Subcutaneous bursa is important in insertional achilles tendinopathy

NewsBot · Jun 25, 2016

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Nerve distributions in insertional achilles tendinopathy - a comparison of bone, bursae and tendon.
Andersson G et al
Histol Histopathol. 2016 Jun 20:11790

BACKGROUND/AIM:
In a condition of pain in the Achilles tendon insertion there are multiple structures involved, such as the Achilles tendon itself, the retrocalcaneal bursa and a bony protrusion at the calcaneal tuberosity called Haglund's deformity. The innervation patterns of these structures are scarcely described, and the subcutaneous calcaneal bursa is traditionally not considered to be involved in the pathology. This study aimed at describing the innervation patterns of the four structures described above to provide a better understanding of possible origins of pain at the Achilles tendon insertion.
METHODS:
Biopsies were taken from 10 patients with insertional Achilles tendinopathy, which had pathological changes in the subcutaneous and retrocalcaneal bursae, a Haglund deformity and Achilles tendon tendinopathy as verified by ultrasound. The biopsies were stained using immunohistochemistry in order to delineate the innervation patterns in the structures involved in insertional Achilles tendinopathy.
RESULTS:
Immunohistochemical examinations found that the subcutaneous bursa scored the highest using a semi-quantitative evaluation of the degree of innervation when compared to the retrocalcaneal bursa, the Achilles tendon, and the calcaneal bone.
CONCLUSIONS:
These findings suggest that the subcutaneous bursa, which is traditionally not included in surgical treatment, may be a clinically important factor in insertional Achilles tendinopathy.
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NewsBot · Jun 28, 2016

Structure of the Achilles tendon at the insertion on the calcaneal tuberosity
Mutsuaki Edama et al
Journal of Anatomy; Early View

Findings on the twisting structure and insertional location of the AT on the calcaneal tuberosity are inconsistent. Therefore, to obtain a better understanding of the mechanisms underlying insertional Achilles tendinopathy, clarification of the anatomy of the twisting structure and location of the AT insertion onto the calcaneal tuberosity is important. The purpose of this study was to reveal the twisted structure of the AT and the location of its insertion onto the calcaneal tuberosity using Japanese cadavers. The study was conducted using 132 legs from 74 cadavers (mean age at death, 78.3 ? 11.1 years; 87 sides from men, 45 from women). Only soleus (Sol) attached to the deep layer of the calcaneal tuberosity was classified as least twist (Type I), both the lateral head of the gastrocnemius (LG) and Sol attached to the deep layer of the calcaneal tuberosity were classified as moderate twist (Type II), and only LG attached to the deep layer of the calcaneal tuberosity was classified as extreme twist (Type III). The Achilles tendon insertion onto the calcaneal tuberosity was classified as a superior, middle or inferior facet. Twist structure was Type I (least) in 31 legs (24%), Type II (moderate) in 87 legs (67%), and Type III (extreme) in 12 legs (9%). A comparison between males and females revealed that among men, 20 legs (24%) were Type I, 57 legs (67%) Type II, and eight legs (9%) Type III. Among women, 11 legs (24%) were Type I, 30 legs (67%) Type II, and four legs (9%) Type III. No significant differences were apparent between sexes. The fascicles of the Achilles tendon attach mainly in the middle facet. Anterior fibers of the Achilles tendon, where insertional Achilles tendinopathy is most likely, are Sol in Type I, LG and Sol in Type II, and LG only in Type III. This suggests the possibility that a different strain is produced in the anterior fibers of the Achilles tendon (calcaneal side) where insertional Achilles tendinopathy is most likely to occur in each type. We look forward to elucidating the mechanisms generating insertional Achilles tendinopathy in future biomedical studies based on the present results.
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NewsBot · Aug 5, 2017

The Achilles tendon and the retrocalcaneal bursa: An anatomical and radiological study.
P. A. Pękala, B. M. Henry, J. R. Pękala, K. Piska, K. A. Tomaszewski.
Bone Joint Res 2017;6:446–451.

Objectives Inflammation of the retrocalcaneal bursa (RB) is a common clinical problem, particularly in professional athletes. RB inflammation is often treated with corticosteroid injections however a number of reports suggest an increased risk of Achilles tendon (AT) rupture. The aim of this cadaveric study was to describe the anatomical connections of the RB and to investigate whether it is possible for fluid to move from the RB into AT tissue.

Methods A total of 20 fresh-frozen AT specimens were used. In ten specimens, ink was injected into the RB. The remaining ten specimens were split into two groups to be injected with radiological contrast medium into the RB either with or without ultrasonography guidance (USG).

Results In specimens injected with ink, diffusion outside the RB was observed with staining of the anterior portion of the AT. In eight contrast-injected specimens (five USG, three non-USG), a similar localised diffusion pattern was observed, with the contrast identified superiorly and anteriorly. In two contrast-injected specimens (non-USG), the diffusion pattern was more extensive.

Conclusion This study confirmed the existence of connections between the RB and the AT, especially rich in the anteroinferior portion of the tendon, which should be considered a weak zone for substances injected into the RB. We hypothesise that this part of the AT might be most vulnerable to rupture after corticosteroid injections.
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NewsBot · Oct 3, 2017

Normative size of the osseous part of calcaneal bursa and its comparison with other calcaneal articular areas.
Mahato NK
Foot (Edinb). 2017 Sep 7;32:49-52. doi: 10.1016/j.foot.2017.09.002.

The retro-calcaneal bursa presents a synovial and a non-synovial osseous part of variable dimensions. Studies objectively measuring the variability of the size of this osseous bursal surface cannot be found in literature. The objective of this study was to investigate (i) the dimension variability of the bony part of the bursa and (ii) the relationship of this surface to other articulating areas of the calcaneus. A digital planimeter was used to measure the bursae (n=86) and other articular surface areas of the calcaneus and statistically compared with ANOVA and correlation estimations. The osseous area measured 1.12 (±0.55) cm2, with only the superior articulating area demonstrating a weak correlation to this osseous surface. The osseous area presents a weak correlation with the axial articulating area of the calcaneus. Information on the size of the bony bursa may help safe excision of retrocalcaneal exostoses and in Achille's tendon repair around the posterior tuberosity.
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NewsBot · Jun 19, 2020

Surgical Treatment of Insertional Achilles Tendinopathy: Results After Removal of the Subcutaneous Bursa Alone-A Case Series
Håkan Alfredson, Christoph Spang
BMJ Open Sport Exerc Med. 2020 Jun 9;6(1)

Background: Insertional Achilles tendinopathy is well known to be difficult to treat, especially when there is intra-tendinous bone pathology. This study is a case series on patients with chronic insertional Achilles tendon pain and major intra-tendinous bony pathology together with bursa and tendon pathology, treated with excision of the subcutaneous bursa alone.

Methods: Eleven patients (eight men and three women) with a mean age of 44 years (range 24-62) and a chronic (>6 months) painful condition from altogether 15 Achilles tendon insertions were included. In all patients, ultrasound examination showed intra-tendinous bone pathology together with pathology in the tendon and subcutaneous bursa, and all were surgically treated with an open excision of the whole subcutaneous bursa alone. This was followed by full weight-bearing walking in a shoe with open heel for 6 weeks.

Results: At follow-up 21 (median, range 12-108) months after surgery, 9/11 patients (12/15 tendons) were satisfied with the result of the operation and 10/11 (13/15 tendons) were back in their previous sport and recreational activities. The median VISA-A score had improved from 41 (range 0-52) to 91 (range 33-100) (p<0.01).

Conclusion: In patients with chronic painful insertional Achilles tendinopathy with intra-tendinous bone pathology, tendon and bursa pathology, open removal of the subcutaneous bursa alone can relieve the pain and allow for Achilles tendon loading activities. The results in this case series highlight the need for more studies on the pain mechanisms in insertional Achilles tendinopathy and the need for randomised studies to strengthen the conclusions
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NewsBot · Apr 14, 2022

Investigating the Presence of Connective Tissue Progenitor Cells within the Retrocalcaneal Bursa
Anna Jorgensen, Anna Jorgensen, Owen P. Karsmarski, ...
Foot & Ankle Orthopaedics April 9, 2022

Introduction/Purpose:
The purpose of this study was to evaluate the presence of connective tissue progenitor cells within the retrocalcaneal bursa. The study evaluation included an assessment of the viability of connective tissue progenitor cells, their proliferative potential, and their ability to differentiate into osteoblasts, adipocytes, and chondrocytes.

Methods:
The retrocalcaneal bursa samples were excised from 10 patients (age: 51.5 +- 10.8 years) undergoing Achilles surgery in which the retrocalcaneal bursa is routinely excised. Bursal tissue was processed by digesting cells with collagenase and obtaining nucleated cell counts and cellular concentrations. The cells were cultured, and differentiated into osteoblasts, adipocytes, and chondrocytes. Analysis of bursal derived cells consisted of fluorescent activated cell sorting (FACS) analysis, cellular proliferation and viability assay, and analysis of differentiation into osteoblasts, adipocytes, and chondrocytes. The CTP differentiation was confirmed using histology staining to qualitatively express differentiation, and qPCR to quantify gene expression.

Results:
Cell migration at 3 weeks on average was found to be 3.84x107 nucleated cells/gram of tissue and nucleated cellular concentration on average was found to be 6.28x105 cells/mL of suspension. The proliferation data showed high levels of proliferation on average of 1.72 +-0.58. The FACS analysis showed a high percentage of positive surface markers for CTPs measuring greater than 96% (CD105, CD90, CD73) and measuring < 1.1% for negative surface markers (CD45 and CD31). Differentiation into osteoblasts, adipocytes, and chondrocytes were stained appropriately displaying differentiation.

Conclusion:
The retrocalcaneal bursa is a novel source of connective tissue progenitor cells. This is the first study to our knowledge analyzing the retrocalcaneal bursa as a novel source for CTPs, making it a potential augment to expedite the healing process of the Achilles tendon. Overall, it is unclear what the role of the CTPs within the bursa is, however, they may help to reduce the extensive healing time for the Achilles tendon thereby returning patients with Achilles tendon pathology back to functional status more promptly.
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