Achillodynia and Haglund Exostosis Treatment

01.04.2020

DEFINITION/DEVELOPMENT

Like many tendons in the body, the Achilles tendon can also cause pain due to degenerative changes. Repetitive or unusually heavy strain can occasionally be found as a cause. Overweight or additional malpositioning of the foot are also considered to be triggers for such degenerative changes. In most cases, however, no actual trigger can be identified.

Fig. 1 Normal Achilles tendon (left) and thickening at a typical location (right)

Typically, in achillodynia, the degeneration is found about 6 cm above the heel bone. At this height, the blood supply to the tendon is less than at other locations due to anatomical conditions. The spindle-shaped, usually painful swelling in this area is striking (Fig. 1). The second most common area affected is the Achilles tendon insertion. In addition to the degenerative changes, calcifications and spur formations can also occur here (Fig. 2).

Fig. 2 Calcification at the Achilles tendon insertion

 

Fig.3 Haglund exostosis

Certain patients have a very prominent heel bone protrusion at the rear outside, called Haglund exostosis (Fig. 3). Occasionally, this “excess leg” causes complaints, especially in hard, closed shoes.

SYMPTOMS

Achillodynia regularly causes pain under stress. The first steps after getting up in the morning are often very painful but the pain decreases in the course of the first hour, only to increase again in the course of the day.
Pain at the base of the Achilles tendon is also usually load-dependent. This is possibly compounded by problems when wearing hard, closed shoes.
Haglund exostosis primarily leads to pressure problems in footwear.

 

EXAMINATION

The examination reveals prominent bone protrusions. In addition to the shape of the foot, the length of the Achilles tendon is assessed, especially when the knee is stretched. There is often a slight shortening of the muscles and tendon. To determine the further procedure, an MRI may be useful for achillodynia and Achilles tendon insertion complaints. This allows the exact extent of the degeneration to be determined and the risk of a possible tear of the tendon to be estimated. Partial tears of the tendon can occasionally be detected which cannot be identified by a clinical examination.

Fig.4 Soft heel wedge and a special bandage for the Achilles tendon

TREATMENT

A) Non Surgical
Physiotherapy: If there is no risk of a tear and no treatment has been performed yet, a non surgical treatment should be chosen. Here, special attention is paid that the stretching of the muscles and the chronic inflammation of the tissue around the tendon is treated locally. The tendon can be specifically strengthened by eccentric strengthening (braking power). In addition, a soft insole can be placed under the heel or a special bandage can be worn (Fig.4).

PRP-Infiltration: PRP (platelet rich plasma) is obtained from the blood by centrifugation and contains a high concentration of platelets and growth factors. These growth factors are important in the healing processes and also appear to have a positive effect on tendon changes. The PRP is obtained from the blood of the affected patient, i.e. it is the body’s own growth factor, which is brought directly to the altered tendon parts in higher concentrations. Since the positive effect in the area of the Achilles tendon has not been scientifically proven, however, the health insurance does not cover the costs.

Shock wave therapy: Shock waves are sound waves that cause irritation and thus lead to increased blood flow to the altered tendon tissue. This promotes the healing process and can sometimes even lead to a dissolution of calcium deposits.

B) Surgical
If there is no improvement after three to six months, an operative procedure may be advisable. First of all, the changed areas are cut out. If the tendon attachment is affected, calcifications and bone spurs are removed. Depending on the amount of the remaining tendon, it may have to be additionally strengthened by the body’s own tendon (tendon transfer, Fig.5).

Various surgical techniques are used here. The long flexor tendon of the big toe is used most frequently. Due to existing connections to the other flexor tendon, you can still bend the big toe after such an operation. The force is slightly reduced, but this is not relevant for everyday activities. At most young, very athletic patients occasionally notice a difference. Follow-up treatment must be individually coordinated in each case. However, immobilization in a VACOped (Fig.8) for several weeks is always necessary.
IMPORTANT: Rehabilitation after Achilles tendon surgery is lengthy, it can take up to 2 years!
Haglund exostosis: If suitable footwear and stretching of any shortening in the calf muscles does not lead to an improvement in symptoms, a Haglund exostosis can be surgically removed (Fig 6.). Follow-up treatment also consists of immobilization in a VACOped (Fig.8), but usually for less time than with the surgery of the tendon itself. The loss of work and sports break are shorter.

Kelly Keck Osteotomy: In certain situations, there is the possibility of indirect removal of the bone spurs with simultaneous slight relief of the Achilles tendon without surgery on the tendon itself. This is usually associated with an overall somewhat shorter rehabilitation phase.
A wedge is removed from the heel bone from the outside (Fig.7a) and the bone is then reattached with a clasp, plate and/or screws (Fig.7b). Follow-up treatment involves immobilization in a VACOped (Fig.8) and partial weight bearing for 6 weeks. Afterwards, the load can be increased relatively quickly.

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