JFAS 33(1): 87-90, 1994

Achilles Peritendinosis: An Unusual Case Due to Frostbite in an Elite Athlete

Achilles peritendinosis is common in running and jumping sports and can present with or
without Achilles tendinosis itself. Several authors describe this condition as associated
with over-use syndromes. This article describes an Achilles peritendinosis subsequent to
frostbite in an elite runner who eventually underwent surgical treatment and was able to
resume running 3 weeks postoperatively.

Amol Saxena, DPM, FACFAS1

Achilles peritendinosis has been described by many authors. Essentially, it is an

inflammation of the Achilles peritendinous tissue (the paratenon) (1-3, 5, 7, 8). Unlike
most tendons, the Achilles tendon lacks a true synovial sheath; therefore, pathologic
changes vary (1-8). The histopathologic changes with peritendinosis include an increase
in fibrinous exudate, proliferation of fibroblasts, and synovial cell hyperplasia. The
subsequent decrease in oxygenation of the tissues, along with destructive enzymatic
changes, results in reduction of the gliding mechanism of the Achilles tendon within its
paratenon (4, 5). The increase in friction from the Achilles tendon trying to glide within
the paratenon produces crepitus in various areas of the tendon. This is most typical in the
relatively avascular "watershed" area (2 to 6 cm. proximal to the Achilles tendon
insertion) (9). Trauma, particularly lacerations, poor gastrocnemius-soleus flexibility,
faulty biomechanics, can result in paratenon scarring and instigate peritendinosis (1-8). In
addition, chronic Achilles tendinitis with tendon degeneration can result in peritendinosis
due to the associated inflammatory changes (1-3, 6-11). Symptoms include pain, edema,
and crepitus (which is worse with activity) in the watershed region. Generally, on the
medial and lateral sides of the Achilles tendon, palpable peritendinous fibrosis may be
evident (1, 2, 58, 10, 11).
Treatment of Achilles peritendinosis is varied and is primarily based on its
etiology. Patients who develop symptoms associated with biomechanical abnormalities,
such as excessive pronation or supination, may obtain relief with functional orthoses (7).
Additional successful treatment modalities include some combinations of oral anti-
inflammatories, physical therapy, Dimethyl Sulfoxide (DMSO), and heel lifts (2, 3, 6, 7).
Surgical decompression (tenolysis) is recommended in recalcitrant cases or in instances
where trauma/scar tissue is evident (1-3, 7, 8, 11).

Case History

A 27-year-old male elite distance runner with a history of Achilles tendinitis

utilized a "blue" ice pack for icing his left Achilles tendon in December 1991. He had no
prior history of peritendinosis. As he was traveling during the holiday season, he utilized
different freezers to store the chemical ice pack. In late December, after applying the ice
pack for approximately 5 min. directly to the skin, he developed blistering and
suppuration.
Within a few days, he returned to his local area and was seen in the author's
office. A diagnosis of a 4 x 3 cm. region of Grade II frostbite occurring over the
watershed area, which contained blisters and mild suppuration, was made. Frostbite may
be defined in four grades (first degree through fourth degree) and is applicable to clinical
course (12) (Table 1). Local superficial wound debridement and treatment with 1% silver
sulfadiazine was started. His wound healed by secondary intention with the eschars
sloughing, revealing pink skin at approximately 4 weeks. At the time, the patient was
rehabilitating plantar fascitis of his right foot and was unable to run for a period of
approximately 4 weeks. When he tried to resume running in February 1992, he noted that
after one run of a relatively short distance (2 miles), he developed marked swelling, pain,
and crepitus of his left Achilles tendon. He had not experienced this sensation before. He
had not noted any other burning or soreness in the region of the Achilles tendon.

___________________________________________________________
From the Department of Sports Medicine, Pale Alto Medical Clinic.
1067-2516/94/3301 -0087$3.00/0
Copyright © 1994 by the American College of Foot and Ankle Surgeons

87

Physical examination and symptoms were negative (including Thompson's test) for both
partial and complete tear of the Achilles.2
The patient then began daily physical therapy with ultrasound, electrical
stimulation, and cool water baths. He made several attempts of trying to resume running
during a 6-week time-frame. Each time he tried running, even after 5-to-7 day periods of
rest, he developed marked swelling, pain, and crepitus of the left Achilles tendon. Rest
and electrical stimulation rendered the patient free of pain and crepitus, which remained
only until he resumed running. Therefore, he resorted to trying additional therapeutic
measures including functional orthoses, heel lifts, Dimethyl Sulfoxide, and acupuncture,
with no relief. The region of the healed frostbite spanned approximately 4 cm. of the
typical watershed area. There was no other evident sign of wound breakdown, infection,
fibrosis, or Achilles tendon tear. Clinical examination revealed marked crepitus
peritendinously after each training run. Palpable peritendinous fibrosis was evident
especially laterally.
Time became critical as the patient was to compete in his country's Olympic trials
in approximately 12 weeks. The decision was made to have the patient undergo magnetic
resonance imaging examination. This was undertaken 12 weeks after the initial frostbite
injury. The magnetic resonance imaging revealed marked peritendinous fibrosis,
inflammation, and edema. The magnetic resonance imaging, which utilized 3-mm. slices
(Fig. 1) showed no evidence of focal, fatty, or mucoid degeneration of the Achilles
tendon. Other treatment options, including surgery, were discussed with the patient and
he elected to undergo surgical debridement of the abnormal paratenon and tenolysis. This
was undertaken 12 weeks after the initial frostbite injury.

Surgical Technique

With the patient in the prone position, a linear peritendinous incision of

approximately 7 cm. long was made, lateral to the left Achilles tendon where a majority
of the paratendinosis appeared to occur, according to the magnetic resonance imaging
study. The subcutaneous tissue was found to be fibrotic.

TABLE 1. Staging of frostbite

——————————————————————————————
First degree: Hyperemia and edema developing in 3 hr and lasting up to 10
days.
Sloughing of superficial skin occurs after 1 week.

Second degree: Hyperemia, edema, and blistering developing in the 1 st day.

Blisters desiccate and black eschars form in 2 to 4 weeks. Pink skin is
revealed under the sloughed eschar.

Third degree: Full-thickness damage with extension into the subcutaneous

tissues.
Blisters appear on the edge of the damaged tissue with a hard,
black eschar taking 2 months to heal. A tourniquet effect may occur
if circumferential.

Fourth degree:
Injury may be deep to bone and all tissues may be black and dry,
demarcating in a few months. This may autoamputate.
——————————————————————————————

Figure 1. Magnetic resonance imaging showing peritendinous edema and

inflammation (P) circumferentially around the left Achilles tendon at two different levels
of the watershed region. Normal left Achilles tendon (T) is evident in both figures. In
comparison note the normal appearing right paratenon and posterior ankle contours,
especially in Figure 1 B.

88

There was marked thickening and gristly appearing paratenon, 3 x 1 cm. in size, which
was lobulated and necrotic. Similar findings on the medial portion of the paratenon (2 x 1
cm. in size) were also noted. Anteriorly, there were degenerated fatty changes in the
paratenon. These degenerated, fibrotic areas were excised. There were no abnormalities
found in the Achilles tendon itself (Fig. 2). There was no yellowing, nodular or fusiform
thickening, nor any other fibrotic change of the tendon noted. Tendon decompression was
performed throughout the entire length of the Achilles tendon dorsally, laterally, and
medially. This coursed proximally near the myotendinous junction to distal to the
calcaneal insertion. Subsequently, only the anterior portion of the paratenon remained.
The wound was closed with a 4-0 buried absorbable suture, taking great care to
avoid placement posterior to the tendon which may contribute to additional fibrosis. The
skin was closed with running subcuticular fashion utilizing 4-0 Prolene.3 The patient was
placed in a posterior splint and remained nonweightbearing for 1.5 weeks
postoperatively.
Sutures were removed at 2 weeks postoperatively. He then utilized a 1/4-inch heel
lift in both shoes, along with his previously dispensed prescription functional orthoses.
His wound healed without complications. Pathology The pathologic report indicated
marked proliferation of fibroblasts. There was edematous collagenous tissue and synovial
cells on the inner lining of the paratenon which had been sloughed and replaced by
fibrinous exudate (Fig. 3). The pathologic diagnosis was Achilles paratenon with fibrosis,
capillary proliferation, and fibrinous exudate, along with synovial hyperplasia, consistent
with clinical history of frostbite.

Postoperative History

The patient's postoperative physical therapy regimen began 1 day postoperatively

with exercise-biking (without placement of the left foot and leg on the pedal). He started
cycling with the left leg within 4 days postoperatively. After suture removal 2 weeks
postoperatively, he started running in the deep end of the pool.
By 3 weeks postoperatively, he was able to perform several repetitions of heel
raises, exercises for strengthening his ankle plantar flexors with surgical tubing, as well
as run in the shallow end of a pool without any discomfort. He had no sign of crepitus
and, therefore, was allowed to begin a light jogging program on land at 3 weeks
postoperatively. The patient was able to resume competitive training 7 weeks
postoperatively and was able to compete in his country's national championships. He
returned to 100% of his competitive and training level within 3 months postsurgery. One
year postsurgery, the patient remained completely asymptomatic, having qualified for the
World Championships.

Discussion

Peritendinosis can be a relatively disabling pathologic condition. Most cases of

Achilles peritendinosis are due to chronic fibrosis. However, isolated peritendinosis does
occur without Achilles tendinitis. Many authors have described separate classification of
these entities (2, 3, 7, 11). Clement et al. describes Achilles tendinosis to occur with
peritendinitis and speculates it is due to microtrauma secondary to excessive pronation
(2). Williams further divides and classifies Achilles tendon pain into: rupture, focal
degeneration, tendinitis, peritendinitis, mixed lesions, origin/insertion lesions, and other
cases such as metabolic/rheumatic causes (11).
 Surgical lysis of adhesions is indicated in recalcitrant cases and is often successful
in athletes (1-3, 6, 10). Magnetic resonance imaging examination is useful to help
evaluate the tendons and rule out any areas of tendinosis that may have developed
associated with peritendinosis (3, 7). Several authors have described various surgical
techniques for chronic Achilles tendinitis. Nelen et al. used a straight, longitudinal
incision based medially to the tendon. Adhesions are freed medially, laterally, and
dorsally, and the hypertrophic paratenon and inflammatory "fur" is excised.

Figure 2. The abnormal paratenon (P) laterally, to be excised; note normal

Achilles tendon (1).

89

They advised avoiding complete circular dissection so as not to damage the anterior
blood supply of the Achilles (8). Leach et al. resected or stripped the involved paratenon
and addressed other coexisting deformities such as retrocalcaneal exostoses and bursae
by excising them also (6).
Although literature has implicated overuse, trauma, and lacerations as causes for
peritendinosis, review of the literature did not reveal frostbite as a cause for
peritendinosis. The patient presented in this case was successfully treated by resection of
the paratenon and tendon decompression (tenolysis). This patient was able to resume
running 3 weeks postoperatively with the surgical technique described.

Acknowledgment

The author acknowledges Charles Lombard, M.D., for his assistance in

preparation of the pathology slides.

Figure 3. A, Synovial lining with sloughed synovial lining cells and fibrinous
exudate (F). Small capillaries with fibrin thrombi M underlie the synovium. Perisynovial
soft tissues show edema and proliferating reactive fibroblasts. (Magnification, H & E, xl
50.) B, Marked capillary proliferation (C) in perisynovial soft tissues. (Original
magnification, H & E, x120.)

References

1. Schepsis, A. A., Leach, R. E. Surgical management of Achilles tendinitis. Am.

J. Sport Med. 15:308-315, 1987.
2. Clement, D. B., Taunton, J. E., Smart, G. W. Achilles tendinitis and
peritendinitis: etiology and treatment. Am. J. Sport Med. 12:179-184, 1984.
 3. Galloway, M. T., Jokl, P., Dayton, D. W. Achilles tendon overuse injuries. In
Clinics in Sports Medicine, pp. 771-782, edited by P. Renstrom and Wayne
Leadbetter, W. B. Saunders Co., Philadelphia, 1992.
4. Kvist, M., Jarvinen, M. Clinical histochemical and biomechanical features in
repair of muscle and tendon injuries. Int. J. Sport Med. 3 (Suppl) 1:12-
14, 1982.
5. Kvist, M., Jozsa, L., Jarvinen, M. J., Kvist, H. Chronic Achilles paratendonitis
in athletes: a histological and histochemical study. Pathology 19:1-11, 1987.
6. Leach, R. E., James, S., Wasilewski, S. Achilles tendinitis. Am. J. Sport Med.
9:93-98, 1981.
7. Lemm, M., Blake, R. L., Colson, J. P., Ferguson, H. F. Achilles Peritendinitis.
A Literature review with Case Report. J. A. P. M. A. 82:482-490, 1992.
8. Nelen, G., Martens, M., Burssens, A. Surgical treatment of chronic Achilles
tendinitis. Am. J. Sport Med. 17:754-759, 1989.
9. Hume, E. L. Traumatic disorders of the ankle or overuse syndromes. In
Traumatic Disorders of the Ankle, pp 56-58, edited by W. C. Hamilton,
Springer Verlag, New York, 1984.
10. Warren, M. P., Brooks-Gunn, J., Hamilton, L. H., Warren, L. F., Hamilton,
W. G. Scoliosis and fractures in young ballet dancers. N. Engl. J. Med.
314:1348-1353, 1986.
11. Williams, J. G. Achilles tendon lesions in sports. Sport Med. 3:114-135, 1986.
12. Frey, C. C., Shereff, M. J. Chemical, Environmental and foreign body injuries
to the foot and ankle, ch. 92. In Disorders of the Foot and Ankle, 2nd ed., vol. 3,
pp. 2574-2576, edited by M. H. Jahss, W. B. Saunders Co., Philadelphia, 1991.

90