In previous articles, I have described some of the misconceptions about the management of achalasia, and this chapter focuses on some of the disorders associated with disorders of the Achilles tendon and posterior heel region. Although there are some similarities in the presentation of Achilles pain and disorders of the Achilles tendon and posterior heel region, they are very different when it comes to treatment. The Achilles tendon and posterior Achilles region are susceptible to a wide range of acute and chronic injuries throughout their length due to their wide range and functional demands. In our daily lives, we are increasingly active, and injuries and overexertion produce a range of effects, including a variety of painful symptoms throughout the length of the Achilles tendon and its attachments. This article focuses on this type of disorder, including various tendonitis, lesions of the Achilles tendon attachment, posterior Achilles bursitis and Haglund’s disorder, degeneration of the Achilles tendon, and acute and chronic tears. The Achilles tendon, posterior Achilles, posterior Achilles bursa, and anterior Achilles bursa make up the posterior heel of the foot. The metatarsalis muscle originates from the lateral epicondyle of the femur and is located just above the lateral head of the gastrocnemius muscle. The belly of the muscle is short because its tendon is located at the medial edge of the Achilles tendon and attaches to the distal medial aspect of the Achilles tendon. The posterior heel capsule is located in the upper part of the posterior heel tuberosity, which acts as a lubricant and cushion for the anterior border of the Achilles tendon and the upper part of the posterior heel tuberosity. It resembles the shape of a horseshoe and it is a source of pain in the hindfoot, especially regarding the distinction between Achilles tendinitis and posterior Achilles bursitis. In their study, they objectively studied the anatomy of the posterior heel bursa and its imaging technique. There is a connection between the attachment of the Achilles tendon and the bursa, so some non-foot and ankle specialists may damage the Achilles tendon when treating posterior heel pain with corticosteroid injections from the posterior heel area. An excessive protrusion over the heel bone may cause both the Achilles tendon and bursa to impinged, called a “Haglund deformity”. The normal anatomic pattern of the posterior heel is varied and includes a posterior bird’s nodule and a broad posterior nodule. Although there appears to be little reported association between the heel shape and various Achilles tendon attachment pathologies, the larger deformities are usually more associated with posterior heel pain and impingement disorders. When running, the Achilles tendon can be subjected to forces up to eight times its body weight. This tremendous functional demand makes the Achilles tendon susceptible to acute inflammation, attrition (wear) degeneration, or various types of tears. In addition to the large stresses generated on the Achilles tendon, various anatomical and structural variations of the ankle may affect the Achilles tendon (to the detriment of the Achilles tendon). For example, patients with flat feet, who rotate forward excessively while standing, may accelerate or worsen these natural processes, causing various types of Achilles tendonitis. Achilles tendonitis Achilles tendonitis can be divided into: non-attachment Achilles tendonitis and attachment Achilles tendonitis. Patients with fatiguing injuries (overuse) of the Achilles tendon often participate in activities that may produce repetitive stresses on the tendon that exceed its physiological healing capacity. For example, when a classical ballerina performs a standing pointe position, the magnitude of stress acting on the Achilles tendon may be normal, but the frequency is significantly increased and, therefore, the likelihood of fatigue (overuse) is increased. However, we cannot consider Achilles tendinitis as a single sign, because the epidemiology, pathogenesis and treatment are significantly different. Therefore, from an anatomical and functional point of view, the authors classified the disorder as non-attachment or attachment Achilles tendonitis. In addition to some anatomical factors, excessive rotation of the foot forward can lead to additional stresses acting on the medial Achilles tendon, causing Achilles tendinitis. This stress is specific to runners, for example, and a higher incidence of non-attachment Achilles tendonitis in this category has been reported, ranging from 6.5% to 18%. Similar conditions have also been reported in ballerinas, tennis players, squash (short tennis racquet wall ball) players, soccer players, and basketball players, and the pathogenesis of Achilles tendinitis may be different from that of professional runners. In general, non-attachment Achilles tendinitis appears to occur more often in high-level athletes, where repeated high biomechanical stresses such as jumping, pushing heavy objects, and strenuous movements can cause this type of Achilles tendinitis. In contrast, the adherent Achilles tendonitis is seen in regular, amateur athletes, and in overweight sedentary patients. Alternatively, a large number of patients with adherent Achilles tendinitis may have inflammatory onset/stop disease, the latter mostly in younger adult males. Non-attachment Achilles tendinitis The histopathologic classification system for non-attachment Achilles tendinitis encompasses the functional, clinical, and pathologic aspects of the various disorders. Non-attachment Achilles tendonitis is usually located 4 cm proximal to the heel bone although ossification is often seen in the attachment of the Achilles tendon, but may also be seen on the Achilles tendon proper. The ratio of the two is 2:1, with a male prevalence, and it can occur in all age groups. Excessive rotation of the foot forward seems to be common in runners, which can cause Achilles tendinitis. Probably the simplest explanation for the development of Achilles tendinitis is an overuse fatigue injury accompanied by excessive external forces acting on the Achilles tendon. The stress on the Achilles tendon during running is approximately 10 times the body weight, and repeated overactivity alone may lead to Achilles tendonitis. It is usually a change in training style, regardless of the activity, and whether the athlete is amateur, professional or elite. Changes may be obvious, including the duration, intensity, or frequency of the exercise. However, sometimes these changes can be more subtle, combining changes in running contact surfaces, local environment (conditions), or choice of athletic shoes. These alter the physiologic response, resulting in a cascade of pathologic changes within and around the Achilles tendon. In the acute phase, patients present with pain, swelling, fever, and a maximal pressure point 2-6 cm proximal to the Achilles tendon attachment. The typical presentation is a progressive worsening of symptoms: pain with activity, pain after training, and finally pain that persists independent of movement. Usually, the diagnosis is very obvious based on history and physical examination. The incidence of Achilles tendinitis seems to be directly related to the intensity of training and running. One scholar followed 115 athletes preparing for marathon training and assessed the occurrence of all their injuries until 18 months after the marathon. They found a clear association between injury and training and between injury and overtraining; they also found a progressive increase in the number of patients with Achilles tendon injuries during training. In acute paratendinous inflammation, diffuse pyknotic swelling, twisted pronation, and tenderness along the entire length of the Achilles tendon were seen, with persistent pain over the range of motion, accompanied by slippage of the tendon from plantarflexion to dorsiflexion. Gradual compression of the Achilles tendon with the thumb and index finger causes pain, and twisting and rubbing sounds are fully and distinctly felt when the skin is slid over the tendon. Pressure points are often present. MRI is also available and can reveal a slight thickening of the paratendinous Achilles tendon. In paratendinous inflammation with Achilles tendinitis, the maximum pressure point in the Achilles tendon is irregular, with diffuse thickening and easily limited lesions. The pain is more pronounced when the tendon is squeezed (compressed). The condition differs from chronic Achilles tendinitis in that the former has an irregularly confined area with pain and thickening of the Achilles tendon. Passive dorsiflexion is usually increased because the Achilles tendon is elongated and the patient is more easily identified when rotated posteriorly. Although it is not necessary to rely on MRI for diagnosis, it can be helpful when planning for surgical treatment. Conservative treatment: In most acute cases, no specific imaging is required and the diagnosis can be made based on the clinical presentation. Changes in exercise patterns and shoe changes are largely effective. In addition to reducing the weekly mileage of running, it is important to avoid running on hills and the intervals between training should be longer. It is necessary to stretch the Achilles tendon by resting the foot on a hard object and stretching slowly and continuously for 30 seconds. Treatment of acute paratendinous inflammation (with or without Achilles tendinitis) includes heel elevation of 0.5 inches, ice, and nonsteroidal anti-inflammatory medications. In severe cases, the use of ultrasound therapy, and wearing a walking boot with a rock sole type (brace) can be helpful. Corticosteroid injections (adrenocorticosteroids) are not recommended because they may be accompanied by abrasion of the Achilles tendon, tears, or both. After the acute phase, about 4 to 14 days, physical therapy and rehabilitation should be started, with stretching and strengthening exercises feasible. If the results are satisfactory, further systematic training can be performed to prepare for return to the track. If there is excessive anterior rotation of the foot and mild undercorrection, orthopedic treatment seems to be effective because anterior rotation of the subtalar joint can compensate for the limitation of ankle dorsiflexion, which is occasionally seen in such patients. Probably the most important issues that clinicians need to be aware of are: avoidance of overtraining, prophylaxis, and cross-training, including swimming and cycling, as well as all rehabilitative exercises. If tension is found in the Achilles tendon, night splinting is recommended to maintain and increase passive stretching of the Achilles tendon in addition to stretching it. For chronic and persistent paratendinous inflammation, an injection of 3 ml of sterile saline into the tendon sheath may be attempted. Tearing therapy to separate the diseased adherent paratendinous tissue from the Achilles tendon is successful in approximately 30% of patients. Chronic or recalcitrant cases lasting up to 12 to 24 weeks are amenable to surgical treatment. Surgical treatment: Patients who have not responded to regular conservative treatment should be considered for surgical treatment: the lesioned, thickened paratendinous tissue is removed thickly. After surgery, the patient is braked for 10 days, and then can bear weight and perform rehabilitation exercises. After surgery (patients can walk and move around in shoes), exercise and gradual weight-bearing within the range of motion are started early. The rehabilitation focuses on a gradual return to sports, similar to after an acute tear. One thing to keep in mind: after chronic Achilles tendinitis, the patient’s recovery may not be as fast as expected. Adhesive Achilles tendonitis Pain in the posterior part of the heel , Histopathologic changes in adhesive Achilles tendonitis include abrasion degeneration, cystic changes in the posterior nodes of the heel, and ossification of the distal Achilles tendon. Patients complain of heel pain, which is worse after prolonged standing, walking, running uphill (up hills), or running on hard surfaces. The pain usually radiates from the posterior part of the heel and can be aggravated by active or passive activity. x-ray films reveal partial ossification of the most proximal part of the Achilles tendon attachment and a bone spur protruding above the heel bone. From the surgical anatomy, the authors found that the Achilles tendon attachment did not insert a bone spur, but rather the Achilles tendon attachment was attached to the posterior wall of the heel bone. Imaging, such as MRI and ultrasound, is generally rarely required unless the possibility of extensive degeneration is considered, and these patients may tolerate reconstructive surgery. An interesting finding is that some patients present with bone spurs without symptoms in the heel, suggesting that chronic inflammation should present with pain. Thus, the mere presence of a bone spur does not adequately suggest this diagnosis. For most patients, initial non-surgical treatment is effective. Most patients with this type of Achilles tendonitis are either sedentary or amateur athletes, and for those who are more athletic or play competitive sports, non-surgical treatment should be adhered to more consistently. For athletes, training modifications, ice packs, NSAIDs, as well as heel elevation, stretching and strength training are all effective. Other simple methods, such as widening and deepening the heel (volume) of the shoe, have also been effective, and for athletes, upper or insoles made of silicon are also used to distribute the pressure. All kinds of insoles should reduce the pressure on the attachment of the Achilles tendon. A 5-8cm heel elevation pad made of fur is placed inside the shoe, and this will elevate the heel, giving it a tendency to leave the shoe. In recent cases, the authors have added a wedge-shaped pad to the sole of a running shoe. A horseshoe-shaped elevation pad is most effective and can be used inside the shoe or at the back of the heel. If these changes are not effective, stretching exercises for the Achilles tendon can be reinforced and the foot can be immobilized in the maximum dorsiflexion position with a night splint. If the disease is intractable, a short-leg walking cast or walking shoe may be used for 6 weeks. If symptoms persist and all non-surgical treatments are ineffective, surgical treatment may be considered. After surgery, no weight bearing is allowed until the wound is completely healed and the skin is well aligned. 2 weeks later, most patients can be fully weight-bearing with a short-leg cast or a removable walking shoe that immobilizes the foot in a slight horseshoe position. The duration of braking depends on the extent of the Achilles tendon debridement and is usually between 4 and 8 weeks. After a period of progressive treatment and rehabilitation, the goal is to improve strength and reduce swelling and inflammation. For inflammatory attachment Achilles tendonitis, especially after removal of a large bone spur, it may take up to 12 months to return to normal. Most importantly, this needs to be kept in mind when treating patients with seronegative spondyloarthropathies and patients with attachment point disease, as it takes longer for these patients to regain full function.