what is tendinopathy in podiatry
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Here is a comprehensive overview of tendinopathy as it relates to podiatry and foot/ankle care:
Tendinopathy in Podiatry
What Is Tendinopathy?
Tendinopathy is the preferred umbrella term for degenerative tendon conditions, replacing older terms like "tendinitis" or "tendinosis." It describes a process of disorganized collagen, mucoid degeneration, and failed healing response with minimal true inflammatory cells. Injuries exist on a spectrum: acute overuse tendinopathy → chronic tendinosis → partial tears → complete rupture.
Most Common Tendinopathies of the Foot & Ankle
1. Achilles Tendinopathy (most common in podiatry)
The Achilles tendon — formed by the distal gastrocnemius and soleus muscles, inserting on the posterior calcaneus — is the most frequently affected tendon in the lower limb.
Types:
- Non-insertional (mid-portion): occurs 2–6 cm proximal to the calcaneal insertion; accounts for ~75% of cases
- Insertional: degenerative process at the calcaneal attachment; accounts for ~25% of cases
Causes / Risk Factors:
- Repetitive eccentric loading (running, jumping)
- Systemic disease (diabetes mellitus, renal disease, ankylosing spondylitis)
- Fluoroquinolone antibiotic use
- Haglund deformity (bony prominence on the posterior calcaneus)
Clinical Presentation:
- Pain, swelling, burning, and stiffness in the posterior heel or distal lower leg
- Worsened with push-off activities: walking uphill/stairs, running, jumping
- Palpable swelling and "wet crepitus" from fluid in the peritenon
- Thompson test to assess tendon integrity (squeeze midgastrocnemius — if ankle fails to plantarflex, rupture is suspected)
Investigations:
- X-ray: usually not needed initially; can reveal calcific tendinopathy, Haglund deformity, insertional enthesophyte, or bone spur
- Ultrasound / MRI: for assessing partial tears and extent of degeneration (changes can persist even after functional recovery)
Management:
| Approach | Details |
|---|---|
| Conservative | Ice, relative rest, NSAIDs (short-term), heel lifts, shoe modification |
| Eccentric training | Best evidence — eccentric loading programs show favorable results in both mid-portion and insertional forms |
| Physical therapy | Stretching, strengthening, proprioception exercises; heavy-load training for insertional type |
| Orthotics | Silicone heel sleeves/pads, heel-lift orthotics |
| Extracorporeal shock wave therapy (ESWT) | Option for refractory cases |
| PRP injection | Evidence is mixed; for chronic insertional type, combined ESWT + PRP lacks definitive support; PRP for mid-portion Achilles has shown no benefit over saline in some trials |
| Steroid injection | Avoid — associated with significant risk of tendon rupture |
| Surgery | Reserved for chronic refractory cases; involves debridement ± tendon transfer/grafting |
2. Retrocalcaneal Bursitis / Haglund Deformity (associated with insertional tendinopathy)
- Presents with deep posterior heel pain, fullness, and tenderness medial and lateral to the tendon
- Increased pain with dorsiflexion
- Lateral foot X-ray shows the Haglund deformity
- Management: NSAIDs, padding, ice, heel-lift orthotics, shoe modification; steroid injection avoided due to rupture risk
- Surgery: débridement of bursa + excision of Haglund deformity when indicated
Pathophysiology
The underlying mechanism is a failed healing response — the tendon undergoes repetitive microtrauma that overwhelms its repair capacity, leading to:
- Disorganized collagen architecture
- Mucoid degeneration
- Neovascularization (visible on Doppler ultrasound)
- Nociceptor sensitization (explains chronic pain)
Treatment Principles (General)
- Address inflammation (early): NSAIDs, ice — limited role in chronic disease
- Stimulate collagen remodeling: eccentric exercise, deep friction massage, needling (percutaneous tenotomy)
- Autologous growth factor therapy: Platelet-rich plasma (PRP) initiates stalled healing by delivering growth factors to degenerative tissue
- Surgical fallback: for those who fail 6+ months of conservative care
Key teaching point: The term tendinopathy reflects our modern understanding that chronic tendon pain is primarily degenerative, not inflammatory — which is why anti-inflammatory strategies (NSAIDs, steroids) have limited efficacy in chronic cases, while mechanical loading programs (eccentric exercise) remain the gold standard of treatment.
Sources: Textbook of Family Medicine 9e; Miller's Review of Orthopaedics 9th Edition
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