When Conservative Care Fails For Tendinopathies

Patients with tendinopathies can undergo conservative care for months without resolution of the condition. Delayed presentation is often an issue as well. Accordingly, this author emphasizes the differences between tendinopathy and tendinosis, and offers salient insights on surgical modalities and procedures.

   At podiatric medical conferences, one will see rows and rows of vendors displaying a wide variety of products involving fixation of bone. However, there are very few vendors who display products that foot and ankle surgeons can use in the treatment of tendon-related problems. The majority of these products are conservative in nature. They include devices that immobilize, devices that utilize static and dynamic stretching, and topical therapies.

   The lack of emphasis on surgical products reflects the lack of clear understanding regarding the pathological process of tendinopathies and its treatment.

   This article is not meant to serve as a literature review or a comprehensive overview of tendon anatomy, physiology, pathology or treatment. It is also beyond the scope of this article to discuss each tendon and its specific issues. Instead, we will take a closer look at important aspects that are critical in the surgical treatment of tendinopathies.

   The exact number of those who suffer from tendinopathies in the foot and ankle is unknown. The majority of published studies focus on Achilles tendon disorders in athletes. These disorders reportedly occur in 7 to 9 percent of the athletic population.1,2 However, there is a growing population of relatively sedentary individuals who suffer from tendinopathies as well. While the exact etiology for tendinopathies is unclear, training errors, biomechanical faults, muscle weakness and inflexibility have been implicated.3-7

   Clinicians often refer to tendinopathies as “overuse” injuries. This implies that patients continue to aggravate the problem over time. The majority of patients who present with tendinopathy relate a long history of pain that may have lasted for several months to years. Patients often cannot identify a specific event that initiated this process. More often, patients report a history that progresses from occasional pain with increased activities to continuous pain and discomfort. Swelling may also be associated with this problem.

   Due to the insidious onset of tendinopathies, patients often do not seek medical care at the initial presentation of the problem. Patients will wait until the pain becomes so debilitating that they often present to our offices with an antalgic gait.

   Patients suffering from tendinopathies often undergo conservative treatment for many months with only minor or no resolution to their problem. The typical conservative treatments include: immobilization in a cast or Cam Walker; physical therapy including eccentric stretching; heel pads; nonsteroidal anti-inflammatories; or injectable or oral steroid therapy. Unfortunately, these therapies are nominally effective in the treatment of tendinopathies. 8-11 The limited success of these conservative therapy modalities may be more indicative of the delay in treatment rather than the inefficacy of that treatment. 12,13

   In the acute setting, conservative management may be effective. However, as previously stated, patients have been suffering from this problem for many months prior to their initial treatment by a clinician. Therefore, the problem has already progressed beyond the acute stage of tendinopathy and is accordingly chronic in nature. It is not surprising that conservative management is largely ineffectual at this point. One must consider surgical management to treat the tendinopathy effectively.

Keys To Differentiating Between Tendinitis And Tendinosis

   Tendinopathy is a general term but differentiating between a tendinitis and a tendinosis is critical in the appropriate treatment of tendinopathies. Tendinitis is an acute process marked by an inflammatory response while tendinosis is a chronic process marked by degeneration. 7,14-16 Once a damaged tendon reaches a chronic state, the efficacy of conservative management is limited. One must convert tendinosis back to a tendinitis in order for healing to take place.

   It is also important to understand that both a tendinitis and a tendinosis can be occurring at the same time in the same tendon. While the injury is in the tendinitis state, there is potential for self-repair with the assistance of conservative measures. However, with continued strain and repetitive injury, the tendon may progress into the chronic state of tendinosis. Unfortunately, exactly when this occurs during a timeline is unclear. Once this transition to tendinosis occurs, the tendon becomes mired in this chronic state.

   Medical imaging becomes an important component in the evaluation of tendons, especially when one is considering surgical intervention. Magnetic resonance imaging (MRI) provides vital information on the integrity and condition of the tendon. Gross longitudinal tears are readily visible. The areas of increased signal intensity one sees on T2 or STIR images help to identify areas of pathology. It is important to understand that the lack of areas with increased signal intensity does not necessarily indicate that the tendon is healthy. Tendinosis is a non-inflammatory condition. Therefore, one would expect that there would be a lack of fluid (increased signal intensity) on an MRI.

   On the other hand, the presence of areas of increased signal intensity does not mean that this is an acute process (tendinitis). As previously stated, a tendinitis and a tendinosis can occur simultaneously in adjacent tendon segments. To further complicate matters, there is a relatively high false positive rate when it comes to diagnosing tendinopathies via MRIs. 17 One can also utilize ultrasound to identify areas of lesions or fluid collections about diseased tendons. 18 These imaging modalities are especially helpful in surgery in identifying areas that require treatment.

A Pertinent Overview Of Surgical Goals

   All too often, there is a significant delay before the patient presents to a physician for treatment. Therefore, it is much more common for a patient to present with a tendinosis rather than a tendinitis. Surgical treatment is a necessity at this point because the body’s own reparative measures have failed to heal the tendon. The goals of surgical intervention include the following: 19

   • alter tissue structure and restore strength;
   • remove nonviable tendon segments;
   • encourage revascularization;
   • relieve extrinsic pressures;
   • relieve tensile overload;
   • repair tendon tears; and
   • augment injured tendon segments.

Essential Insights On Tendon Degeneration

   The surgical approach differs depending on the degree of tendon degeneration. The surgeon should always conduct careful dissection with special respect to the tendon sheath. Careful incision into the tendon sheath will ensure reapproximation with an absorbable suture after one has repaired the tendon. This ensures that the tendon has a tunnel to glide within and also potentiates the infiltration of new blood vessels that feed the repaired tendon segment.

   It is much more common to encounter longitudinal tears than transverse ruptures/tears. This is due to the longitudinally oriented, dense, regular connective tissue that makes up tendon fibers. Separation between fibers occurs more easily than transection of them.

   For longitudinal tears, one should ellipse any nonviable tendon segments and suture together (tubularize) the adjacent tendon sections by utilizing a non-absorbable suture. A transverse tear/rupture indicates the extreme of a tendinopathy (with the exception of acute traumatic cases). The degenerative process has progressed to a point where a partial or complete rupture occurs. Intraoperatively, the ruptured tendon segments appear to have a “spaghetti end” appearance and may appear frayed or bulbous. Resection of the bulbous and frayed components is necessary and augmentation with an allograft or autograft tendon is often required to supplement the loss of tendon substance.

   The structures about the tendon often indicate a disease process as well. For example, the paratenon, which is the fatty or synovial tissue located between the tendon and the tendon sheath, often appears to be injected with small vessels. One may also encounter amber-colored synovial fluid (tenosynovitis). These injected vessels are the result of neovascularization that occurs during the tendon’s healing process.

   As an aside, researchers have noted neovascularization and an increase in levels of vascular endothelial growth factors (VEGF) in areas of chronic tendon pathology. 20-22 This is an interesting finding since one of the goals of surgical treatment is to stimulate an increase in vascularity.

   On the surface, this appears contradictory. Why would one want to stimulate vascularity in an area with increased vascularity? It is likely that neovascularization and increases in VEGF levels may be markers of the disease process that has stalled in cases of tendinosis. Instead of returning to baseline, the levels remain elevated. In other words, they may be indicators but not perpetuators of the problem.

   The tendon itself may appear yellow and bulbous. This reflects the disorganized and interrupted healing that occurs. Calcifications may also be present within the tendon substance. These calcifications can be a result of improper healing of a degenerated tendon. 23,24 All of these changes one encounters in the tendon indicate a chronic disease process (tendinosis).

Salient Perspectives On Treatment Modalities

   Typically, the surgeon roughens the adjacent segments in the area of the ellipsed tendon with a curette or other sharp instrument. Doing so stimulates an acute inflammatory response to the area. 25 A newer technique of microdebridement utilizing a radiofrequency Coblation device (Topaz®, Arthrocare) can alternatively serve the same function. 26 This technique involves creating microthermal trauma at varying depths within the tendon substance.

   For tendinopathies with no associated tears, one can utilize microdebridement alone. Researchers have reported that the combination of debulking (excision), debriding and tubularization has positive results in the treatment of tendinopathies of the foot and ankle. 4,7,27-29

   However, some of the reported positive results have been called into question. 30 Furthermore, the exact mechanism of how these surgical treatment options assist in the healing of the tendon is unknown.

   Additionally, a collagen matrix can encircle or be integrated into the damaged tendon segment. The collagen matrix provides structural protection, decreases scarring and provides a tunnel for smooth tendon gliding. There are a variety of products available that serve this function. These products include TenoGlide® (Integra Life Sciences), GraftJacket® (Wright Medical Technology) and OrthAdapt® (Pegasus Biologics).

   These collagen scaffolds are particularly helpful for peroneal and posterior tibial tendon tears. However, there is still a paucity of long term, peer-reviewed publications showing the efficacy of these products as adjunctive materials in the treatment of tendinosis.

What You Should Know About Ancillary Procedures

   Ancillary surgical procedures are vital for an ultimate successful outcome. Direct repair of the tendon is only the first step for the treatment of the tendinosis. The second step for the treatment of tendinosis includes other surgical procedures.

   If the surgeon does not address the underlying etiology that caused the problem, then continued pain or recurrence is possible. For example, insertional Achilles tendinosis may result from an equinus deformity. This deformity causes increases in tensile forces within the tendon during ambulation, which causes a tendinopathy. 6 Therefore, a gastrocnemius recession or tendo-Achilles lengthening may be necessary to address the underlying cause of the problem. 31

   Another example is peroneal tendinosis resulting from peroneal subluxation syndrome. It may be necessary to address the subluxation with additional procedures including groove deepening, retinacular repair or reconstruction. Further, lateral ankle instability due to pes cavus may also contribute to peroneal tendinopathy. Accordingly, lateral ankle stabilization techniques or osteotomies/fusions may be necessary.

   Another example is posterior tibial tendinosis, which may be the result of biomechanical faults related to pes planus. Depending on the severity of this deformity, realignment osteotomies and/or fusions may be necessary. Ultimately, the combination of surgical and conservative orthotic management may be necessary to address the underlying etiology to prevent recurrence of the problem.

   The postoperative course for surgical intervention largely depends on the degree of tendon damage or the adjunctive procedures one performs. There is a delicate balance between early range of motion to prevent adhesions and immobilization to promote undisturbed healing. Typically, if no adjunctive procedures occur and one uses no collagen products, the physician should initiate passive range of motion sooner. Every clinician has his or her own timeline for facilitating a return to activity. However, it is important to note that tendons may take longer to heal than bones.

   Furthermore, if the tendon is surgically detached, there would be a greater risk of the tendon pulling away from the bone if an early return to activity occurs. Accordingly, a longer period of immobilization may be warranted in this case. The goal of surgical treatment is to reduce pain and improve function. Interestingly but not surprisingly, the tendon may not return to its original size or shape despite the cessation of symptoms. 32 In these cases, one should forewarn the patient that the tendon may never be “normal” again.

What Issues Remain Unresolved?

   Due to the complexity of tendinopathies that occur in the foot and ankle, there still remain unresolved issues. The timeline in which conservative therapies become less effective and when surgical interventions are needed is still not clear.

   A review of the literature reveals that patients report months to years of having symptoms. Some patients respond to conservative measures and others do not. A definitive timeline of when surgery is recommended would be invaluable. This would result in less time and money invested in conservative therapies. Further, the role of new technologies such as extracorporeal shockwave therapy must undergo more evaluation to assess its impact in the treatment of tendinopathies. 33

   The delay in treatment for tendinopathies often results in a chronic condition. The chronic nature of tendinopathies is not readily amendable to conservative management. Recognition of a tendinosis is an important first step in its proper treatment. This includes an accurate history and advanced imaging modalities to isolate the problem.

   Researchers have shown that surgical intervention is an effective means of treating tendinopathies. Although the exact mechanism of how surgical intervention is effective is unknown, the clinical results are favorable. Further, studies are needed to uncover the pathological etiology as well as the efficacy of current surgical treatment options.

Dr. Kim is an Assistant Professor at the Midwestern University College of Health Sciences in Glendale, Az.

For a related article, see “Achilles Tendinopathy: What Are The Best Treatment Options?” in the October 2006 issue of Podiatry Today.

References:

1. Johansson C. Injuries in elite orienteers. Am J Sports Med 1986;14:410-52. 2. Lysholm J, Wiklander J. Injuries in runners. Am J Sports Med 1987;15:168-71. 3. Brandes CB, Smith RW. Characterization of patients with primary peroneus longus tendinopathy: a review of twenty-two cases. Foot Ankle Int 2000;21(6):462-468. 4. Dombek MF, Lamm BM, Saltrick K, Mendicino RW, Catanzariti AR. Peroneal tendon tears: a retrospective review. J Foot Ankle Surg 2003 Sep-Oct;42(5):250-258. 5. Holmes GB, Lin J. Etiologic factors associated with symptomatic Achilles tendinopathy. Foot Ankle Int 2006;27(11):952-959. 6. Kaufman KR, Brodine SK, Shaffer RA, Johnson CW, Cullison TR. The effect of foot structure and range of motion on musculoskeletal overuse injuries. Am J Sports Med 1999;27(5):585-593. 7. Rolf C, Movin T. Etiology, histopathology and outcome of surgery in Achillodynia. Foot Ankle Int 1997;18(9):565-569. 8. Angermann P, Hovgaard D. Chronic Achilles tendinopathy in athletic individuals: results of nonsurgical treatment. Foot Ankle Int 1999;20(5):304-306. 9. Brown R, Orchard J, Kinchington M, Hooper A, Nadler G. Aprotinin in the management of Achilles tendinopathy: A randomized controlled trial. Br J Sports Med 2006;40(3):275-279. 10. McLauchlan GJ, Handoll HH. Interventions for treating acute and chronic Achilles tendinitis. Cochrane Database Syst Rev 2001;(2):CD000232. 11. Sayana MK, Maffulli N. Eccentric calf muscle training in non-athletic patients with Achilles tendinopathy. J Sci Med Sport 2007;10(1):52-58. 12. Kvist M. Achilles tendon injuries in athletes. Ann Chir Gynaecol 1991;80:188-201. 13. Nicholson CW, Berlet GC, Lee TH. Prediction of the success of nonoperative treatment of insertional Achilles tendinosis based on MRI. Foot Ankle Int 2007;28(4):472-477. 14. Astrom M, Rausing A. Chronic Achilles tendinopathy. A survey of surgical and histopathologic findings. Clin Orthop Relat Res 1995;316:151-164. 15. Maffulli N, Khan KM, Puddu G. Overuse tendon conditions: time to change a confusing terminology. Arthroscopy 1998; 12(8):840-3. 16. Puddu G, Ippolito E, Postacchini F. A classification of Achilles tendon disease. Am J Sports Med 1976;4:145-50. 17. Soila K, Karjalainen PT, Aronen HJ, Pihlajamaki HK, Tirman PJ. High-Resolution MR Imaging of the asymptomatic Achilles tendon: New observations. Am J Roentgenol 1999;173:323-328. 18. Astrom M, Gentz CF, Nilsson P, Rausing A, Sjoberg S, Westin N. Imaging in chronic Achilles tendinopathy: a comparison of ultrasonography, magnetic resonance imaging and surgical findings in 27 histologically verified cases. Skeletal Radiol 1996;25(7):615-620. 19. Leadbetter WB, Mooar PA, Lane GJ, Lee SJ. The surgical treatment of tendinitis. Clinical rationale and biologic basis. Clin Sports Med 1992;11(4):679-712. 20. Movin T, Gad A, Reinholt FP, Rolf C. Tendon pathology in long-standing Achillodynia. Biopsy findings in 40 patients. Acta Orthop Scand 1997;68(2):170-5. 21. Maffulli N, Testa V, Capasso G, Ewen SW, Sullo A, Benazzo F, King JB. Similar histopathological picture in males with Achilles and patellar tendinopathy. Med Sci Sports Exerc 2004;36(9):1470-5. 22. Pufe, T, Petersen WJ, Mentlein R, Tillman BN. The role of vasculature and angiogenesis for the pathogenesis of degenerative tendon disease. Scand J Med Sci Sports 2005;15:211-222. 23. Benjamin M, Qin S, Ralphs JR. Fibrocartilage associated with human tendons and their pulleys. J Anat 1995;187:625-633. 24. Uhthoff HK, Sarkar K. Classification and definition of tendinopathies. Clin Sports Med 1991;10(4):707-720. 25. Friedrich Th, Schmidt W, Jungmichel D, Horn LC, Josten CH. Histopathology in rabbit Achilles tendon after operative tenolysis (longitudinal fiber incisions). Scan J Med Sci Sports 2001;11:4-8. 26. Tasto JP, Cummings J, Medlock V, Harwood F, Hardesty R, Amiel D. The tendon treatment center: new horizons in the treatment of tendinosis. Arthroscopy 2003; 19(10)S1:213-222. 27. Bare, AA, Haddad SL. Tenosynovitis of the posterior tibial tendon. Foot Ankle Clin 2001;6(1):37-66. 28. McCormack AP, Varner KE, Marymont JV. Surgical treatment for posterior tibial tendonitis in young competitive athletes. Foot Ankle Int 2003;24(7):535-538. 29. Paavola M, Kannus P, Orava S, Pasanen M, Jarvinen M. Surgical treatment for chronic Achilles tendinopathy: a prospective seven month follow up study. Br J Sports Med 2002;36:178-182. 30. Tallon C, Coleman BD, Khan KM, Maffulli N. Outcome of surgery for chronic Achilles tendinopathy. A critical review. Am J Sports Med 2001;29;315-320. 31. Costa ML, Donell ST, Tucker K. The long-term outcome of tendon lengthening for chronic Achilles tendon pain. Foot Ankle Int 2006;27(9):672-676. 32. Alfredson H, Zeisig E, Fahlstrom. No normalization of the tendon structure and thickness after intratendinous surgery for chronic painful midportion Achilles tendinosis. Br J Sports Med. 2008 Oct 16. [Epub ahead of print] 33. Rasmussen S, Christensen M, Mathiesen I, Simonson O. Shockwave therapy for chronic Achilles tendinopathy: A double-blind, randomized clinical trial of efficacy. Acta Orthop 2008;79(2):249-256.