collagen matrix in patients with tendinosis (18). Over
time type 1 collagen is replaced by type 3, the tendon
thickens, and mucoid degeneration and abnormal
neovascularization occurs (19,21). Thickening of
the tendon results in increased friction between the
tendon and its paratenon. Achilles ruptures typically
occur after the degenerative changes have been made
and an excessive force is applied to the tendon. They
are more common in males participating in vigorous
activities such as sports, running, sprinting etc.
The paratenon is a single-celled layer that is critical
for vascularization to the tendon. Paratendinopathy
can occur on its own or in addition to tendinosis and
is typically seen in younger distance runners (20).
Paratendinopathies can be acute or chronic in nature.
In acute paratendinopathy edema, hyperaemia,
easily palpable crepitus, inflammatory cells, and
fibrinous exudate is seen between the paratenon and
the tendon. In chronic paratendinopathy there is
less noticeable crepitus and swelling. The paratenon
becomes thicker due to the proliferation of fibroblasts
and adhesions are deposited by the fibroblasts
circumferentially (8).
Haglund’s deformity, first described by Patrick
Haglund in 1927, is a common cause of pain at the
insertion of the Achilles tendon. The deformity is
easily identified on a lateral foot or ankle radiograph.
The Fowler and Phillip and parallel pitch lines are
two common radiographic angles that are used to
measure the severity of the deformity (21). An osseous
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