Key Insights For Diagnosing And Treating Tendinosis

   Tendinosis is one of those diagnostic terms that took me a while to truly understand. People most often use this term in relation to the Achilles complex but tendinosis can be related to any tendon of the foot or ankle. In most cases, tendinosis is associated with the tendons about the ankle and the most commonly affected tendons are the Achilles, posterior tibial and peroneals.    While tendinosis is a very simple concept to explain, it is a far more difficult concept to truly understand and treat. Essentially, tendinosis involves the fraying or scarring of the fibers of the associated tendon and the replacement of a small or extended region of the tendon with scar tissue or fibrous tissue. The level of scar may be palpable to pressure on the associated region or may be microscopic in nature. There may be a bulbous region of damage or very small, scattered regions of damage.    When tendinosis involves the posterior tibial or peroneal tendons, there is no associated peritenon and accordingly no peritenonitis or peritenosis. The most common regions of tendinosis are at stretch areas such as the associated malleolar bends, the navicular insertion for the posterior tibial tendon and the fifth metatarsal base for the peroneus brevis tendon. There are also far less visible signs of problems and one may define the major pathology with an ultrasound or an MRI of the region. The Achilles is a totally different animal and may have many different pathology findings due to the fact that there is a tendon, a prominent insertion site and a paratenon.

Understanding And Addressing Achilles Tendon Pathology

   The overall result with the Achilles tendon pathology is that one can have a peritenonitis, a peritenosis, a tendonitis, a tendinosis, a partial tear, an exostosis or any combination. For the sake of this article, we will only address the tendinosis concept and leave the treatment of Achilles tendon pathology for a subsequent article.    That said, we now understand that tendinosis is a fibrotic replacement of the true substance of a tendon with possible microscopic or small partial tears. When it comes to mild internal pathology, we know it is best to visualize this with an MRI or ultrasound.    How does this pathology occur? The truth is it is not well understood in detail. The general concept is there is tension along the line of pull of the tendon, resulting in microscopic or macroscopic trauma to the tendon and a resulting partial tear of the tendon. The tearing may also be microscopic or macroscopic in nature. As there is minimal pain and discomfort on a daily basis at first, patients will continue to perform their regular activity and continue the microscopic damage to the region. Over time, the accumulation of trauma causes a replacement of the fibrils of tendon with scar tissue.    The result is a tendon that is less flexible and stiffer with possible internal bulbous or linear tears, and degeneration of the tendon. One can best note this in a large tendon such as the Achilles. On a microscopic level, clinicians may see small linear tears and scar formation, mild thickening of the tendon and mild internal cystic changes. Over time, the scarring and cystic changes increase, and there may be thickening and bulbous enlargement of the tendon, which one can easily see through the skin and palpate with pressure along the tendon. With further neglect, there may be frank tears of the tendon or even complete replacement of a section of tendon with either bone or complete scar formation.    Dealing with the underlying problem is a multifactorial situation. What is the patient’s overall goal (competitive sports, walking, no pain)? What is the patient’s lifestyle (sedentary, very active)? How bad is the pathology of the tendon (complete scarring, a severe tear, microscopic damage)? How long has the problem existed (many years, one month, a couple of days)? What is the overall makeup of the foot function (equinus, cavus, valgus, forefoot pathology and malalignment)? Once you have assembled the entire picture in regard to diagnosis and treatment goals, you can proceed with a course of treatment.

A Review Of Pertinent Treatment Options

   From the simplest to most complicated treatment options, we often begin with a course of conservative care without much lifestyle change. This often will include the use of orthotics during athletics and as much as possible with dress shoes. We also are strong proponents of physical therapy to decrease swelling and scarring about the tendon. This can help address any underlying biomechanical issues of gait pattern and muscle tightness or imbalance in the extremity. We would also begin a course of antiinflammation medication for two weeks.    If a course of simple conservative care is not helpful, we may consider a functional bracing versus casting of the region. We often do this as a form of conservative care in cases of more damaged tendons and when the tendon has been traumatized for an extended period of time. After removing the cast at about one month, we initiate physical therapy and orthotic therapy. The patient may use the functional bracing for an extended time during traumatic periods such as with running and sports.    The treatment options for severe cases of tendinosis are fairly straightforward (see “How To Treat Severe Tendinosis” below). However, perhaps the most difficult case to treat is mild damage to the tendon with microscopic scarring and damage that is not resolving with conservative care and when there is pain with activity.    Previously, in such cases, surgeons often explored the tendon and had difficulty finding pathology to treat. They would traumatize the tendon via stab incisions into the fiber of the tendon and linear opening of the tendon with debridement of minor portions in order to increase blood flow to the region. While this type of treatment would be helpful, there was no understanding of why we did what we did.    The true underlying treatment involves limited trauma to the region in order to increase circulation and healing to the region, and emphasizing subsequent protection during the healing period. One can achieve this with splitting of the tendon, stabbing of the tendon or any other form of trauma. The more controlled the trauma and the better one directs the trauma to the location of the problem, the better the results of the treatment.

How To Treat Severe Tendinosis

   In the case of severe scarring and damage, and partial tears and cystic changes, the treatment options are often simple.    One would perform surgical debridement of scar tissue through a split tendon approach. In many cases, surgeons would perform a tendon grafting to assist with the function of the original tendon.    In the case of the Achilles tendon, one may transfer a flexor hallucis tendon graft to the calcaneus for added strength and support of a severely damaged Achilles. Surgeons may often graft the peroneal tendons to each other for added support and a decrease in pull on one or the other tendons. One may graft the posterior tibial tendon with a flexor digitorum tendon in the arch region for added support and better arch function.    Be sure to use stabilizing or osseous procedures to deal with underlying osseous deformities such as ankle instability, hindfoot valgus or varus, equinus or forefoot varus, or instability of the forefoot.

A New Approach To Treating Chronic Microscopic Tendinosis

   We have begun using a plasma mediated, radiofrequency-based microtenotomy probe also known as the Topaz system (Arthrocare) for the treatment of chronic microscopic tendinosis. In such cases, there is no severe bulbous damage and no gross fibrosis of the tendons. The major trauma is microscopic and there is fibrosis of the internal tendon only on a microscopic level. To the naked eye, the tendon may look slightly more fibrotic but there is no gross pathology to remove.    The microtenotomy technique with radiofrequency allows for minor trauma to the region and resulting angiogenesis to the area. This technique allows for added circulation to heal the damaged region. The treatment is very precise and has less trauma associated with it compared to stab incisions or linear tendon clean-up procedures.    The surgeon would make multiple small stabs into the tendon at differing depths along the region of damage. One would employ a saline medium to soak the region during treatment. This causes an increase in energy that breaks the molecular bonds about the treated area and causes dissolving of the scar tissue. The benefit is limited damage and preservation of the surrounding tendon and soft tissue.

Final Thoughts

   I have found such a treatment to be outstanding and have begun to use this type of treatment, even in the severe scar cases after removing the severe damaged area. I use the treatment now instead of shockwave therapy prior to proceeding to surgery in severe plantar fascia cases. I have also begun using it on mild cases that do not resolve with conservative therapy.    I believe the future will see the continued use of devices that increase circulation and limit damage to microscopic levels. Surgeons should consider using such a device in their tendinosis cases. They will be pleasantly surprised at the improvement. Dr. Baravarian is Co-Director of the Foot and Ankle Institute of Santa Monica. He is an Associate Professor at UCLA Medical Center and is the Chief of Podiatric Surgery at Santa Monica/UCLA Medical Center. Dr. Baravarian may be reached via e-mail at bbaravarian@mednet.ucla.edu