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Ansatznahe Erkrankungen der Achillessehne

Differenzierte Diagnostik und Therapie

Insertional Achilles tendinopathy

Differentiated diagnostics and therapy

  • Leitthema
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Zusammenfassung

Beschwerden am Ansatz der Achillessehne werden in Ansatztendopathie, retrokalkaneare und oberflächliche Bursitis unterschieden. Ziel dieses Beitrags ist es, die aktuelle Evidenz zu den Therapieoptionen bei Erkrankungen am Ansatz der Achillessehne darzustellen. Zur konservativen Erstlinientherapie zählen Reduktion des Aktivitätsniveaus, Gabe von nichtsteroidalen Antirheumatika (NSAR), Adaptation des Schuhwerks, Fersenkeile und ggf. eine Orthese oder Immobilisation. Darüber hinaus existieren mehrere erweiterte konservative Maßnahmen. Exzentrisches Training als Bestandteil der physiotherapeutischen Behandlung können eine Schmerzreduktion um ca. 40 % erzielen. Die extrakorporale Stoßwellentherapie erreicht im Mittel eine Schmerzreduktion um ca. 60 % und eine gute bis exzellente Zufriedenheit bei ca. 80% der Patienten. Aufgrund der sehr eingeschränkten Studienlage werden Injektionen von „platelet-rich plasma“ (PRP), Dextrose (Prolotherapie) oder Polidocanol (Sklerotherapie) nicht empfohlen. Die operative Therapie ist nach 6 Monaten frustraner konservativer Therapie indiziert. Das offene Débridement eignet sich bei sämtlichen, einschließlich ossären und intratendinösen, Pathologien. Der über 70 %igen Erfolgsrate stehen Komplikationen in bis zu 40 % der Fälle gegenüber. Eine zu über 50 % abgelöste Achillessehne sollte refixiert werden. Für den additiven Transfer der Sehne des M. flexor hallucis longus (FHL) fehlen valide Daten; regelhaft erfolgt er nach mehr als 50 %igem Débridement des Sehnendurchmessers. Die Verlängerung des M. gastrocnemius kann aufgrund unzureichender Studienlage nicht empfohlen werden. Bei Vorliegen einer isolierten retrokalkanearen Bursitis führt die Tendoskopie zu mindestens der offenen Operation vergleichbaren Ergebnissen bei deutlich geringerer Komplikationsrate.

Abstract

Achilles tendinopathy at the calcaneal insertion is classified into insertional tendinopathy, retrocalcaneal and superficial bursitis. The aim of this study was to present the current evidence on conservative and surgical treatment of insertional tendinopathy of the Achilles tendon. Conservative first-line therapy includes reduction of activity levels, administration of non-steroidal anti-inflammatory drugs (NSAID), adaptation of footwear, heel wedges and orthoses or immobilization. In addition, further conservative therapy options are also available. Eccentric stretching exercises should be integral components of physiotherapy and can achieve a 40% reduction in pain. Extracorporeal shock wave therapy has been shown to reduce pain by 60% with a patient satisfaction of 80%. Due to the limited evidence, injections with platelet-rich plasma (PRP), dextrose (prolotherapy) or polidocanol (sclerotherapy) cannot currently be recommended. Operative therapy is indicated after 6 months of unsuccessful conservative therapy. Open debridement allows all pathologies to be addressed, including osseous abnormalities and intratendinous necrosis. The success rate of over 70% is contrasted by complication rates of up to 40%. The Achilles tendon should be reattached, if detached by >50%. No valid data are available for the transfer of the tendon of the flexor hallucis longus (FHL) muscle but it is frequently applied in cases of more than 50% debridement of the diameter of the Achilles tendon. Lengthening of the gastrocnemius muscle cannot be recommended because insufficient data are available. Tendoscopy is a promising treatment option for isolated retrocalcaneal bursitis and has shown similar success rates to open debridement with significantly lower complication rates.

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  1. Klinik für Allgemeine, Unfall‑, Hand- und Wiederherstellungschirurgie, Ludwig-Maximilians-Universität, Nußbaumstr. 20, 80336, München, Deutschland

    S. F. Baumbach, M. Braunstein, F. Maßen, W. Böcker &  H. Polzer

  2. Radiologie München, München, Deutschland

    M. G. Mack

  3. Praxis für Hand‑, Ellenbogen- und Fußchirurgie, ATOS-Klinik Heidelberg, Heidelberg, Deutschland

    S. Polzer

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Baumbach, S.F., Braunstein, M., Mack, M.G. et al. Ansatznahe Erkrankungen der Achillessehne. Unfallchirurg 120, 1044–1053 (2017). https://doi.org/10.1007/s00113-017-0415-1

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