Insertional tendinopathies

Achilles tendinopathy

• Epidemiology & Risk Factors
  • Overuse/running/jumping sports; sudden increase in training volume/intensity.
  • Medications: Fluoroquinolones (e.g., ciprofloxacin), systemic corticosteroids.
  • Associated conditions: Seronegative spondyloarthropathies (enthesitis), familial hypercholesterolemia (xanthomas), DM.
• Pathophysiology
  • Degenerative tendinosis: Repetitive mechanical overload exceeding repair capacity leads to failed healing (predominantly degenerative, non-inflammatory tissue response).
  • Collagen disruption: Normal parallel Type I collagen is degraded and replaced by weaker, disorganized Type III collagen with increased proteoglycans/mucoid matrix.
  • Vascular watershed area: Relative hypovascularity 2–6 cm proximal to calcaneal insertion predisposes to micro-ischemia, tissue breakdown, and impaired healing.
• Clinical Features
  • Burning posterior heel pain and stiffness (worse in AM and after exercise; improves with light activity).
  • Midportion tendinopathy (most common): Tenderness/swelling 2–6 cm proximal to calcaneal insertion.
  • Insertional tendinopathy: Pain directly at calcaneal attachment ± Haglund deformity.
  • Negative Thompson test (intact plantarflexion on calf squeeze).
• Diagnosis
  • Initial / Primary: Clinical diagnosis via H&P.
  • Ultrasound (US): Thickened tendon, hypoechoic degenerative areas, neovascularization.
  • MRI (Gold Standard / Confirmatory): Increased T1/T2 signal; evaluates partial vs. full-thickness tears.
  • X-ray: Normal or shows calcaneal spur/calcification (rules out avulsion or stress fracture).
• Differential Diagnostics
  • Calcaneal Apophysitis (Sever Disease): Diff by occurrence in skeletally immature pediatric/adolescent athletes (ages 8–12) during growth spurts; pain localized over the posterior calcaneal apophysis with (+) calcaneal squeeze test.
  • Achilles Tendon Rupture: Sudden “pop” or “gunshot” sensation, palpable gap, (+) Thompson test.
  • Plantar Fasciitis: Inferior/plantar heel pain, worse with first morning steps.
  • Calcaneal Stress Fracture: Pain with calcaneal squeeze test (medial-lateral compression).
  • Retrocalcaneal Bursitis: Pain on two-finger palpation anterior to the Achilles insertion.
• Management
  • First-line:
    • Relative rest, activity modification, ice, temporary heel lifts.
    • Physical therapy: Eccentric loading exercises (mainstay of rehab). c
    • Short-term oral NSAIDs for acute pain control.
  • High-Yield Contraindication: NO local glucocorticoid injections (high risk of tendon rupture).
  • Refractory (>3–6 months): Extracorporeal shock wave therapy (ESWT) or surgical debridement.
• Complications
  • Achilles tendon rupture (partial or complete).
  • Chronic debilitating pain and altered gait biomechanics.

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Iliotibial band syndrome

• Etiology & Risk Factors:
  • Repetitive friction of the distal ITB against the lateral femoral epicondyle (~30° knee flexion).
  • Common in: Distance runners, cyclists, military recruits.
  • Biomechanical trigger: Weak hip abductors (gluteus medius) causing pelvic drop and increased ITB tension; running on banked/downhill surfaces.
• Clinical Features:
  • Sharp, burning lateral knee pain worsening with repetitive foot-strikes/downhill running.
  • Pain relieved by rest; no joint effusion and no mechanical symptoms (no true locking/catching).
• Physical Exam Findings:
  • Point tenderness over the lateral femoral epicondyle (~2–3 cm proximal to lateral joint line).
  • (+) Noble test: Pain reproduced at ~30° flexion while compressing the lateral femoral epicondyle.
  • (+) Ober test: Inability to adduct hip past midline with knee flexed in lateral decubitus (confirms ITB tightness).
• Diagnosis:
  • Clinical diagnosis based on typical Hx and localized epicondylar tenderness.
  • Imaging (X-ray/MRI) not routinely required; reserved only to rule out intra-articular pathology if atypical.
• Key Differentials:
  • Lateral meniscal tear: Tenderness at lateral joint line (not epicondyle), (+) joint effusion, (+) McMurray test, mechanical catching/locking.
  • LCL sprain: Acute varus trauma, laxity on varus stress testing.
  • Patellofemoral pain syndrome: Anterior/peripatellar pain, worse with prolonged sitting (“theater sign”).
• Management:
  • 1st-line (Conservative):
    • Activity modification (relative rest, avoid downhill running), cryotherapy, short course of NSAIDs.
    • Physical Therapy: Strengthening of hip abductors (gluteus medius) + ITB/tensor fasciae latae stretching.
  • 2nd-line (Persistent pain > 4–6 weeks):
    • Local corticosteroid injection deep to the ITB at the lateral femoral epicondyle.
  • Refractory (Rare, > 6 months failed therapy):
    • Surgical ITB release or lateral bursectomy.

Lateral epicondylitis (Tennis elbow)

• Etiology & Pathophysiology:
  • Overuse tendinopathy (angiofibroblastic degeneration) of the extensor carpi radialis brevis (ECRB) origin.
  • Triggered by repetitive, forceful wrist extension and supination (e.g., tennis backhand, screwdriver use).
• Clinical Presentation:
  • Point tenderness localized to the lateral epicondyle.
  • Pain reproduced with resisted wrist extension (with elbow extended).
  • Pain reproduced with resisted middle-finger extension.
  • Pain reproduced with passive wrist flexion.
  • Normal elbow ROM and intact neurovascular exam.
• Diagnosis:
  • Clinical diagnosis (no labs or imaging needed routinely).
  • XR: Indicated only to rule out bony pathology, OA, or calcific tendinitis.
  • MRI / US: Reserved for atypical presentations or refractory cases prior to surgery (shows ECRB thickening/tears).
• Key Differentials:
  • Radial tunnel syndrome: Maximal tenderness is 4–5 cm distal to the lateral epicondyle over the mobile wad (PIN compression); lacks epicondyle point tenderness.
  • Cervical radiculopathy (C6–C7): Radiating neck pain, dermatomal paresthesias, diminished reflexes, and (+) Spurling sign.
  • Elbow osteoarthritis: Decreased active/passive elbow ROM, joint line tenderness, and osteophytes on XR.
• Management:
  • First-line (Conservative): Activity modification, short-term NSAIDs, eccentric strengthening PT, and a counterforce elbow strap (forearm band).
  • Second-line: Local corticosteroid injection (provides rapid short-term relief, but high recurrence rate and risk of tendon rupture).
  • Refractory (failed 6–12 months of conservative care): Surgical debridement and release of the ECRB origin.
• Complications:
  • Chronic lateral elbow pain and reduced grip strength.
  • Iatrogenic tendon rupture or subcutaneous fat atrophy/depigmentation from corticosteroid injections.