on the medial and lateral Close anatomic review shows that the Achilles sides of the posterior heel. Occasionally, the distal tendon inserts into the posterior central third of the several centimeters of the tendon are inflamed. heel with significant medial andlateral expansions. Pain can often be elicited by passive and active The central third of the posterior heel is separated ankle joint dorsiflexion. from the inferior third by a well-defined bone Conservative care is used to reduce the ridge. It is the enlargement of this ridge which inflammatory process. The application of heat or ice, forms a Type I calcification pattern. Therefore, the physical therapy, nonsteroidal anti-inflammatory retrocalcaneal exostosis is mainly posterior to the therapy, stretching exercises, heel lifts and immobi- body of the Achilles tendon (Fig. 4). The soft tissue lization are coffinonly used. Corticosteroid injections posterior to the exostosis is primarily periosteum. also helpful. Although there anecdotal ^re is The Type II calcifications are generally just evidence of tendon rupture post iniection, the author superior to the exostosis, again usually in the is unaware of any clear evidence documenting this posterior portion of the tendon. Intra-operatively the association. Animal studies have shown some tendon Type II calcifications are intimately approximated to weakening with intratendinous injections but normal the retrocalcaneal exostosis. In all instances of Type tendon strength is returned in 2 weeks.3,a No clear I calcifications, a portion of the exostosis was not alteration in tendon strength is noted with firmly attached to the calcaneus. It is therefore peritendinous injections. possible to perform the surgery with minimal CIilPTER 6 37

Figure 1. Type I calcification, a typical retrocalcaneel exostosis. Figure L Type II c.rlcification located in the distal Achilles.

Figure J. An apparent retrocalcaneal exostosis (Type I) with Figure 4. &IRI of the heel, Note the Achilles tendon attaches above tenocalcinosis (Type II). the retrocalceneal exostosis. There is no tendon posterior to the exostosis. disruption to the Achilles tendon. Only on rare to the Aciiilles tendon. If Type II calcifications are occasions is it necessary to detach the Achilles present, the periosteum and posterior 1 mm to tendon. 3 mm of tendon are reflected superiorly. The A 6 cm, transverse incision is placed directly calcifications are identified and removed. The over the high point on the posterior aspect of the tendon is repaired with 2-0 or 3-0 absorbable heel. The incision needs to be of sufficient length suture (Figs. 5-6). Tendon anchors are usually not to allow for superior-inferior retraction. Because required. the subcutaneous tissue is so dense inferiorly, and Postoperatively, the patient is placed in a retraction is difficuit, it is best to keep the incision removable walking cast with a rocker sole. The close to the inferior heel. The incision is deepened patient is kept non-weight bearing for the first two until the tendon is visualized. weeks, with progressive weight bearing then The tendon,/periosteum is transversely incised initiated. The bandage and sutures are removed at directly to bone. Fluoroscopic exam may be 7 to 10 days at which time bathing and sleeping required to assist in accurately placing the incision. without the cast is permitted. Most patients are At this point, it is clear that the exostosis is "retfo" completely out of the cast by the end of six weeks. 38 CHAPTER 6

CONCLUSION

Most patients with retrocalcaneal exostosis/Achilles calcific tendinitis have a rather acute onset of pain despite the presence of a mature exostosis. This fact plus the intra-operative findings discussed, lead the author to believe the detachment or fracture of these calcifications leads to the onset of pain. The surgical approach should be directed at removing these "loose" pieces of bone. This will preserve the inseftion of the Achilles tendon leading to faster rehabilitation and fewer post-

Figure 5. Intraoperative view of the posterior hee1. A transverse operative complications. Complete detachment of incision was made over the exostosis. The periosteum is reflected the Achilles tendon with aggressive posterior inferiorly, and minimal tendon is reflected superiorly. exostectomy is rarely required.

REFERENCES

1. Moris Kl, Gracopelli JA, Granoff D; Classifications of radiopaque lesions of the tendo Achllhs J Fctot Sutg 29: 533-541, 1980 2. Black AS, Kanat IO: A review of soft tissue calcifications. /-Foot Surg 24:243-250, 7985 3. Kennedy JC, Nfiils RB; The effects of local steroid injections on tendons: A biomechanical and microscopic correlative study. Am J Sports Med 4:1.1.-21., 1976 Matthews LS, Sonstegard DA, Phelps DB: A biomechanical study of rabbit patellar tendon; Effects of steroid injectiott. J Spo?ts Med 2:349-357, 1974

Figure 6. The exostosis is identified.