16 Achilles Tendon Disorders in Athletes

American Journal of Sports
Medicine
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Achilles Tendon Disorders in Athletes

Anthony A. Schepsis, Hugh Jones and Andrew L. Haas
Am. J. Sports Med. 2002; 30; 287
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THE AMERICAN JOURNAL OF SPORTS MEDICINE, Vol. 30, No. 2
2002 American Orthopaedic Society for Sports Medicine
Current Concepts
Anthony A. Schepsis,* MD, Hugh Jones, MD, and Andrew L. Haas, MD
From the Department of Orthopaedic Surgery, Boston University Medical Center,
Boston, Massachusetts
tubercle on the posterior surface of the femur. The lateral
head arises from the lateral surface of the lateral condyle
of the femur, proximal and posterior to the lateral epicondyle. Each of these heads has additional attachments from
the posterior capsule of the knee joint and from the
oblique popliteal ligament.29 The soleus muscle lies deep
to the gastrocnemius muscle, arising from the posterior
surface of the upper tibia along the soleal line, the posterior aspect of the proximal third of the fibula, and from the
intermuscular septum.
The medial and lateral heads of the gastrocnemius muscle gradually coalesce and incorporate into a broad, robust
tendon in the posterior aspect of the lower leg. This tendon
gradually narrows and becomes more rounded as it extends distally. The soleus muscle forms a broad tendon
about midway down the leg, in a position deep to the
tendon of the gastrocnemius. This tendon glides freely
deep to the gastrocnemius muscle in its more proximal
extent, thereby allowing independent movement of the
two muscles.
The tendinous components of these two muscles are
variable. The gastrocnemius component is the longer portion, contributing 11 to 26 cm. The soleus, in contrast, is
shorter, containing a tendinous component from 3 to 11
cm in length. The width of the tendon at its point of
insertion into the calcaneus varies from 1.2 to 2.5 cm.29
Approximately 5 to 6 cm proximal to the calcaneal insertion, the independent tendons of the gastrocnemius
and soleus fuse to become one tendon. At about 12 to 15 cm
proximal to the insertion of the tendon, at about the level
the soleus muscle begins to contribute fibers to the Achilles tendon, rotation of the tendon begins. This rotation
becomes more marked in the terminal 5 to 6 cm of the
tendon. The tendon spirals approximately 90 with the
medial fibers rotating posteriorly and the posterior fibers
rotating laterally.
The tendon inserts on the posterior surface of the calcaneus distal to the posterior-superior calcaneal tuberosity.23 Deep to the tendon, proximal to the point of insertion, between the tendon and the calcaneus, is the
retrocalcaneal bursa. The posterior wall of the bursa is
ABSTRACT
Achilles tendon disorders are among the more common maladies seen by sports medicine physicians.
Understanding the anatomy and biomechanics of the
Achilles tendon and contiguous structures is essential
to the diagnosis and treatment of Achilles tendon overuse injuries. Posterior heel pain is multifactorial and
includes paratenonitis, tendinosis, tendinosis with partial rupture, insertional tendinitis, retrocalcaneal bursitis, and subcutaneous tendo-Achillis bursitis. Each of
these entities is distinct, but they often occur in combination. Although most cases of this disorder are successfully treated nonoperatively, a small subgroup of
recalcitrant cases may benefit from surgical intervention. Complete ruptures in active, athletic persons
should be treated operatively in most cases and result
in predictably good outcomes. There may be some
cases that escape early recognition and require a reconstructive procedure to salvage a potentially severe
functional deficit.
ANATOMY
Since the time of Homers Iliad, the name of Agamemnons
greatest warrior, Achilles, has been attached to the triceps
surae tendon. As knowledge of the specific anatomy of this
tendon was crucial to Achilles opponents success, so such
knowledge is equally crucial to the orthopaedic surgeon in
the management of Achilles tendon-related maladies, both
acute and chronic in nature.
The Achilles tendon is a confluence of the gastrocnemius
and soleus muscles. The gastrocnemius muscle is composed of a medial and lateral head. The medial head arises
from behind the medial supracondylar ridge and adductor
* Address correspondence and reprint requests to Anthony A. Schepsis,

MD, Sports Medicine Orthopaedic Surgery, Boston University Medical Center,
Doctors Building, Suite 808, 720 Harrison Avenue, Boston, MA 02118.
No author or related institution has received financial benefit from research
in this study.
287
288
Schepsis et al.
American Journal of Sports Medicine
formed by the tendon itself. Anteriorly, the bursa is bordered by a 0.5- to 1.0-mm thick cartilaginous layer on the
posterior aspect of the calcaneal tuberosity. Proximally,
the bursa is bordered by a synovial lining that separates
the bursa from the proximal fat pad.97 This fat pad rests
anterior to the tendon and occupies an area bordered
anteriorly by the flexor hallucis longus muscle, posteriorly
by the Achilles tendon, and caudally by the superior aspect of the calcaneus. Superficial to the tendon lies a
subcutaneous tendo-Achillis, or retrotendo-Achillis bursa
between the tendon and the overlying skin.
Snow et al.109 evaluated the Achilles tendon insertion
and its relation to the plantar fascia. They found that the
neonate has a thick continuation of fibers of the tendinous
insertion into the plantar fascia. This continuity gradually
diminishes with age and the thick continuation of fibers of
the neonate becomes solely a connection of superficial
periosteal fibers in the middle-aged foot. The foot of the
elderly patient appears to have separate insertions altogether, with periosteum between the Achilles tendon and
the plantar fascia. This finding indicates that, in the management of heel pain, stretching regimens of the Achilles
tendon and plantar fascia appear to alleviate insertional
stresses rather than relieve stresses on a contiguous
structure connecting the Achilles tendon and plantar
fascia.
The Achilles tendon is not encased in a true synovial
sheath but is encased in a paratenon made up of a single
layer of cells. This paratenon anteriorly consists of fatty,
mesenteric-like areolar tissue. This tissue is richly vascularized and is responsible for a significant portion of the
blood supply to the tendon.20 This supply comes through a
series of transverse vincula, which function as passageways for blood vessels to reach the tendon. In addition to
these mesotenal vessels, the blood supply to the tendon
comes from two other sources: the musculotendinous junction and the osseous insertion. Angiographic studies have
shown that the area of most tenuous blood supply is 2 to 6
cm proximal to the insertion in the calcaneus.24 Additionally, the number of intratendinous vessels and the relative
area occupied by these vessels is lowest 4 cm from the
calcaneal insertion.104
Although not classically considered part of the Achilles
tendon, the plantaris muscle anatomy should be discussed
because of its intimate relationship with the Achilles tendon and its frequent use in operative management of
chronic Achilles tendon tears. The plantaris muscle originates from the lowest part of the lateral supracondylar
ridge, the adjacent area of the posterior surface of the
femur, and the knee joint capsule. The tendon of the
plantaris crosses obliquely from lateral to medial in a
depression in the soleus muscle. It continues its course
distally between the gastrocnemius and soleus muscles,
emerging on the medial side of the Achilles tendon 12 cm
from the Achilles insertion to the calcaneus. Cummins et
al.29 studied 200 cadaveric specimens and noted four patterns of insertion of the plantaris tendon. The plantaris
tendon inserts most commonly (47%) via a fan-shaped
expansion into the medial aspect of the insertion site of
the calcaneal tuberosity of the Achilles tendon. Occasion-
ally, thin slips of fascial strands may extend from the

plantaris tendon to the medial border of the Achilles tendon. In the second most frequent pattern (36.5%), the
plantaris tendon inserts into the calcaneus 0.5 to 2.5 cm
anterior to the medial border of the Achilles tendon.
The third most common pattern (12.5%) demonstrates
a broad insertion along the dorsal and medial surfaces
of the Achilles tendon. In the least common finding (4%),
the plantaris tendon inserts into the medial border
of the Achilles tendon from 1 to 16 cm proximal to the
Achilles insertion into the calcaneus. The plantaris tendon is
absent in 7.05% of people as tabulated from the literature.29
BIOMECHANICS
The gastrocnemius muscle and soleus muscle, via the
Achilles tendon, function as the chief plantar flexors of the
ankle joint. In walking as well as in running and jumping
activities, this musculotendinous unit provides the primary propulsive force for locomotion. Whereas the gastrocnemius muscle functions primarily as a plantar flexor
at the ankle, the soleus muscle has a postural role as well,
preventing the body from falling forward during standing.
Contraction of this musculotendinous unit also functions
to flex the knee and supinate the subtalar joint.
The gastrocnemius and soleus musculotendinous unit
function during the second and third intervals of the
stance phase of the gait cycle.114 During the second interval, extending from 15% to 40% of the gait cycle, the
activity in the posterior calf musculature is mainly directed at controlling the forward movement of the tibia
over the planted foot. At about 34% of the gait cycle, heel
rise begins. The third interval of the gait cycle extends
from 40% to 62%. During this interval there is rapid
plantar flexion of the ankle joint due to concentric contraction of the triceps surae muscle.78 Komi et al.54 performed
an in vivo evaluation of the Achilles tendon force during
ambulation. They demonstrated that after heel strike
there is an initial silent period of force in the Achilles
tendon, and that there is a rapid increase in force leading
to a peak at the end of the push-off phase. This is
consistent with the triceps surae muscle activity demonstrated by Mann78 during the third interval of the
stance phase of gait.
At the end of the stance phase in normal walking, muscle tension through the Achilles tendon is estimated at
250% of body weight.99 Studies using both implanted electrodes and biomechanical force analysis have demonstrated that the Achilles tendon force during running approaches 6 to 8 times body weight, a load close to the
ultimate strength of the tendon.5, 24
The 90 spiral of the Achilles tendon is believed to
explain some of the seeming elastic qualities of the tendon. When landing from a jump, the body will remain
upright while the foot attains a plantar flexed position due
to activity in the triceps surae muscle. On landing, the
strain is absorbed by the Achilles tendon, which produces
a recoil effect.97
Because of the Achilles tendons insertion into the calcaneus, the tendon can be exposed to forces secondary to
Vol. 30, No. 2, 2002
subtalar motion. This is particularly notable in the hyperpronated or cavus foot and in runners who pronate. It is
believed that a hyperpronated or cavus foot may lead to a
greater chance of rupture of the Achilles tendon because of
the diminished shock absorption associated with these
malalignments.5 James et al.45 have implicated this functional overpronation as a causative factor in noninsertional Achilles tendinitis as well. The foot pronates during
the midstance phase, leading to an internal rotation force
on the tibia. With extension of the knee, an external rotation force is applied to the tibia. It is believed that during
midstance with the foot pronated and the knee in extension, there are contradictory rotational forces that present
themselves across the Achilles tendon and are directed
toward the Achilles tendon insertion.24, 45, 89, 104 Arndt et
al.7 demonstrated that activation of the triceps surae muscle results in a tensile force, leading to plantar flexion.
They showed that an eversion moment could be created by
isolated activity of the lateral head of the gastrocnemius
muscle; however, all other patterns of firing of the triceps
surae muscle led to an overall inversion moment.7 This
inversion moment may contribute additionally toward the
increased stress across the Achilles tendon during the
period of midstance with the foot pronated and the knee
extended.
289
TABLE 1
Classification of Achilles Tendon Disordersa
Paratenonitis
Tendinosis
Partial rupture
Paratenonitis with tendinosis
Degeneration
Partial tears
Calcification
Insertional tendinitis
Retrocalcaneal bursitis
Haglunds deformity
Tendo Achilles bursitis
Complete rupture
Acute
Neglected
a
According to the classification of Puddu et al.101
sive pronation has been implicated. The motion of the

hindfoot going from a supinated to a pronated position and
then back during the running gait cycle creates a whipping action on the Achilles tendon, which creates shear
forces across the Achilles tendon, placing particularly high
eccentric stresses on the medial side of the tendon. Malalignment factors above the ankle, such as genu varum,
can also contribute to increased stress on the Achilles
tendon.
ACHILLES TENDON OVERUSE INJURIES

The term Achilles tendinitis has previously been used
for any pain in the posterior part of the heel. This term is
misleading because it implies an inflammatory pathologic
process within the tendon itself. It has been well established that there are several pathologic conditions that
cause posterior heel pain.9, 26, 34, 58, 59, 61 63, 67, 106 The literature is confusing in regard to the classification of Achilles tendon overuse injuries. For example, there are many
terms given for the same type of pathologic entity denoting inflammation of the paratenon (such as tenosynovitis,
tenovaginitis, peritendinitis, or paratenonitis). Furthermore, various pathologic conditions sometimes coexist (for
example, paratenonitis with tendinosis), making the distinction between these various classifications somewhat
vague. The authors prefer a modification of the classification as set forth by Puddu et al.,101 which is presented in
Table 1.
With more than 10% of the American adult population
participating in running today, as well as increasing participation in other running and jumping sports, posterior
heel pain and Achilles tendon injuries are among the more
common entities seen by sports medicine physicians.
Contributing Factors
In runners, the most common cause of Achilles tendon
injuries is training errors, including sudden increase in
training mileage or intensity, or both, a change of terrain
(particularly hill running), an increase in interval training, or a solitary intense run. Biomechanical factors have
also been shown to come into play with these injuries.17, 25, 28 A cavus foot as well as a flat foot with exces-
Paratenonitis
The paratenon of the Achilles tendon is composed of a
single layer of cells that has a variable structure. This
layer is better termed a tenovagium rather than tenosynovium, which implies a double-layered sheath lined by
synovial cells.25 The ventral paratenon consists of fatty
mesenteric-like areolar tissue that is rich in blood vessels
that nourish the tendon. Paratenonitis is accompanied by
diffuse discomfort and swelling within the tendon. In
acute cases, the tendon appears sausage-like because of
its diffusely swollen, edematous condition, and crepitation
is often noted (Fig. 1).62 This is commonly encountered
acutely in marathon runners. Usually there is palpable
tenderness on both sides of the tendon, but the medial side
is more commonly involved than the lateral side. In some
cases, tender nodules form within the paratenon, representing localized hypertrophy and connective tissue proliferation. The involved area may either be over a segment
of several centimeters or it can involve the entire tendon
sheath from the insertion to the muscle. Paratenonitis
may result from abnormal biomechanics, but it can occasionally occur because of extrinsic pressure causing friction between the Achilles tendon and its adjacent sheath,
often from poor-fitting shoes, although this is more likely
to cause subcutaneous tendo-Achillis bursitis. Although
symptoms are typically aggravated by activity and relieved by rest, runners often complain of stiffness and pain
at the beginning of their run and then are able to run
through the discomfort. However, if left untreated, symptoms may increase to the point that running is no longer
possible.
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Schepsis et al.
Figure 1. Acute paratenonitis: note the diffuse, circumferential swelling involving the entire tendon sheath, from the
insertion up to the musculotendinous junction. Crepitus will
be noted on palpation with ankle movement as well.
eccentric and shear stresses. This area is also the most

hypovascular zone of the tendon. In many cases, the onset
of symptoms is related to a partial rupture or series of
microruptures in the area of degeneration.69 A history of
transient sharp pain or repeated episodes of sharp pain
within the tendon while running should alert the physician to the possible presence of a partial rupture. These
patients will have a localized medial thickening of the
tendon (Fig. 2). The pain is usually exacerbated by loaded
dorsiflexion of the foot, and there is often limited dorsiflexion.105 In rare cases, heterotopic ossification can occur
within the tendon itself.70 In the authors experience, middle-aged men who suddenly increase their activity level or
resume strenuous activity after a long period of inactivity
seem to be most susceptible to developing micro or partial
ruptures within an area of preexisting tendinosis. If the
degenerative process is extensive, leading to repetitive
partial ruptures, the tendon may actually elongate and
not function well in continuity with a paradoxical increase
in passive dorsiflexion.90 stro m and Rausing10 studied a
series of 342 operative cases of tendinosis (81% were male
patients). A partial rupture was found in 23%, tendinosis
in 49%, and no macroscopic abnormalities in 28% of the
tendons. They found that the lesion was more common in
the distal part of the tendon; predisposing factors were
physically active lifestyle, age slightly below middle-age,
and, particularly, local steroid injection before surgery.
Tendinosis
Retrocalcaneal Bursitis
Although painful areas of the Achilles tendon are commonly called Achilles tendinitis, this term is actually a
misnomer. Histologically, these areas of the tendon are
characterized by a degenerative noninflammatory process
that is best termed tendinosis.25 These areas in the
tendon consist of mucinoid or fatty degeneration with a
disorganized collagen structure. These degenerative
changes in the tendon seem to be related to the normal
aging process and will usually eventually be present in all
persons to some degree.113 These changes do not necessarily progress to clinical symptoms. Interestingly, these
histologic changes may be seen in young patients as well.
The symptoms of Achilles tendinosis may be secondary to
microtrauma or failure of this degenerative tissue, leading
to partial tears and subsequent symptoms. Kannus and
Jozsa50 have demonstrated the degenerative changes that
are found in ruptured tendons soon after their spontaneous failure. Tendons that are subjected to high eccentric or
stretching stresses, such as the Achilles tendon, seem to
be most susceptible. Therefore, abnormalities within the
tendon itself that lead to symptoms should best be termed
Achilles tendinosis. Puddu et al.101 have documented histologically that long-standing degeneration can exist in
the absence of clinical symptoms but may become symptomatic with heavy training, leading to localized pain,
tenderness, and thickening in the tendon. The onset of
symptoms is usually gradual, but well localized to an area
within the mid-third of the tendon. A nodule develops
within the tendon and is more commonly seen on the
medial side, where the tendon experiences its highest
Retrocalcaneal bursitis is a distinct entity hallmarked by

pain that is anterior to the Achilles tendon and just superior to its insertion on the os calcis. The retrocalcaneal
Figure 2. Tendinosis with chronic partial rupture. An asymmetrical, nodular thickening of the tendon, more commonly
seen on the medial (tension) side of the Achilles tendon.
Vol. 30, No. 2, 2002
bursa, which lies between the anterior aspect of the tendon and posterior aspect of the os calcis, becomes inflamed, hypertrophied, and adherent to the underlying
tendon. This may be associated with a prominence of the
posterosuperior angle of the os calcis. Patients with retrocalcaneal bursitis will have a positive two-finger squeeze
test. Pain is elicited by applying pressure both medially
and laterally with two fingers just superior and anterior to
the Achilles insertion at about the level of the posterosuperior angle. This entity should be distinguished from
inflammation of the subcutaneous tendo-Achillis bursa
lying between the posterior aspect of the tendon and the
skin that occurs secondary to an abrasive heel counter or
high-heeled shoes. When this entity is bilateral, the clinician should always exclude the possibility of a systemic
inflammatory disease. There is an association of retrocalcaneal bursitis with rheumatoid arthritis seen in up to
10% of patients with this disease.120
Many studies have been made of the morphologic variations of the posterior calcaneal seen in association with
retrocalcaneal bursitis. The three most common variations in the shape of the superior tuberosity of the calcaneus are hyperconcave, normal, and hypoconcave. Although prominence of the posterior tuberosity has been
associated with retrocalcaneal bursitis, it is well known
that it is not uncommon to find retrocalcaneal bursitis in
runners without any associated calcaneal deformity. Compression of the bursa between the calcaneus and the Achilles tendon occurs every time the ankle is dorsiflexed, and
in a runner the repetitions are countless, particularly with
uphill running where ankle dorsiflexion is increased.
Thus, it is not surprising that long-distance runners who
use uphill running as a training method frequently develop this clinical entity. Other biomechanical abnormalities that are associated with the development of retrocalcaneal bursitis include rearfoot varus and a rigid plantar
flexed first ray.
The retrocalcaneal bursa is a significant structure that
is horseshoe-shaped and 4 mm in width and 8 mm in
depth.99 Its anterior surface is composed of fibrocartilage
and its posterior boundary blends in with the paratenon.
It contains 1 to 2 mm of bursal fluid. In some cases, the
fluid in the bursa can actually become ballottable. There is
usually some element of contiguous inflammation in the
sheath or at the Achilles tendon insertion. The pain is
typically aggravated by dorsiflexion of the ankle.
Haglunds Deformity
Prominence of the posterosuperior lateral aspect of the
calcaneus causing irritation of the bursa (both the retrocalcaneal and the adventitial bursa), particularly from a
poor-fitting shoe, has been termed Haglunds deformity.107 This entity often goes hand-in-hand with retrocalcaneal bursitis and frequently there is an element of insertional tendinitis as well. The term pump bumps has
also been used to describe this condition. Often this pump
bump is asymptomatic, but it may become symptomatic
from a poor-fitting shoe or an irritating heel counter. This
tender prominence is typically present on the lateral side
291
of the Achilles tendon insertion, not directly on its central

portion. Although this is more commonly found in women
who wear high-heeled shoes, in the athletic population it
is sometimes found in hockey players who wear a rigid
heel counter that causes irritation. The patient population
that has this superolateral bone prominence tends to be
younger than the patients with retrocalcaneal bursitis.
These patients likewise often have an element of retrocalcaneal bursitis, tendo-Achillis bursitis, as well as insertional tendinitis. Multiple studies have attempted to delineate Haglunds deformity radiographically by looking
at the height, length, and the angular relationships of the
calcaneus. In our experience, none of these views have
been very helpful or reliable in making a diagnosis or
planning treatment, and the authors cannot recommend
one particular radiographic view as being consistently
helpful in demonstrating this bony prominence.
Numerous biomechanical risk factors have been associated with Haglunds deformity, including a high-arched
cavus foot, rearfoot varus, rearfoot equinus, and trauma to
the apophysis in childhood.28, 45, 55 It is important in these
cases to look for associated retrocalcaneal bursitis, as well
as insertional Achilles tendinitis.
Insertional Tendinitis
Patients with insertional tendinitis have a true inflammatory reaction within the tendon. These patients have direct tenderness over the Achilles tendon insertion, often
associated with calcification or spurring within or in juxtaposition to the tendon just above its insertion on the
superior aspect of the calcaneus. It must be emphasized,
however, that the Achilles tendon does not actually attach
to these spurs since it is contiguous with the whole posterior wall of the calcaneus. There is a high association
of insertional tendinitis with retrocalcaneal bursitis or
Haglunds deformity. The athlete typically complains of
pain directly at the insertion of the Achilles tendon that is
initially worse after exercise but may eventually become
constant. As in other conditions with the Achilles tendon,
it is frequently aggravated by hill running and interval
training. Training errors are also common in this group
when there is a sudden increase in mileage and improper
stretching techniques. Insertional tendinitis is also seen
in heel runners. Running on hard surfaces also tends to
aggravate the pain.
On physical examination, the tenderness is localized at
the Achilles tendon insertion. Insertional tendinitis is frequently aggravated by passive dorsiflexion. Loss of passive dorsiflexion is common in this group.105 Radiographs
frequently demonstrate calcification or ossification coming off the superior portion of the calcaneus and the upper
part of the insertion of the Achilles tendon. These changes,
however, are often seen incidentally as part of the normal
aging process, and clinical correlation is paramount before
assuming that the patients symptoms are secondary to
these abnormalities shown on radiographs. Often, these
radiographic changes can be seen bilaterally, although the
patients clinical complaints may be only for one side.
292
Schepsis et al.
Patients with insertional tendinitis are usually older than

patients with paratenonitis or Haglunds deformity.
Imaging
Plain radiographs are only occasionally of any value in
determining treatment for any of these predominantly soft
tissue injuries. In rare cases of long-standing tendinosis
with or without partial rupture, ossification may be seen
within the tendon. Plain radiographs are more helpful
in evaluating patients with retrocalcaneal bursitis,
Haglunds deformity, and insertional tendinitis, not only
to delineate the morphologic characteristics of the posterosuperior aspect of the calcaneus, but also to look for any
ossification or osteophytes at the Achilles tendon
insertion.
The two imaging techniques that best demonstrate abnormalities within the Achilles tendon are ultrasonography and MRI.86 Sonography seems to play a larger role in
European countries, particularly in Scandinavia, whereas
MRI appears to be the test of choice for most clinicians in
the United States. These imaging techniques seem to be
most helpful in delineating abnormalities within the
Achilles tendon itself, as well as imaging of the retrocalcaneal bursa. Ultrasonography is much less expensive
than MRI and also allows for dynamic examination. It is,
however, very examiner-dependent, and reliability appears to correlate with the experience of the examiner.
Ka lebo et al.49 compared sonographic findings in 37 patients who subsequently underwent surgery for Achilles
tendon disorders. In particular, they looked at the reliability of diagnosing partial ruptures of the Achilles tendon
and found that ultrasound had a sensitivity of 0.94, a
specificity of 1.00, and an accuracy of 0.95. Paavola et al.96
found that ultrasonography was reliable in delineating
focal lesions within the Achilles tendon, but they concluded that it was inaccurate for differentiating partial
rupture from a focal area of tendinosis. They did note,
however, that ultrasonography was not completely reliable for diagnosing paratenonitis and tendinitis unassociated with a lesion within the tendon itself. For diagnosing
retrocalcaneal bursitis, they found ultrasonography to be
accurate in six of eight cases.
Magnetic resonance imaging has been shown to be extremely helpful in the preoperative evaluation of Achilles
tendon overuse injuries. This modality is extremely sensitive to pathologic changes that occur within the tendon
as a result of tendinosis, partial rupture, or both. Particularly in smaller areas of intrasubstance degeneration
that are not clinically palpable, MRI can help localize foci
that require exploration and debridement. Marcus et al.80
noted an excellent correlation between MRI and pathologic findings at the time of surgery, which has also been
our experience.106 Magnetic resonance imaging is extremely sensitive to pathologic changes within the tendon
(Fig. 3). Again, clinical correlation is paramount, as areas
of increased signal seen on MRI may in some cases represent incidental areas of asymptomatic degeneration similar to those seen in the menisci or the supraspinatus
muscle that may not be clinically significant. Our exami-
Figure 3. Axial MR image of the midsubstance of the Achilles tendon in a patient with tendinosis. Note the areas of high
signal within the tendon (arrow).
nation protocol includes 2-mm slices taken in both T1- and
T2-weighted images in the axial and sagittal planes.
In patients with paratenonitis, even in chronic cases
with significant thickening and fibrosis of the paratenon,
MRI has not been reliable in demonstrating pathologic
changes within the sheath, and we have found that surgical correlation is poor in these circumstances.106 In
these cases, MRI is only helpful in ruling out abnormalities within the tendon itself. Retrocalcaneal bursitis demonstrates a high signal within the retrocalcaneal bursa
and is best seen on T2-weighted images (Fig. 4). It is also
helpful for delineating contiguous changes within the ten-
Figure 4. Retrocalcaneal bursitis. Sagittal MR image demonstrating high signal within the retrocalcaneal space associated with an osteophyte and prominence of the posterior
superior angle of the calcaneus (arrow).
Vol. 30, No. 2, 2002
don and tendon insertion itself in juxtaposition to the

bursa. Magnetic resonance imaging is also helpful in demonstrating any degenerative and inflammatory changes
within the tendon insertion in patients with insertional
tendinitis. Again, as in all diagnostic studies, correlation
of positive MRI findings with clinical symptoms is
paramount.
Conservative Management
Most cases of Achilles tendon overuse injuries and posterior heel pain are successfully managed nonoperatively.
Training errors are the most common cause of Achilles
tendon overuse injuries.57 Rest or modification of activities should always be part of the initial treatment. The
decision whether to recommend complete cessation of any
running or athletic activities versus modifying the running program should be individualized and based on the
severity of the problem and the duration of symptoms. A
cross-training program that includes stationary bicycling,
water therapy, and aqua jogging will usually allow the
athlete to remain fit while allowing symptoms to resolve.
As the symptoms improve, progression to machines that
replicate cross-country skiing and stair-climbing can be
used as a transitional step before resuming running
activities.
In milder cases of Achilles tendon overuse injuries, a
decrease in weekly mileage can be recommended as initial
treatment. We usually recommend cutting back to 25% of
the usual mileage level and then increasing by about 10%
per week, depending on symptoms. A temporary cessation
of interval training and hill workouts should also be recommended, as these are particularly stressful on the
Achilles tendon. In a runner training on a hard or banked
running surface, the recommendation should be to train
on a flat, softer surface. A quarter- to half-inch heel pad
built into the running shoe may also be useful in reducing
stress on the tendon. In acute cases, particularly when
there is an inflammatory component involved, such as in
paratenonitis or retrocalcaneal bursitis, a course of oral
antiinflammatory medication may prove useful.
In addition to nonsteroidal antiinflammatory medications, ice massage in acute cases and contrast treatments
in subacute and chronic cases can be helpful. A course of
physical therapy, combining modalities with stretching
and strengthening exercises, is usually beneficial. In severe cases, the use of ultrasound sometimes with the
delivery of topical steroids, known as phonophoresis, can
be useful. We have found that most patients with chronic
symptoms have limited passive dorsiflexion.105 Gentle
stretching exercises done in a passive, static manner are
most helpful. In acute cases, it is important for the athlete
not to overstretch and thereby increase symptoms.
Stretching should be performed before and after exercise
with the knee extended as well as flexed, as well as with
the guidance of the physical therapist. In some cases, a
night splint for a period of 6 to 8 weeks in a dorsiflexed
position is helpful to maintain and enhance passive
dorsiflexion.
Biomechanical and alignment problems are frequently
293
associated with Achilles tendon overuse injuries. If there

is a foot alignment problem, orthoses that place the hindfoot in a neutral position are appropriate. Excessive pronation may place abnormal stresses on the tendon, producing a whipping action on the tendon during the
running stride.28 In a study on the effectiveness of orthotic
shoe inserts in the long-distance runner, Gross et al.38
looked at 347 long-distance runners who had used or were
using orthotic shoe inserts for symptomatic relief of lower
extremity complaints. More than 18% of these patients
had a diagnosis of Achilles tendinitis. Almost 75% of these
patients had either a complete cure or great improvement
as a result of the orthotic shoe insert. Any minor leglength discrepancy should also be corrected by orthotic
inserts. These orthotic devices seem to be most successful
in patients who have either excessive pronation or leglength discrepancy or both. In our experience, a fulllength, flexible or a semirigid, as opposed to a rigid, orthotic device seems to work the best. Most runners or
athletes will continue to use the orthoses after symptoms
have resolved. The use of a shock-absorbing insole can also
be helpful, particularly if the runner is running on hard
surfaces.
After addressing training errors, alignment problems,
and flexibility issues, a program of strengthening should
be initiated, as most of these patients will have some calf
muscle weakness. Aggressive strengthening performed
before acute symptoms have resolved may exacerbate the
problem, and so should be appropriately timed. Electrical
stimulation and isometric exercises are initially recommended, gradually progressing to isotonic and then eccentric strengthening. In a study evaluating the effectiveness
of heavy-load eccentric calf muscle strengthening for the
treatment of chronic Achilles tendinosis, Alfredson et al.4
prospectively studied the results of eccentric strengthening in 15 athletes who had a diagnosis of chronic Achilles
tendinosis with a long duration of symptoms, despite conventional nonsurgical management. They compared this
group with a group of 15 athletes with the same diagnosis
of the same duration who had been treated with conventional measures. Before the exercise program, most of the
patients had significantly lower calf strength on the injured compared with the noninjured side. After 12 weeks
of increasing-load eccentric calf muscle-strengthening exercises, all 15 patients were back to their preinjury running levels with full running activities. Of the other 15
athletes treated with conventional measures, only one had
resolution of symptoms. Our policy is to include an eccentric strengthening program as the final phase of rehabilitation before resumption of running or athletic activities.
In subacute or chronic cases of refractory paratenonitis,
occasionally brisement (distention of the paratenon-tendon interface) can be useful. This is particularly useful if
there is audible crepitus and squeaking with ambulation
that has not improved. Johnston et al.46 have recommended the use of 5 ml of 0.25% bupivacaine, with a
permanent resolution of symptoms and disappearance of
crepitus in three of nine patients. Jones47 recommended
the use of 15 ml of local anesthetic injected into the subparatenon space. Brisement can also be performed with
294
Schepsis et al.
saline and, if available, ultrasound guidance can be helpful to ensure proper placement of the needle. A corticosteroid solution should not be used for this procedure.
The authors, as well as others, have found that the use
of injectable steroids is contraindicated as it may lead to
tendon rupture; however, we have found that in refractory
cases of retrocalcaneal bursitis, a one-time steroid injection directly into the retrocalcaneal bursa is sometimes
helpful. Extreme care must be taken not to inject any
steroid solution into the tendon, and it is important that
only one injection be used. In an occasional case, one may
be able to aspirate bursal fluid from the bursa itself before
injection of corticosteroid. Although the use of steroid injection in refractory cases before resorting to surgery can
be tempting, multiple studies have delineated the deleterious effects of injecting the corticosteroid solution into the
Achilles tendon. stro m and Westlin11 studied a group of
patients who had a partial rupture and a history of chronic
Achilles tendon symptoms. In a logistic regression analysis, only preoperative steroid injections in men were predictive of a partial rupture. Furthermore, in highly competitive athletes who have been known to use anabolic
steroids, either oral or injectable, it has been reported that
the use of anabolic steroids produces a stiffer tendon that
absorbs lower loads before failure and fails with less
elongation.43
Surgical Management
Although nonoperative management of Achilles tendon
overuse injuries is usually successful in getting patients
back to activity, there will be a small group of patients
who continue to be symptomatic, despite the measures
previously outlined. In particular, competitive and serious
recreational runners who would like to continue running
may seek a surgical solution after other measures have
failed. Preoperative planning and exact delineation of the
cause of the symptoms is crucial. Often these entities
occur in combination (for example, paratenonitis with tendinosis, or retrocalcaneal bursitis with insertional tendinitis). In our initial review of 45 surgical cases, we found
7 patients (15%) actually had a combination of retrocalcaneal bursitis along with more proximal paratenonitis or
tendinosis, or both.105
In our surgical treatment method, we use a longitudinal
approach made 1 cm medial to the Achilles tendon to avoid
the sural nerve. The length of the incision varies according
to the extent and site of primary abnormality. In most
cases of paratenonitis or tendinosis, the incision spans
from the musculotendinous junction to just above the insertion. In cases of retrocalcaneal bursitis, where exposure of the retrocalcaneal bursa and the posterior aspect of
the calcaneus is necessary, it is essential to have exposure
from both sides. Our original approach was to perform a
skin incision that continued transversely from medial to
lateral below the Achilles insertion in a J-shaped fashion.
Subsequently, we have converted to a more conventional
double-incision technique, making a smaller longitudinal
lateral incision on the lateral side of the retrocalcaneal
bursa and carefully avoiding the sural nerve. This second
incision should leave a skin bridge of at least 4 cm; we

have not had problems with skin necrosis using this technique. Dissection should be carried directly down to the
Achilles paratenon, and a full-thickness flap should also
be created by dissecting between the Achilles tendon and
the paratenon, and not above this layer. This is paramount to preserve blood supply to the skin flap, particularly in older patients. In cases of chronic paratenonitis,
the tendon sheath is usually found to be hyperemic, thickened, and adherent to the underlying tendon (Fig. 5). By
sharp dissection, the involved tissue is freed from the
underlying tissue and excised. We are careful not to excise
the anterior portion of the paratenon or disturb the anterior fatty tissue for fear of jeopardizing the blood supply to
the tendon. A complete circular dissection could also potentially lead to extensive postoperative fibrosis.
In cases of tendinosis or partial rupture, or both, often
the thickened area of the abnormality is obvious. In more
central or subtle cases, the tendon should be carefully
inspected and palpated for areas of thickening, defects, or
softening. This is where preoperative MRI can be very
helpful in delineating areas of tendon degeneration or
rupture that are not clinically palpable (Fig. 6). If there is
no clinically palpable defect or nodule within the tendon
and a well-done MRI does not demonstrate any echogenic
signal changes within the tendon, an exploratory splitting
incision within the tendon is usually not warranted.
In those patients where the tendon substance is involved, a longitudinal splitting incision is made within the
tendon at the site of the abnormality. The foci of symptomatic degeneration should be completely excised. Histo-
Figure 5. Chronic paratenonitis. The paratenon is markedly

thickened and fibrotic, requiring sharp dissection off the tendon. Care should be taken not to disturb the anterior soft
tissues.
Vol. 30, No. 2, 2002
Figure 6. Clinical case of tendinosis. A longitudinal splitting

incision has been made, revealing extensive diffuse mucinoid degeneration within the tendon.
logically, this will usually represent areas of mucinoid
degeneration. The abnormal scar tissue has a different
consistency, usually harder and nodular, and appears disorganized in reference to the surrounding normal tendon.
All abnormal tissue should be excised.
Maffulli73 recommends exploration by three to five longitudinal tenotomies with excision of the abnormal tissue.
In another study by Maffulli et al.,75 they described a
percutaneous technique using a No. 11 blade inserted
parallel to the long axis of the tendon fibers in marked
symptomatic areas and then plantar flexing and dorsiflexing the foot, creating a 3- to 4-cm area of tenolysis obtained through this percutaneous incision. This is repeated four to five times in the surrounding quadrants of
the tendon.
When a longitudinal splitting incision is made in the
tendon, care should be taken to use a minimal amount of
suture in closing the tenotomy. The use of excessive synthetic absorbable sutures can initiate an extensive fibrotic
reaction in the tendon, creating fibrosis and thickening.106
Maffulli et al.75 recommend not closing the longitudinal
tenotomies at all.
In cases of extensive tendinosis or partial rupture, or
both, the decision as to when to perform a reinforcement of
the tendon remains controversial. In our retrospective
long-term study,106 the area of partial rupture did not
require reinforcement in most cases. In fact, many of the
patients with these symptoms will have marked thickening of the tendon so that after debridement the tendon
may have a more normal diameter in comparison with the
contralateral, unaffected side. Based on our clinical experience, we have developed an algorithm for surgical management of tendinosis or partial ruptures of the Achilles
295
tendon. In cases of moderate deficiency (20% to 40%), we

would reinforce the tendon with either a turn-down flap or
a plantaris patch. In cases where there is 50% to 75%
involvement of the tendon, augmentation is necessary.
This can be either in the form of a direct augmentation
with the use of autograft (such as semitendinosus or gracilis tendon graft) or, more recently, we have used allograft tendon with less morbidity and equally good results.
If more than 75% of the tendon is involved and there is
very little normal substance left, autogenous tendon
transfer or reconstruction with the use of allograft is indicated. Mann et al.79 reported on seven patients in whom
they performed a transfer of the flexor digitorum communis tendon for chronic rupture of the Achilles tendon. They
believe there is an advantage in using this tendon instead
of the peroneus brevis because it brought in a richer vascular supply, allowing retention of plantar flexion as well
as a more biomechanically correct insertion into the calcaneus. They believe the use of the peroneus brevis muscle
changes the balance between the invertor and evertor
muscles. In their study, however, all patients had gross
incontinuity of the tendon, and most patients were in their
6th and 7th decades of life.
Hansen40 has recommended the use of the flexor hallucis longus muscle for treating prerupture syndrome of the
Achilles tendon. He recommends splitting the Achilles
tendon and inserting the muscle belly of the flexor hallucis
longus muscle to improve the blood supply to the Achilles
tendon. We believe that this procedure helps correct the
vascular insufficiency in the tendon. Concerns must be
raised about the transfer of the flexor hallucis longus
muscle in an athlete, particularly in a runner, as there is
an effect on the flexion strength of the first interphalangeal joint. The biomechanical imbalance created by this
procedure, although relatively minor, could potentially
have a significant impact in an athletic person.
In most of our patients, the involvement was well below
50% of the diameter of the tendon, and the biomechanical
implications of a more major surgical procedure with tendon transfer may seriously jeopardize the patients return
to athletics and running. However, if the majority of the
tendon is involved, tendon augmentation or transfer
should be used. These patients have usually already been
forced to a lower activity level, being functionally disabled,
even with activities of daily living. At the present time, we
more commonly perform tendon augmentation using tibialis or semitendinosus tendon allograft rather than tendon transfer.
In patients with retrocalcaneal bursitis, the retrocalcaneal bursa should be completely excised. Again, it cannot
be overemphasized that exposure is essential from both
sides of the tendon, and a second longitudinal lateral
incision is necessary. The bursa is usually found to be
hyperemic, thickened, and in some cases filled with fibrinous loose bodies and bursal fluid. In most patients, the
bursa was found to be scarred and adherent to the anterior surface of the Achilles tendon (Fig. 7). After excision of
the retrocalcaneal bursa, the posterior superior angle of
the os calcis should be generously excised using a 0.5-inch
flat osteotome. The ostectomy should be started just su-
296
Schepsis et al.
Figure 7. Chronic retrocalcaneal bursitis. The bursa is

markedly thickened and adherent to the tendon.
perior to the insertion of the Achilles tendon fibers on the
os calcis and performed in approximately a 40 to 50
angle to the long axis of the tendon, up to the posteriorsuperior surface of the os calcis (Fig. 8). It is critical to
expose the area between the anterior surface of the tendon
and the posterior os calcis as distally as possible. Since the
Achilles tendon has an extensive insertion all the way
down to the inferior aspect of the calcaneus, this does not
jeopardize the Achilles tendon insertion. Most failures of
this procedure are related to an inadequate ostectomy.106
Figure 8. Ostectomy for retrocalcaneal bursitis. A wide, thin

osteotome is used to perform a generous ostectomy of the
posterior superior angle of the calcaneus starting right at the
insertion and angled at approximately 45.
The edges should be carefully smoothed to remove any

sharp ridges and the ankle should be brought through a
complete range of motion to ensure that there is no longer
any impingement of the os calcis on the anterior surface of
the Achilles tendon. Enough bone should be removed so
that there is clearance the size of one finger between the
posterior aspect of the os calcis and the anterior aspect of
the Achilles tendon with dorsiflexion of the foot. Some
authors have described the use of a lateral incision only,
as the primary prominence of the posterior superior os
calcis is located laterally.89, 90 Although some authors,
such as Keck and Kelly,52 have described simple excision
of the retrocalcaneal bursa without ostectomy in patients
without a bone prominence, most authors, including us,
advocate a generous ostectomy in all cases of retrocalcaneal bursitis. A ridge of bone is often left at the distal
insertion site that must be carefully removed with a rongeur, curette, and rasp so that no irritating prominence
remains above the distal insertion. Most cases of failure
referred to us were secondary to an inadequate ostectomy,
often performed through a single incision.
In cases of Haglunds deformity, the ostectomy should
be more generous on the lateral than on the medial side,
and the primary incision should be lateral. In addition, the
superficial adventitial bursa needs to be removed as well,
taking care not to devascularize the skin flap. This pump
bump condition is not frequently seen in athletes and
usually can be treated conservatively. Hockey players are
the one group of athletic patients in which we have most
frequently found this condition. The rigid heel counter of
the skate is the causative factor.
Insertional tendinitis is usually seen in older athletes.
We tend to treat these patients conservatively for a longer
period, even resorting to a period of immobilization in a
short-leg walking cast, and, in most cases, symptoms will
resolve. Often, a fish hook osteophyte is seen with or
without ossification of the distal Achilles tendon. In some
cases, this osteophyte may actually fracture and cause
pain. Again, it is important to be certain that this is
actually contributing to the pain, as it is often seen as an
incidental radiographic finding. Local inflammation secondary to this osteophyte also occurs in conjunction with
degeneration and erosion of the central portion of the
Achilles tendon in this area, which contributes to the pain
as well. If surgery is necessary, the soft tissues must be
handled very carefully, particularly in an older population. Although Baxter and Thigpen12 recommended a central longitudinal incision, most authors, including us, prefer a longitudinal incision either placed medially or
laterally, or in some cases, in both positions. A small
splitting incision is made within the tendon at the insertion and any spurs and areas of degeneration are debrided
(Fig. 9). Involvement of the retrocalcaneal bursa and some
prominence of the posterior os calcis is common in these
patients, and these entities should be addressed as well.
Complete detachment of the tendon, debridement, and
reattachment should be avoided. Again, excessive suture
material in closing the splitting incision within the tendon
should also be avoided.
Vol. 30, No. 2, 2002
Figure 9. Insertional tendinitis with loose osteophyte exposed through a midline longitudinal splitting incision at the
insertion.
Postoperative Regimen
In cases of paratenonitis only, range of motion exercises
are instituted immediately to prevent scarring and fibrosis. A removable boot walker is used, but the patient is
allowed to remove the boot for gentle range of motion
exercises. Weightbearing is usually limited for the first 2
to 3 weeks to control soft tissue swelling and to aid wound
healing. In those cases where there is a small area of
tendinosis, a boot walker will be used for approximately 4
to 6 weeks and range of motion is begun after good wound
healing is present. Weightbearing is also limited for the
first 4 to 6 weeks. Where there is an extensive area of
tendinosis requiring augmentation or tendon transfer, patients are treated with a complete rupture regimen. Patients are initially placed in a short-leg cast in a relaxed
plantar flexed position and serial casting is performed at
weekly intervals for the first 3 to 4 weeks postoperatively
to bring the patients up to a neutral position. They are
then placed in a boot walker, at which time range of
motion exercises are begun, avoiding aggressive dorsiflexion for the first 8 weeks postoperatively. In cases of retrocalcaneal bursitis, range of motion can be begun immediately and a boot walker is used for 2 weeks with protected
weightbearing, and then weightbearing is resumed with
the walker being replaced with a heel lift. Patients with
insertional tendinitis tend to be older, and wound healing
is a major concern. Therefore, we recommend placing patients in a boot walker for 4 to 6 weeks and keeping them
nonweightbearing during this time. When good wound
healing is evident after the first 2 weeks, range of motion
exercises are begun.
297
Early emphasis in the postoperative treatment regimen

should be on regaining passive dorsiflexion. This is
achieved with passive stretching, both in the nonweightbearing and weightbearing positions with the knee extended as well as flexed. A graduated program of swimming and stationary bicycling, along with isometric,
isotonic, and eccentric strengthening in the later stages is
prescribed. Light jogging is usually permitted between 2
and 3 months postoperatively, unless there was extensive
tendon involvement, in which case we discourage any
running until at least 4 to 5 months postoperatively. Initially, a softer running surface such as a track is recommended. Mileage is gradually increased, and the patient is
initially discouraged from doing hill workouts or interval
training. Return to a competitive level usually is not until
5 to 6 months postoperatively, and may be longer in cases
of extensive tendon involvement.
Alfredson et al.2 performed a prospective study of 13
patients with chronic Achilles tendinitis who underwent
surgical treatment. The authors were interested in return
of calf muscle strength. They concluded that 6 months of
postoperative rehabilitation for chronic Achilles tendinitis
was not enough for patients to recover concentric and
eccentric plantar flexion muscle strength compared with
the noninjured side. However, in their series, the patients
were immobilized in a cast for 6 weeks postoperatively. In
a further study, the same authors3 prospectively looked at
the calf muscle strength in patients who were immobilized in a cast for only 2 weeks, followed by an aggressive rehabilitation program. Again, they found that the
concentric strength as well as the eccentric strength
return is very slow, taking up to 1 year, and even at that
point there was still concentric strength deficit. We
counsel patients, particularly if they have extensive
tendon involvement, that any running activities may
not be possible for 6 months, and complete recovery may
take up to 1 year.
Results
In our initial surgical series105 we reviewed 45 surgical
cases in 37 patients. Overall, there were 87% satisfactory
results. Interestingly, 92% of the patients with involvement of the paratenon or tendon, or both, had a satisfactory outcome, as compared with only 71% of patients with
retrocalcaneal bursitis. In this early study, it was apparent that many of these patients had had an inadequate
ostectomy. In our subsequent study, looking at 79 cases in
66 patients, 80% of whom were competitive or serious
recreational runners, overall there were 79% satisfactory
and 21% unsatisfactory results.106 The percentage of satisfactory results in the paratenonitis group was best
(87%), and the percentage in the tendinosis group was the
worst (67%). Satisfactory results were found in 75% of
patients with retrocalcaneal bursitis and in 86% of patients with insertional tendinitis. Furthermore, in 7 of the
45 cases (16%) with longer than 5-year follow-up and
initially satisfactory results, patients results deteriorated
with time and reoperation was required. This scenario
298
Schepsis et al.
was most commonly seen in the older male runner with

tendinosis who, despite adequate debridement at the
time of the initial operation and a period of symptomatic
relief, had slow recurrence of the degenerative process
within the tendon and the development of symptomatic
tendinosis. We were able to obtain 2-year follow-up in
five of the seven cases after revision surgery, with only
three of the five patients able to return to long-distance
running.
In a larger series, Nelen et al.91 treated 170 patients
surgically and had follow-up on 143 tendons in 91 patients, only in those patients with paratenonitis or tendinosis, or both. In 50 patients with tendon involvement,
they resected the diseased tendon only with a side-to-side
repair of the tendon. In the other 24 cases of tendinosis,
reinforcement was performed with a turn-down flap. They
reported a satisfactory surgical outcome in 82 of 92 cases
(89%) of paratenonitis. A satisfactory outcome was obtained in 19 of 26 patients (73%) with debridement and
side-to-side repair, and in 21 of 24 cases (87%) with a
turn-down flap in cases where there was extensive debridement. Johnston et al.46 reported on 17 patients who
underwent surgery, all of whom were able to return to
unrestricted activity after an average of 31 weeks of rehabilitation. Maffulli et al.75 reported on the surgical outcome of 14 athletes with central degeneration and tendinosis who underwent surgery. Only 5 of these patients
(36%) had an excellent or good result, despite reexploration in 6 of the 14 patients. The average duration of
symptoms, however, from onset of symptoms to surgery
was 87 months. It was their conclusion that surgery in
this condition should be performed at an earlier stage. It is
our policy that, if symptoms have been recalcitrant to
conservative measures for at least 6 months and there is
actual tendon involvement, and if the patient is a surgical
candidate, surgery should be performed at that time. It is
well known that any intrinsic tendon healing that occurs
after tendon injury will be relatively complete by 6
months.
Complications include skin necrosis, infection, extensive fibrosis in and about the tendon, and permanent loss
of motion or strength, or both. Complications can be
avoided by meticulous handling of the soft tissues, avoiding extensive use of suture material in or about the tendon, performing an adequate ostectomy in cases of retrocalcaneal bursitis, and instituting range of motion
exercise at an early stage of rehabilitation. Rolf and
Movin103 reported a complication rate of 13% in 58 patients treated surgically. These included two superficial
and two deep infections, two deep vein thromboses of the
lower leg, one total rupture and one hypertrophic scar.
Although a satisfactory surgical outcome can be achieved
in most cases, patients with extensive tendinosis, particularly older male runners, should be warned of the high
rate of recurrence as well as a possibility that they may
not return to a strenuous running program. In most cases,
however, surgery does offer a solution in well-selected
cases.64
ACHILLES TENDON RUPTURES

Diagnosis
Since Ambrose Pare98 first described Achilles tendon rupture in 1575, there is evidence that the incidence of Achilles tendon rupture is increasing in western society.48, 67, 82
This may be associated with an increase in athletic participation in a predominantly sedentary, white collar population. Leppilahti et al.67 suggest that the incidence may
have increased from 2 in 100,000 in 1986 to 12 in 100,000
in 1994.
Typically, Achilles tendon rupture occurs most commonly in men in their 4th and 5th decades, with an average age of between 30 and 40 in many studies; such
ruptures account for 40% of all operated tendon ruptures.21, 22, 41, 43, 48, 53 Rupture in association with racquet
or ball sports or other athletic activity has been noted
in 75% to 80% of cases.16, 21, 33, 48, 67, 82, 93, 111, 112 Mo ller
et al.82 have commented that the age distribution is bimodal, with a maximum incidence of sports injuries in the
4th decade of life followed by a second but lower peak of
other injuries in the 8th decade. Achilles tendon ruptures
are less commonly seen in women. The male-to-female
ratio has been reported by most authors in the range of 5:1
to 6:1.13, 16, 21, 43, 44, 53, 67, 81 Additional risk factors for rupture include prodromal symptoms seen in 15% to 20% of
patients with ruptures,110 a history of previous corticosteroid injection,76 gout,13 and treatment with flouroquinolone antibiotics.81, 84, 85 Several authors have noted a
greater incidence of left-sided ruptures and an association
with type O blood group.21, 41, 48, 67 In a recent study, an
association between high longitudinal arches with less
pronation of the ankle and less varus of the forefoot was
noted.66 The authors hypothesized that an underpronating foot and ankle, which are linked with poor shock
absorption, increases stress on the Achilles tendon, placing a torsional force on the tendon in midstance and pushoff that may cause an ischemic wringing out at or near
the avascular zone.
The mechanism leading to rupture is not fully understood; however, the interplay of intrinsic pathologic
changes within the tendon and extrinsic factors combine
to result in acute musculotendinous injury. Intrinsic factors include pathologic degenerative changes in the region
of the rupture as found in more than 50% of 292 patients
in the study of Jo sza et al.48; corresponding rupture typically occurs in the hypovascular region of the tendon 4 to
6 cm proximal to its insertion. Recurrent microtrauma to
this region with subsequent inability to heal has been
proposed as the cause. Against this are the relative paucity of prodromal symptoms, suggesting a silent degenerative process, and conflicting histologic data, failing to
show an association between degenerative change and
rupture.43 Corticosteroids, oral or injectable, have been
implicated in collagen necrosis, and flouroquinolone antibiotics have been suggested to be toxic to tenocytes and to
inhibit matrix formation.76, 81, 85
The role of extrinsic factors in Achilles tendon rupture is
also significant. Acceleration/deceleration mechanisms
Vol. 30, No. 2, 2002
have been noted in up to 90% of sports-related injuries.110

Inglis et al.43 proposed a malfunction of the normal protective inhibitory neuromuscular pathway of the musculotendinous unit in the fatigued or poorly trained athlete,
a theory that is supported by data suggesting that rupture
typically occurs 30 minutes or more into the athletic endeavor. Biomechanical factors may also contribute, as
noted by stro m and Rausing10 and Leppilahti et al.66
Clearly, the cause is multifactorial, with a complex interplay of contributing factors.
The clinical history of Achilles tendon rupture is frequently typical, with the athlete describing an audible
snap and sudden pain, as if being kicked or hit from
behind. Many clinical tests have been described to detect
acute rupture.74, 94, 108, 117 A recent study attempted to
validate several of these tests and found that the calf
squeeze test described by Thompson117 and Simmonds108
was the most reliable, with a 93% sensitivity.73 The palpable gap test was the least sensitive, with a value of 73%
with the patient awake, improving to 81% under anesthesia. All tests had a high negative predictive value, and we
have found a combination of these two tests to be highly
reliable. Imaging is generally not indicated except when
tendinous avulsion is suspected, which, in our experience,
is uncommon. Magnetic resonance imaging and ultrasound are sensitive and specific; however, they do not
influence surgical planning in acute cases and, in our
opinion, are not warranted except perhaps in the rare case
when clinical findings are equivocal. Perhaps somewhat
surprisingly, a reported 20% of ruptures are missed by
primary treating physicians.43
Treatment Options
There has been much debate over the relative merits of
operative versus nonoperative management of acute
Achilles tendon ruptures. A lack of defined universally
accepted outcome measures, a multitude of different reparative techniques, and a similarly diverse range of postoperative immobilization and rehabilitation protocols
have made comparison of results difficult.
In the early 20th century, closed treatment was widely
accepted as the standard of care; however, the increasing
functional demands of the athletic population and improved surgical technique have caused operative treatment to gain popularity in recent times. Patient selection
remains the most important factor decision. Operative
treatment, particularly with early functional rehabilitation, seems to confer better functional outcome with
accurate restoration of tendon length and a lower rerupture rate.13, 16, 21, 32, 44, 124 Against this are the reported complication rates associated with open treatment and the acceptable functional results of closed
treatment
in
the
less-demanding
athletic
population.21, 37, 43, 65
Nistor,93 in a randomized prospective trial of 105 patients, noted 2 deep infections and 2 reruptures complicating operative treatment versus 5 reruptures in the
closed treatment group. After evaluation of subjective and
objective plantar flexion strength and power using func-
299
tional tests and a dynamometer, the author concluded

that operative surgical treatment conferred no great advantages and that closed treatment was therefore preferable. Of note, only nine patients in this series participated
in competitive sports.
Beskin et al.13 evaluated 42 patients who underwent
primary repair using a number of techniques including
direct repair, plantaris tendon augmentation, and peroneus tendon augmentation. No reruptures were noted,
with a 7% minor wound complication rate. Better results
were noted in the three-bundle technique, but rehabilitation was not uniform and, in the latter group, consisted of
early functional treatment.
Augmented repair has also been described. This may be
performed with local tissue, such as a fascial turn-down
from the proximal tendon, plantaris muscle, peroneus brevis muscle, or with synthetic material.32, 68, 71, 116 Ferna ndez-Faire n and Gimeno32 reviewed the results of repair
augmented with a polyethylene terephthalate mesh synthetic graft that permitted immediate mobilization with
weightbearing in the 3rd week. Twenty patients were
high-level amateur athletes and nine were professional
athletes. Average flexion strength was 96% of the normal
side, as measured with a dynamometer.
Gerdes et al.36 studied the efficacy of repair using a
fascial turn-down technique. Biomechanical cadaveric
studies were performed and strength was compared with
two interrupted Kessler sutures, revealing a 35% increase
in strength to failure. In a small series of seven patients,
immediate postoperative weightbearing was allowed in a
cast for 6 weeks. Five patients had excellent results at 1
year and one had a good result; all athletes returned to
their previous levels of activity. Plantar flexion strength
measured 94% of the contralateral limb.
Cetti et al.21 reviewed 111 patients in a nonrandomized
prospective study in 1993. There were 10 major complications (9%; 4% with deep infection) in the operatively
treated group and 18 (16%) (8 were reruptures) in the
nonoperative group. Repair was performed with an endto-end Bunnell suture, and cast immobilization with nonweightbearing was implemented postoperatively. Although hospitalization was longer in the operative group,
return to work was 2 weeks earlier. Perhaps more importantly, 63 patients (57%) returned to sports at the same
level, versus 32 (29%) in the nonoperative group. The
authors also reviewed the literature on 4083 Achilles tendon ruptures treated operatively and noted a difference in
rerupture rate after operative and nonoperative treatment (1.4% to 13.4%) and also a lower overall rate of
complications (3.5% to 18.1%). Simple end-to-end repair
without flaps or augmentation had a trend toward a lower
rerupture rate (0.65%) and decreased wound complications. Various methods have been used to objectively evaluate functional recovery, and in those studies in which a
dynamometer was used, mean plantar flexion strength
after surgery was 87%, versus 78% with nonoperative
treatment. Similarly, return to sports at preinjury levels
was 62% versus 51%.
Inglis et al.43 studied 79 patients, 48 of whom were
treated operatively and 31 nonoperatively. Complications
300
Schepsis et al.
in the former group included two superficial infections, no

reruptures, and only two dissatisfied patients. This contrasts with the results in the nonoperative group where,
although immobilization ranged from 5 to 9 weeks in
short- and long-leg casts, there were 9 reruptures and only
9 of 23 patients were satisfied. Strength/power/endurance
measured objectively were 101/88/91 versus 73/62/64, all
significantly less in the nonoperative group. Furthermore,
in 17 cases that were operated later in the study, endurance was 20% less. The authors noted that their complication rate had decreased with surgeon experience, and in
1981 they reported on a series of 159 patients with a
complication rate of 12.5%.44 Kellam et al.53 reported a
rerupture rate of 3% and an incisional complication rate of
13%, with 92% of the patients returning to previous levels
of participation. Wills et al.124 reviewed complications in
the literature and noted a trend toward a decreasing operative wound complication rate with time. Arner and
Lindholm,8 in their 1959 series, reported a 30% complication rate, whereas in a recent study of repair using several
techniques in 101 patients, of whom 91 were athletes, a
complication rate of 6.9% was noted. The authors also
described a standardized scoring protocol for evaluation of
outcome.
Percutaneous repair was first described by Ma and Griffith72 in 1977 in an attempt to avoid the potential wound
complications of open repair while obtaining the advantages of operative apposition of the tendon ends and restoration of tendon length. FitzGibbons et al.33 reported on
the follow-up of 14 patients after percutaneous repair,
noting two sural nerve injuries and no other significant
complications; however, a 13% loss of power was seen on
isokinetic testing at 180 deg/sec. Subjectively, satisfactory
results were noted in recreational athletes, with all of
them returning to preinjury activity levels.
Bradley and Tibone16 reported on a series of 12 percutaneous repairs and compared these with a series of 15
patients treated with an open technique using a gastrocnemius muscle flap as described by Lindholm.68 Two reruptures (13%) occurred in the percutaneous group, but
otherwise no differences were noted in subjective or objective outcome as measured isokinetically. No complications
were noted and the authors concluded that percutaneous
repair should be reserved for the recreational athlete. Ma
and Griffith,72 in their original series of 18 patients, had
no wound complications, but they reported a rerupture
rate of 12%; plantar flexion power, assessed objectively,
ranged from 72% to 94% of the contralateral limb. Hockenbury and Johns42 suggested that percutaneous repair
may not be strong enough to allow an aggressive rehabilitation program. In a cadaveric study, they performed
biomechanical studies on five specimens with a percutaneous technique and compared the results with those after
a direct end-to-end Bunnell suture technique. They found
a 60% incidence of sural nerve entrapment and 50% relative strength in the percutaneous group. In our opinion,
the difficulty in accurately restoring musculotendinous
length by closed means does not significantly outweigh the
reduced incidence of wound necrosis and potential sural
nerve injury in the athletic population. In a further at-
tempt to avoid the reported 25% wound complication rate

associated with open repair, Esemenli et al.31 described a
combined open and percutaneous technique using a modification of the fascial turn-down technique, avoiding an
open incision directly over the site of repair. The follow-up
was 2 years, but there were only three cases with no
reported reruptures.
The biomechanical strength of several repair techniques
has been evaluated in cadaveric models.123 In an analysis
comparing Bunnell suture with modified Kessler and interlocking suture, investigators found the interlocking suture to be significantly stronger.42 In a further biomechanical evaluation of the percutaneous technique, the
authors demonstrated significant gapping at the repair
site in addition to a high rate of sural nerve entrapment
and concluded that percutaneous repair did not provide
sufficient initial strength to allow aggressive rehabilitation. Mortensen and Saether83 compared a continuous
six-strand suture technique with the Mason and Bunnell
techniques and found significantly greater tensile
strength and gapping resistance. Our concerns with the
more complex suture techniques previously described, as
well as the three-bundle technique described by Beskin et
al.,13 is the bulkiness of these repairs, with higher wound
complication rates noted in some clinical series and the
potential for devascularization of the tendon with multiple
complex grasping sutures.
We believe that surgical repair is indicated in the athletic population primarily to restore functional length of
the musculotendinous unit. Closed and percutaneous
methods are not incompatible with this dictum; however,
achievement of these ends without open means is far less
predictable. For this reason, we advocate repair using a
simple modified Kessler suture with No. 5 nonabsorbable
and a running epitendinous 2.0 absorbable suture, avoiding any knot placement or bulky suture material directly
beneath the incision. We prefer a medial incision with the
patient prone and we routinely use a tourniquet. The
contralateral limb is free-draped to allow a comparison of
resting tension with the normal limb. Careful handling of
soft tissues is mandatory for success, and we attempt to
close the paratenon over the repair after release of the
tourniquet. Appropriate intraoperative tensioning of the
repair is essential and is performed with the knee flexed to
90. In this position, the gently plantar flexed foot should
return to neutral after release. A comparison with tension
on the contralateral side is always helpful.
Various augmentation techniques have been described,
including local gastrocnemius muscle fascial augmentation as described by Lindholm,68 peroneus brevis muscle
transfer as described by Teuffer,116 and plantaris muscle
augmentation as described by Lynn.71 In addition, reconstructive techniques using flexor digitorum longus and
flexor hallucis longus muscles have been described.79, 121, 122 Although these may offer a biomechanical advantage in terms of permitting a more aggressive
rehabilitation program, we do not believe that they are
required in acute cases if an adequate primary repair can
be obtained without the potential for greater wound com-
Vol. 30, No. 2, 2002
plications, as noted by Cetti et al.,21 and potential donor

site morbidity.
Before the 20th century, treatment of Achilles tendon
rupture was primarily nonoperative; however, with the
work of Arner and Lindholm,8 surgery became increasingly popular. However, the significant complication rate
associated with operative treatment in the 1960s and
1970s led Lea and Smith60 to review 56 patients treated
nonoperatively with casting. They recommend this treatment for all patients with acute rupture, citing experimental evidence of tendon regeneration when sectioned. The
authors also argued that rerupture could be avoided by
casting for 8 weeks rather than 6 weeks. Fourteen patients had greater than 6 of increased dorsiflexion and
none were professional or college athletes. No consensus
exists concerning the duration of cast treatment, weightbearing, or the length of cast (that is, above the knee
versus below the knee), although the cadaveric studies of
Davis et al.30 suggest that short-leg cast immobilization is
sufficient.
We recommend closed treatment only for those patients
with limited functional goals and also for those patients
with concurrent medical conditions that preclude adequate wound healing, such as arteriosclerosis, diabetes,
limb edema, or dermatologic problems. In these patients,
we prefer immobilization in a short-leg cast with the foot
in equinus for 4 weeks, followed by a walking cast or boot
walker in neutral plantar flexion, permitting a gradual
increase in weightbearing to 8 weeks and then adding a
2.5-cm heel rise to the shoe for the following 4 weeks.
Rehabilitation
The postinjury rehabilitation of Achilles tendon ruptures,
whether treated operatively or nonoperatively, remains
controversial. Traditionally, treatment has consisted of
cast immobilization for a period of 6 to 8 weeks with
immobilization of the ankle initially in equinus, with subsequent return of the foot to neutral plantar flexion over
the following 3 to 4 weeks. Some authors have advocated
treatment in a long-leg cast; however, this is not supported by the biomechanical cadaveric studies of Davis et
al.,30 who demonstrated minimal tension in the tendoAchillis with the ankle in 25 of plantar flexion, irrespective of knee position.
Experimental work in animals has confirmed that the
benefits of loading the healing musculotendinous unit are
improved vascularity, decreased collagen cross-linkage,
and increased size and number of collagen fibrils. In addition, appropriate loading has been shown to improve
fiber orientation, with corresponding enhanced biomechanical properties when compared with immobilization.87, 111 The detrimental effects of immobilization have
been well documented. Ha ggmark and Eriksson39 demonstrated gross morphologic wasting and histologic changes
in the soleus muscle with atrophy of type 1 fibers in
athletes immobilized for 6 weeks. Neumann et al.92 demonstrated kinematic and neuromuscular alterations in
gait 12 months after surgery for tendo-Achillis rupture,
with subsequent immobilization for an average of 9 weeks.
301
Other potential complications of immobilization include

arthrofibrosis, adhesions, venous thromboembolism, and
pressure necrosis from casts or splints.
Given this experimental evidence for the advantages of
early mobilization, practitioners have subsequently applied these principles clinically. Clearly, the main concerns with early mobilization are the potential for increasing the incidence of wound complication and early
rerupture, which might outweigh any potential long-term
benefits. As such, the initial strength of the surgical repair
must be sufficient to withstand an aggressive rehabilitation program.
Early reports describing limited range of motion with
restricted weightbearing were favorable.22, 111, 118 More
recent protocols have advocated progressively earlier
weightbearing in functional orthoses.77, 112 Using these
regimens, return of objectively measured strength, range
of motion, and power have been to within 97% of the
contralateral limb at 12 months with return to previous
levels of sporting activity. This compares favorably with
previous immobilization techniques resulting in, at very
best, a 10% strength deficit. No reruptures were noted in
the series of Mandelbaum et al.77 and Speck and Klaue,112
and there was a single partial rerupture in a noncompliant patient in the series of 13 patients treated surgically
by Troop et al.,118 with a postoperative regimen that incorporated early weightbearing in a functional orthosis.
Buchgraber and Pa ssler18 retrospectively compared 48
patients who underwent either cast immobilization or
early functional treatment that included full weightbearing after surgical repair with a percutaneous technique;
they found fewer functional deficits, increased range of
motion, and no increased rerupture rate in the functionally treated group. In a recent clinical study, Aoki et al.6
reviewed the results of 22 ruptures in athletes using a
Kirschmayer core suture and cross-stitch epitenon suture.
Clinical results were assessed with MRI findings, which
have been shown to accurately depict tendon healing in
this context.51 Initially, early active motion and partial
weightbearing were commenced, with full weightbearing
at 16 days and return to sport at an average of 13 weeks.
No reruptures were reported. Although no biomechanical
testing and no formal strength testing were performed,
the authors suggested that the increased strength of this
technique might permit a more active and functional early
rehabilitation program with early weightbearing.
Our preference is to initially place the affected foot in an
equinus position that minimizes tension on the soft tissues. At 5 to 7 days, provided the wound is healing well,
we progress with serial casting over the next 3 weeks,
gradually bringing the foot up to neutral plantar flexion,
maintaining some tension on the repair. At that point, a
boot walker with a heel lift, which is gradually decreased
in size, is used and progressive weightbearing is allowed.
The boot is discontinued at 8 weeks. Light jogging is
permitted at 3 months if the patient has regained full
dorsiflexion. Full return to running and jumping sports is
permitted between 4 and 6 months, assuming adequate
strength gains have been made.
302
Schepsis et al.
Chronic (Neglected) Rupture

Chronic ruptures have traditionally been defined as ruptures in which more than 4 weeks have passed since the
initial acute injury.121 This is not an arbitrary period, but
defines the period beyond which significant retraction and
shortening of the gastrocnemius-soleus musculotendinous
unit occurs. Primary end-to-end repair of the Achilles
tendon becomes very difficult to achieve when there is the
essential problem of a shortened musculotendinous unit
with its deleterious biomechanical effects.15, 19, 35, 121
Chronic rupture may result from a number of causes.
First, acute rupture may be missed in 20% to 25% of
cases.8, 43 Alternatively, the patient may be seen late, although this is an uncommon scenario in the athletic population where a deficit in plantar flexion strength functionally manifests itself early, with symptoms such as
inability to perform a heel rise or difficulty climbing stairs.
Rerupture after previous closed or surgical treatment
manifests the same technical problems with respect to
operative treatment as does repeated partial rupture with
chronic elongation of the musculotendinous unit. Several
authors have reported poor results from nonoperative
treatment in active patients with a neglected rupture and
with significant functional disability, although it has been
widely shown in animal studies that the tendo-Achillis
will reconstitute by means of fibroblastic invasion of interposed hematoma.43, 88 It is well recognized that nonoperative treatment is unable to restore precisely the optimal functional length of the musculotendinous unit, with
subsequent deleterious consequences for the athletic
population.
Many operative reconstructive options have been described; however, the basic tenets of reconstruction are
restoration of optimal length and reconstruction of the gap
with appropriately strong tissue that may be obtained
from a number of sources.6, 8, 14, 68, 79, 116, 119 These options
are 1) direct repair (rarely possible)100; 2) augmentation
with or use of local autogenous tissue such as those used
with the various turndown techniques,8, 16 proximal V-Y
advancement,1 or plantaris muscle augmentation71; 3) local tendon transfer, including use of peroneus brevis,116, 119 flexor hallucis longus,122 or flexor digitorum
longus muscle79; 4) the use of free tissue transfer for
reconstruction, including both autograft and allograft; and
5) techniques using synthetic materials such as carbon
fiber and Marlex mesh (C. R. Bard, Murray Hill, New
Jersey) or Dacron.95
Determination of the appropriate technique is ultimately made at the time of surgery, when factors such as
mobility of the proximal complex and gap size, as well as
quality of the local tissue can be fully assessed. Clinical
examination and ultrasound or MRI may be helpful in
preoperative planning. Myerson88 has provided a useful
algorithm for treatment based on the size of the intraoperative gap. Certainly, techniques that involve the use of
local tissue for augmentation are useful for small gaps of
only 2 to 5 cm. Our practice is to attempt end-to-end
apposition if the gap is small (1 cm) and proximal mo-
bility permits. We routinely excise the interposed fibrous

scar, although there is evidence that this may not be
necessary or even helpful. We then augment the repair
with local tissue, such as the plantaris muscle, if intact,
and weave this through the repair. When this tissue is not
available, we have used a single proximal turn-down flap
of fascia and, more recently, we have used semitendinosus
muscle allograft. For larger defects, of around 5 cm, we
prefer the use of proximal V-Y advancement in combination with allograft or autograft (usually semitendinosus
muscle) tissue augmentation. Good results have been reported from V-Y advancement, but the flap mobilization
must be meticulous. We reserve tendon transfer for the
large defects and, although none of the various options are
ideal, our preference is for the peroneus transfer originally
described by Teuffer116 and modified by Turco and
Spinella.119 As a second choice, we would favor the use of
flexor digitorum longus muscle, as described by Mann et
al.,79 because this seems to be less detrimental to plantar
flexion power than the transfer of flexor hallucis longus
muscle described by Wapner et al.,122 although biomechanically the flexor hallucis longus muscle transfer is
perhaps the most appropriate. The use of a posterior compartment fasciotomy to allow direct apposition of the
flexor hallucis longus muscle belly to the Achilles tendon
is also attractive, and good results have been reported
with the use of this technique.121, 122 In addition, it functions as a muscle transfer primarily and a tenodesis
secondarily.
Synthetic materials, including Marlex and carbon fiber, have also been used for reconstruction of large
defects, with mixed results. We have no direct experience with this but are concerned about the potential
problems with wound healing, in addition to the longterm durability.
The use of free tendon transfer has a role in reconstruction, and there have been several reports of successful use of autogenous patellar tendon and allograft
tendo-Achillis in patients with insertional rupture, often after previous corticosteroid injection, or in those
with calcaneal bone loss (for example, a patient who has
undergone previous resection of a Haglunds deformity).
Circumstances requiring such reconstruction are fortunately exceedingly rare.
Technically, surgical principles identical to those of primary repair apply. Full-thickness flaps should be raised to
the paratenon and subsequently these should be handled
atraumatically. Appropriate length is judged intraoperatively in the manner described for primary repair. Similarly, we prefer to keep the repair low profile under the
wound and avoid placing suture material directly beneath
the skin. A higher rate of complications has been noted in
this group and, accordingly, we are more conservative in
our rehabilitation program, depending on the integrity of
the repair. The long-term results are mixed, with reports
of return to activity and loss of plantar flexion strength
being variably reported as 30% to 50% of contralateral
limbs.122
Vol. 30, No. 2, 2002
The Future
The role of growth factors in musculoskeletal repair and
regeneration is well recognized. There have been several
recent reports on the use of such factors to enhance Achilles tendon healing in animal models. Kurtz et al.56 studied
the effects of insulin-like growth factor on Achilles tendon
healing in a rat model and demonstrated an antiinflammatory mechanism as well as a significantly smaller functional deficit and more rapid time to recovery in the insulin-like growth factor-I group. Young et al.125 looked at the
effect of delivering marrow-derived, mesenchymal stemcell seeded collagen implants to a 1-cm tendon gap model
in rabbits. Significantly greater structural and material
properties were noted in the treatment group, and the
collagen appeared to have a greater cross-sectional area
and better alignment than in controls. Aspenberg and
Forslund9 transected Achilles tendons in rats and implanted GDF (growth differentiation factor) 5 and 6
growth and differentiation factors on collagen sponges and
compared these with a control group of collagen sponges
alone. The rats were sacrificed at 2 weeks and the tensile
strength of the regenerated tendon was found to be increased by both proteins in a dose-dependent manner.
Low-energy photostimulation at certain wavelengths
can also enhance tissue repair by releasing growth factors
from fibroblasts. In an animal model, Reddy et al.102 found
a 26% increase in collagen concentration after daily treatment with a helium-neon laser. Combined with current
techniques of surgical repair and optimal functional rehabilitation programs, these innovations offer the real prospect of returning athletes with Achilles tendon injuries to
their preinjury levels of sports sooner and with fewer
functional deficits.
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American Journal of Sports

Achilles Tendon Disorders in Athletes

* Address correspondence and reprint requests to Anthony A. Schepsis,

American Journal of Sports Medicine

ally, thin slips of fascial strands may extend from the

Vol. 30, No. 2, 2002

Achilles Tendon Disorders in Athletes

According to the classification of Puddu et al.101

sive pronation has been implicated. The motion of the

ACHILLES TENDON OVERUSE INJURIES

American Journal of Sports Medicine

eccentric and shear stresses. This area is also the most

Retrocalcaneal bursitis is a distinct entity hallmarked by

Vol. 30, No. 2, 2002

Achilles Tendon Disorders in Athletes

of the Achilles tendon insertion, not directly on its central

American Journal of Sports Medicine

Patients with insertional tendinitis are usually older than

Vol. 30, No. 2, 2002

Achilles Tendon Disorders in Athletes

don and tendon insertion itself in juxtaposition to the

associated with Achilles tendon overuse injuries. If there

American Journal of Sports Medicine

incision should leave a skin bridge of at least 4 cm; we

Figure 5. Chronic paratenonitis. The paratenon is markedly

Vol. 30, No. 2, 2002

Achilles Tendon Disorders in Athletes

Figure 6. Clinical case of tendinosis. A longitudinal splitting

tendon. In cases of moderate deficiency (20% to 40%), we

American Journal of Sports Medicine

Figure 7. Chronic retrocalcaneal bursitis. The bursa is

Figure 8. Ostectomy for retrocalcaneal bursitis. A wide, thin

The edges should be carefully smoothed to remove any

Vol. 30, No. 2, 2002

Achilles Tendon Disorders in Athletes

Early emphasis in the postoperative treatment regimen

American Journal of Sports Medicine

was most commonly seen in the older male runner with

ACHILLES TENDON RUPTURES

Vol. 30, No. 2, 2002

Achilles Tendon Disorders in Athletes

have been noted in up to 90% of sports-related injuries.110

tional tests and a dynamometer, the author concluded

American Journal of Sports Medicine

in the former group included two superficial infections, no

tempt to avoid the reported 25% wound complication rate

Vol. 30, No. 2, 2002

Achilles Tendon Disorders in Athletes

plications, as noted by Cetti et al.,21 and potential donor

Other potential complications of immobilization include

American Journal of Sports Medicine

Chronic (Neglected) Rupture

bility permits. We routinely excise the interposed fibrous

Vol. 30, No. 2, 2002

Achilles Tendon Disorders in Athletes

American Journal of Sports Medicine

Vol. 30, No. 2, 2002

Achilles Tendon Disorders in Athletes

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