Achilles Tendonitis

See Also

Epidemiology

Runners
1. Annual Incidence: 7-9% of current runners
2. Lifetime Prevalence: 52% of prior runners

Pathophysiology

Achilles tendon forms from the union of gastrocnemius and soleus tendons, and inserts into Calcaneus
Achilles-calf complex responsible for Running push-off
1. Allows for airborne phase of Running gait
Mechanism of Running Injury
1. Incorrect Running technique
2. Poorly fitting shoes
3. Over-pronation
4. Running on uneven surface
Rheumatologic Conditions predisposing to Tendonitis
1. Spondyloarthropathy
2. Rheumatoid Arthritis
Exacerbating factors
1. Inappropriate shoes for activity or high heel shoe wear in general
2. Fluoroquinolone use
3. Aging
4. Poor gastrocnemius and soleus Muscle flexibility
5. Malalignment of lower extremity (e.g. Leg Length Discrepancy, Sacroiliac Joint Dysfunction)

Causes
Achilles tendon inflammation

Chronic overuse of calf Muscle
Common overuse injury
1. Occurs in 10% of runners
2. New athletes to sport
3. Dancing
4. Gymnasts
5. Tennis Players

Types

Midsubstance Achilles Tendinopathy (55-65%)
1. Mid-portion of tendon (2-6 cm from insertion)
2. Tendinopathy superior to the insertional region
3. Most common, and more therapy responsive, especially with Eccentric Exercises (see toe raises below)
Insertional Achilles Tendinopathy (20-25%)
1. Tendinopathy in the 2-3 cm region at the insertion of the achilles tendon into the calcaneous
2. More refractory to treatment
  1. Focus on concentric Exercises
  2. Often requires CAM Boot immobilization

Symptoms

Ache or sharp Heel Pain and stiffness at the mid-achilles tendon to insertion at calcaneous
1. Worse with strenuous Exercise
2. Better with walking
Uneven gait may result

Signs

Inflammation at Achilles tendon (3-5 cm above calcaneal insertion) or at calcaneal insertion itself
1. Pain, local tenderness, and swelling (tendon thickening)
2. Gradual onset
Negative Thompson Test (differentiates from Achilles Tendon Rupture)
Dry crepitus may be present on palpation
Provocative maneuvers that aggravate pain
1. Passive Stretching of tendon (ankle dorsiflexion)
2. Lightly squeezing calf
Associated: Peritendinitis
1. Tendon sheath inflammation (2-6 cm above insertion)
2. Pain and burning worse with Exercise
3. Pain on rubbing tendon suggests Peritendinitis

Imaging

Ankle XRay
1. May show spurring at the achilles tendon insertion
Ankle Ultrasound
1. May show achilles tendon thickening

Differential Diagnosis

Management

Relative rest (may require off sport completely)
1. Limit runnng and other activities to flat, level ground
2. Avoid interval training (speed work)
3. Cross-train with non-impact actvitis (e.g. swimming, Bicycling)
Gentle Stretching and strengthening (avoid worsening injury)
1. Indicated in midsubstance Achilles Tendinopathy
2. May also be used for insertional Achilles Tendinopathy after initial immobilization for 4-6 weeks
3. Calf stretches and stregthening of gastrocnemius and soleus Muscles with leg straight and bent
4. Includes slow warm-up before Exercise
5. Eccentric Exercises are most effective (Muscle lengthening in response to external resistance)
6. Heel raises or lowering
  1. Start
    1. Both feet on first, lowest step of stair case or other platform
    2. Ankles and foot start maximally plantar flexed, on tip toes
  2. Heel raises with knees straight
    1. Allow the affected foot and ankle's heel to drop below the level of the step
      1. Maximally dorsiflexing the foot and ankle
    2. Return to tip-toe position (maximally plantar flexed)
  3. Heel raises with knees bent
    1. Repeat toe raises as above, but now with knees flexed
Local Ice Therapy
1. Ice massage after activity for 20 minutes
NSAIDs for 10 days at initial symptom onset
Consider Orthotics or firm heel lift (1/8 to 3/8 inches)
Obtain correct Running Shoe (e.g. over-pronators)
Weight loss if over Ideal Weight
Consider physical therapy
1. Local Ultrasound (consider with Iontophoresis)
2. Flexibility and Strength Training
3. Assist with correcting biomechanics of sport
Short Leg Walking Cast or CAM Boot
1. Consider in persistent or refractory cases
2. Consider in insertional Achilles Tendinopathy for 4-6 weeks followed by Eccentric Exercises (see toe raises as above)
Avoid local Corticosteroid Injections
1. Risk of Achilles Tendon Rupture
Severe refractory cases
1. Consider Nitroglycerin Patches
2. Consider Platelet-rich plasma injections
3. Consider extracorporeal shock wave therapy
4. Surgical Debridement

Course

May persist for months
Athletes often require 4 weeks out of all sports
1. Welsh (1980) Can Med Assoc 122:193-5 [PubMed]

References