1. Dr. Chandrashekhar Sonawane
-Dept. Of Orthopaedics

2. 47 years old male with left heel pain since
15 days
pain more in the morning, aggravated by
weight bearing, relieved with medications
and rest.
no H/O trauma, swelling, fever, any other
joint pain,
no H/O DM , koch’s

3. O/E - tenderness over posterior part of left
heel and painful dorsiflexion of foot

5.  conservative treatment anti-inflammatory
drugs along with heel support
 No improvement after 6 months
Surgery haglund bump excision by a central
tendon splitting method

7. Total no. of cases in last year - 24
Conservative management - 22
Oprative management - 02

9. The largest and strongest tendon in the human
body
 Formed from the tendninous contributions of the
gastrocnemius and soleus muscles
The tendons converge appr. 15 cm proximal to the
insertion at the posterior calcaneus

10. The right Achilles tendon appears to spiral
counterclockwise 30‐150º toward its insertion at
the calcaneus
The spiraling allows for elongation and elastic
recoil within the tendon, facilitating storage
and release of energy during movement

12.  posterior tibial artery and its contributions
to the musculotendinous junction, as well as
vessels which cross the paratenon.
 The watershed zone is an area 2‐6 cm
proximal to the calcaneus, in which the blood
supply is less abundant and becomes even sparser
with age

13. The osteotendinous junction of the
Achilles
tendon is made up of
1) Bone,
2) Fibrocartilage, and
3) Tendon.

14. -Complex interlocking
between calcified fibrocartilage and bone at the
insertion site
-Interlocking is of fundamental importance in
anchoring the tendon to the bone.

15. The triad of
Pain,
Swelling (diffuse or localized),
and Impaired Performance constitutes
tendinopathy.

16. Clain and Baxter classified Achilles tendon
disorders into
Noninsertional and
Insertional Tendinopathy
in 1992

17.  The exact incidence is unclear.
 Often diagnosed in older, less
athletic, and overweight individuals as
well as in older athletes , those wearing
improper footwear

19. Improper footwear

20. Obesity

21. Older athletes

22. Improper exercise

23. Insertional tendinopathy could be
considered an overuse injury, but with
predisposition caused by preexisting
weakening of the tendon.

24. Repetitive Traction Forces
flat foot, pes cavus, obesity,
overuse, poor training
Degeneration , attrition , mechanical and chemical
irritation
chronic inflammatory response
spur formation and calcification

25. Edema, mucoid degeneration, disruption
of collagen bundles, necrosis, small
hemorrhages, and calcification are noted
Also,
areas with proliferating blood vessels with
lymphocytes and histiocytes suggesting a
reparative process

26. -Increased activity of NADP-diaphorase, LDH, β-
glucuronidase, and alkaline phosphatase.
-Submicroscopic
calcification and fibrillar degeneration.
-Increased levels of type II and
III collagen and decreased levels of type I collagen

27. Early morning stiffness,
Pain that deteriorates after exercise
Thickening or nodularity at the insertion.
Range of motion of the ankle may or may
not be limited

29. Insertional tendinopathy of the Achilles
tendon seems to present more
often
as a triad
rather than as a solitary pathology.

30. Insertional tendinopathy of the Achilles tendon,
Retrocalcaneal bursitis,
Haglund’s deformity, the prominent
posterosuperior calcaneal process

31. HAGLUND’S DEFORMITY
( PUMP/ HUMP DEFORMITY)
Two bursae are
appreciated in relation
to distal attachment of
the Achilles tendon .
Retrocalcaneal
bursae.
Tendoachilles bursae

32. COMPONENTS OF
HAGLUNDS DEFORMITY
RETROCALCANEAL BURSITIS
MARROW EDEMA IN THE
CALCANEUM
THICK ACHILLES TENDON
WITH PARTIAL TEAR
TENDOACHILLES BURSITIS

33. Systemic affections -
Gout,
Sarcoidosis,
Systemic corticosteroids,
Oral fluoroquinolones,
Diffuse idiopathic skeletal hyperostosis, and
Seronegative spondyloarthropathies

34. Haglund’s deformity,
Retrocalcaneal bursitis,
Os trigonum,
Posterior talar process fracture,
Flexor hallucis longus tendinopathy,
Peroneal tendinopathy,
Tibialis posterior tendinopathy,
Osteochondral lesions of talus

35. -Blood investigations to rule out systemic conditions
-(MRI scan and US scan) can help to
confirm the diagnosis
-Radiographs help identify ossification of insertion
of the Achilles tendon or a spur (fishhook
osteophyte) on the superior portion of the
calcaneum

37. Radiopacities of the Achilles tendon
were classified into three types by
Morris et al.

38. Type I - Radiopacities at the Achilles insertion or
superior pole of the calcaneus.
Bony changes to the calcaneus are often seen in
type I lesions.
Insertional tendinopathy of Achilles tendon
causes type I abnormality

39. Type II -Radiopacities are intratendinous and are
Located 1–3 cm proximal to the Achilles
insertion, and are separated from calcaneal
surface

40. Type III. Radiopacities are located proximal to
the insertion zone, upward to 12 cm above the
insertion zone.
Type III is subdivided into
IIIA (partial tendon calcification) and
IIIB (complete tendon calcification).

41. Classification based on ultrasonographic
changes at the Achilles tendon
insertion was introduced by
Paavola et al.

42. Classification Insertional Changes
No alteration No calcification. Homogeneous fiber structure in
the insertional area.
Mild abnormality Insertional calcification, length 10 mm or less
and thickness less than 2 mm. Homogeneous
fiber structure in the insertional area.
Moderate Insertional calcification, length more than 10 mm
abnormality and thickness less than 2 mm.
Slight alterations in the echo structure of tendon
in the insertional area.
Severe abnormality Insertional calcification, length more than 10 mm
or thickness more than 2 mm.
Moderate to severe variety in the echo structure
of tendon in the insertional area.

43. -Success rates of 85% to 95% have been reported
with simple measures like rest, ice, modification
of training, heel lift, and orthoses
-stretching and strengthening exercises can also
be effective.
-Tendon loading stimulates collagen
fiber repair and remodeling. Therefore, complete
rest of the injured tendon is not advisable

44. Surgical options are considered after 3 to 6
months
of conservative management
-Debridement of the calcific or diseased portion,
Excision of the retrocalcaneal bursa,
and Resection of the Haglund’s deformity,
if present.

45. Various surgical procedures have been
described
We prefer to reattach the Achilles
tendon using bone anchors if one-third or more
of the insertion is disinserted.

46. A midline posterior
skin incision combined with a central
tendon-splitting approach for debridement,
retrocalcaneal bursectomy, and removal of
the calcaneal bursal projection as described
by McGarvey

54. Calcified areas being probed with needle

55. Haglund’s bump excised after splitting tendo achilles

56. First two weeks- Protected weight bearing
along with leg elevation as much as possible

57. 2 weeks to 4 weeks- A synthetic anterior
below-knee slab is applied, with the ankle in
neutral and secured to the leg with three or four
removable Velcro straps for 4 weeks

58. After 6 weeks- the anterior slab is removed.
-Stationary cycling and swimming from 8th
week
-gentle training
-Gradual progression to full sports activity at 20
to 24 weeks

59. Follow-up - Patients are reviewed at 3, 6, and
9 months from the operation, and at 6-month
intervals thereafter.

60. Insertional tendinopathy of the Achilles tendon
is a degenerative rather than an inflammatory
lesion, though the accompanying bursitis may
paint an inflammatory picture

61. Type I collagen contributes to the tensile
strength in tendons, allowing them to resist
force and tension and to stretch. Therefore,
tendons with an increased type III and a
reduced type I collagen content are less
resistant to tensile stresses

62. The diagnosis is mainly clinical, and radiographs
help in confirming the diagnosis as do
ultrasound scan or MRI scan