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Achilles Tendonitis

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(Redirected from Achilles Tendinopathy)

Other Names

  • Achilles tendinosis
  • Achilles tendinopathy
  • Achilles Tendonitis
  • Achilles tendon pain
  • Achilles tendon overuse injury
  • Achilles tendon inflammation
  • Achilles paratenonitis
  • Midportion Achilles tendinopathy
  • Insertional Achilles tendinopathy

Background

History

  • First mentioned by Fox et al in 1975[1]

Epidemiology

  • General
    • Degeneration of the tendon has been found in 34% of individuals at autopsy[2]
    • In one study, sonographic evidence of degeneration was seen in 32% of asymptomatic individuals[3]
    • Insertional Achilles tendonitis accounts for 20-25% of Achilles tendinopathies[4]
  • Incidence
    • Approximately 2–3 per 1000 patients in general medicine practice[5]
  • Prevalence
    • Affects 9% of recreational runners and may end up to 5% of professional athletic careers [6]
    • During one study, achilles tendinopathy was found in 5.6% of 1394 nonathletes [7]

Introduction

The most common types and anatomic location of Achilles tendon Injuries. There is no official terminology of Achilles tendinopathies, whereas clinicians use widely accepted ones, based on the anatomic location. This terminology includes mid-portion and insertional Achilles tendinopathy, paratendinopathy, and retrocalcaneal and superficial calcaneal bursitis. Except for the tendinopathies, one of the most common Achilles tendon injuries is a rupture[8]
Thickening of the left Achilles tendon suggesting tendinosis. Note the surgical scar
Illustration of the Achilles tendon[9]
Criteria for clinical diagnosis of isolated heel pain, Achilles tendon pain and concurrent injury.[10]

General

  • Overuse injury due to excessive mechanical loading of the Achilles tendon which presents with calf and heel pain
  • Presents with achy, occasionally sharp posterior heel pain that worsens with increased activity or pressure to the affected area
  • Most commonly at the midportion of the tendon, but can also occur at the site of insertion on the calcaneus
  • Treatment is nonsurgical and includes activity modification, physical therapy, analgesics and orthotics

Pathophysiology

  • Failed healing response leading to a degeneration of the tendon (tendinosis), rather than inflammatory response[11]
  • Increased number of tenocytes and concentration of glycosaminoglycans with disorganized and fragmented collagen, and neovascularization [12]
  • Increased tenocyte irregularities leads to apoptosis [11]

Acute Achilles Tendinitis

  • Inflammatory cellular reaction in the tendon sheath, with circulatory impairment and edema
  • Peritendineum may become filled with fibrinous exudate, perceived as crepitus
  • As adhesions start to form, the chronic form of the disease begins to take hold

Chronic Achilles Tendinosis

  • Increased type III collagen, fibronectin, tenascin C, aggrecan, and biglycan [11]
  • Insertional
    • Anterior aspect more common than posterior
    • Retrocalcaneal impingement may exacerbate symptoms

Associated Conditions[13]

Achilles Paratenonitis

  • Also called achilles paratendinopathy
  • Acute or chronic inflammation and/or degeneration of the thin membrane (paratenon) surrounding the Achilles tendon.[14]
  • Distinct from intratendinous pathology and represents one of several entities within the spectrum of Achilles tendon disorders[15]
  • The paratenon is a thick fibrous layer that forms a sheath around the tendon which facilitates tendon gliding
  • Treatment is essentially the same as Achilles tendinopathies

Anatomy of the Achilles Tendon

Risk Factors

  • Older age
    • Among a study of 470 patients with Achilles tendon injuries tendinopathy, 25% were young athletes and 10% were 14 years old or younger [16]
  • Behavioral
    • Moderate alcohol use (7–13 drinks/week for men and 4–6 drinks/week for women)[17]
  • Orthopedic
    • Prior lower limb tendinopathy or fracture [18]
  • Biomechanical leg abnormalities including [19]
    • Malalignment of the leg (genu valgum, tibial torsion) or ankle/foot (pes planus)
    • Leg length discrepancy hyperpronation
    • Immobility or inflexibility specifically of the subtalar joint
  • Medications
  • Environmental
    • Cold weather training [21]
  • Mechanical overload and training errors [11] [19]
    • Increased interval training
    • Abrupt changes in scheduling
    • Excessive hill training
    • Training on hard or sloping surfaces
    • Increased mileage or repetitive loading
    • Poor shock absorption (ie, poor-fitting shoes)
  • Systemic

Differential Diagnosis

Differential Diagnosis Ankle Pain

Clinical Features

Posteromedial swelling of the Achilles tendon due to tendinopathy.[22]
Illustration of the Thompson test. Normal exam in the top image and an abnormal exam in the bottom[23]
Demonstration of the Achilles Palpation test

History

  • Pain, swelling, burning, and decreased mobility of the posterior heel
  • Pain worsened by exercise, walking upstairs

Evidence Based Subjective Findings

  • Hutchison et al[24]
    • Self reported pain: 78% sensitive, 77% specific
    • Morning stiffness: 89% sensitive, 58% specific

Exam: Physical Exam Foot And Ankle

  • Tenderness at the posterior calcaneal tuberosity
  • Pain with resisted ankle plantar flexion
  • Decreased ankle dorsiflexion due to tight Achilles tendon
  • Tenderness near the insertion site suggests insertional Achilles tendinopathy

Evidence Based Palpation Tests

  • Hutchison et al[24]
    • Tendon thickening: 59% sensitive, 90% specific
    • Crepitus: 03% sensitive, 100% specific
    • Palpation: 85% sensitive, 73% specific

Specialty Test

Evaluation

Tendinopathy of the whole Achilles tendon (arrow) in a 62-year-old patient with pain for more than 5 years. The MRI revealed thickening of the whole Achilles tendon (arrow). A-PD-weighted, b and c-PD-weighted with fat suppression.[25]
Ultarsound of a patient with achilles tendinopathy. Note the large retrocalcaneal enthesophyte[26]

Radiographs

  • Standard Radiographs Ankle
    • Weightbearing AP view and Lateral views
    • Lateral view are useful for measuring Achilles shadow
    • Often normal
  • Findings
    • Calcifications may be noted in lateral view [19]

Ultrasound

  • Imaging modality of choice
  • Findings
    • Enlargement of the mid and distal Achilles tendon
    • Disruption of the tendinous fibrils
    • Increase in vascularity in patients with chronic Achilles tendinopathy compared to normal controls [27]

MRI

  • General
    • Not generally required
    • Provide the most information regarding Achilles tendinopathy
    • Used for classifying the degree of degeneration [19]
    • May show intrasubstance abnormalities, increased signal and enlarged retrocalcaneal bursa

Classification

  • Insertional [11]
    • Injury occurs at the calcaneus-Achilles tendon junction
  • Non-Insertional [11]
    • Injury occurs 2 to 6 cm proximal to the insertion of the Achilles tendon into the calcaneus

Management

Tall Walking Boot

Ultrasound view of short axis, in plane paratenon injection. Needle (arrow), paratenon (open arrow), short-axis view of Achilles tendon (asterisk), area of tendinopathy (asterisk).[28]

Heel Cup

Nonoperative

  • Indications
    • Vast majority of cases
    • Non-insertional tendinopathy
  • Activity modification
  • Physical Therapy
    • Emphasis on eccentric exercises[29]
    • Alfredson et al: RCT reported that 82% of patients using eccentric exercises returned to normal activities at 12 weeks, compared with 36% who used concentric exercises, sustained improvement at 12 months[30]
    • In one study, a stretching program resulted in 88% of patients being satisfied with the results[31]
  • NSAIDS
    • In one RCT comparing Piroxicam to placebo, there was no benefit[32]
    • Some authors have suggested that due to inhibition of tendon cell migration and proliferation, NSAIDS may contribute to development of Achilles tendinopathy[33]
  • Orthotics
    • Heel Lift: A graduated shoe raise or heel lift can alleviate pressure on the insertion by plantarflexing the heel
      • May be slightly superior to eccentric exercises for symptom relief at 12 weeks[34]
    • Insoles: Correction of eversion or pronation can improve symptoms
  • Extracorporeal Shockwave Therapy
    • RCT demonstrated significant improvement when this was combined with eccentric exercises compared with eccentric exercises alone[35]
    • RCT reported improved scores after ESWT, particularly in women[36]
    • ESWT in refractory nonoperative cases showed benefit in a case control study[37]
    • Saxena found 78% of patients improved at 1 year after 3 weeks of ESWT in a single arm study[38]
  • Topical Glyceryl Trinitrate
    • One RCT showed benefit for non-insertional tendinopathy compared to control group up to 3 years after treatment[39]

Additional Considerations

Procedures

Operative: Non-Insertional

  • Indications & Goals
    • Failure of conservative measures of at least 4-6 months
    • Goal is to resect degenerative tissue and release adhesions
  • Technique (Non-Insertional)
    • Percutaneous longitudinal tenotomies
    • Minimally invasive tendon stripping
    • Open tenosynovectomies
    • Open debridement and tubularization
    • Tendon augmentation with flexor hallucis longus (FHL)
  • Technique (Insertional) [49]:
    • Removal of calcified tendon
    • Excision of the retrocalcaneal bursa
    • Resection of the posterior calcaneal prominence
    • Insertion reattachment
    • Tendon transfer/graft

Rehab and Return to Play

Physical therapy exercises for Achilles Tendonitis[50]
Classic achilles tendon stretch[51]

Rehabilitation

  • Exercise Rehabilitation - 4 Phases [52] [53]
    • 1) Symptom management and load reduction
      • Stops overloading and continued injury
      • Complete rest and unloading can be detrimental
      • Specific exercises include graduated heel rises
    • 2) Recovery
      • Strengthen calf muscle and improve tendon load teolerance
      • Increasing repetitions, improving range of motion and movement speed
      • Specific exercises include heel rises, quick-bounding heel rises, deep water running
    • 3) Rebuilding
      • Heavier strength training of the calf muscles focused on running and jumping
      • Promotes tendon recovery
      • Exercises include: weight heel rises, plyometrics with bilateral and unilateral jumping, quickbounding
    • 4) Return to sport [53]
      • Goal is return patient to activity and performance

Rehab Program PDFs

Return to Play

  • Goal is return patient to activity and performance
  • Athletes can be expected to return to sport anywhere from 6 weeks to 1 year after the initial injury depending on severity [53]
  • Various factors must be considered when returning to sport:[53]
    • Level of pain
    • Tendon recovery, healing, and load
    • Strength of athlete
    • Range of motion of joint
    • Function
    • Demands of the specific sport
    • Exercises include: sport specific movements, running, heel rises, plyometrics

Prognosis and Complications

Prognosis

  • Patients can expect their symptoms to improve between 3 and 12 months after commencing treatment, but not beyond 12 months[54]
  • Chronic symptoms persist in approximately a quarter of patients 10 years after treatment
  • In an eight-year follow-up study, only 29% failed to respond adequately to non-operative management[55]

Complications

  • Achilles Rupture
  • Surgical
    • Hematoma
    • Seroma
    • Thrombosis
    • Study of 432 patients showed wound necrosis in 3%, superficial infection in 2.5%, and sural nerve injury in 1% following surgery [56]

See Also

References

  1. ↑ Fox, James M., et al. "Degeneration and rupture of the Achilles tendon." Clinical Orthopaedics and Related Research® 107 (1975): 221-224.
  2. ↑ Kannus P, Jozsa L. Histopathological changes preceding spontaneous rupture of a tendon: a controlled study of 891 patients. J Bone Joint Surg [Am] 1991;73-A:1507– 1525.
  3. ↑ Khan KM, Forster BB, Robinson J, et al. Are ultrasound and magnetic resonance imaging of value in assessment of Achilles tendon disorders?: a two year prospective study. Br J Sports Med 2003;37:149–153.
  4. ↑ Kvist M. Achilles tendon injuries in athletes. Ann Chir Gynaecol 1991;80:188–201.
  5. ↑ de Jonge, Suzan, et al. "Incidence of midportion Achilles tendinopathy in the general population." British journal of sports medicine 45.13 (2011): 1026-1028.
  6. ↑ Lysholm J, Wiklander J. Injuries in runners. Am J Sports Med. 1987 Mar-Apr;15(2):168-71. doi: 10.1177/036354658701500213. PMID: 3578639
  7. ↑ Waldecker U, Hofmann G, Drewitz S. Epidemiologic investigation of 1394 feet: coincidence of hindfoot malalignment and Achilles tendon disorders. Foot Ankle Surg. 2012 Jun;18(2):119-23. doi: 10.1016/j.fas.2011.04.007. Epub 2011 Jun 8. PMID: 22443999.
  8. ↑ Romanowska, Magdalena J., et al. "Fluoroquinolone-Induced Achilles Tendon Damage: Structural and Biochemical Insights into Collagen Type I Alterations." International Journal of Molecular Sciences 26.20 (2025): 10028.
  9. ↑ Barfod, Kristoffer Weisskirchner. "Acute Achilles tendon rupture: assessment of non-operative treatment." Dan Med J 61 (2014): B4837.
  10. ↑ Hanlon, Shawn L., Bradley C. Bley, and Karin Grävare Silbernagel. "Determining the feasibility of exercise therapy and activity modification for treating adolescents with heel pain: a study protocol." BMJ Open Sport & Exercise Medicine 8.3 (2022): e001301.
  11. ↑ 11.0 11.1 11.2 11.3 11.4 11.5 Li HY, Hua YH. Achilles Tendinopathy: Current Concepts about the Basic Science and Clinical Treatments. Biomed Res Int. 2016;2016:6492597. doi:10.1155/2016/6492597
  12. ↑ Sharma P, Maffulli N. Understanding and managing achilles tendinopathy. Br J Hosp Med (Lond). 2006 Feb;67(2):64-7. doi: 10.12968/hmed.2006.67.2.20463. PMID: 16498904.
  13. ↑ Malliaras, Peter, et al. "Diagnostic domains, differential diagnosis and conditions requiring further medical attention that are considered important in the assessment for Achilles tendinopathy: a Delphi consensus study." British Journal of Sports Medicine 59.13 (2025): 891-901.
  14. ↑ Van Dijk, C. N., et al. "Terminology for Achilles tendon related disorders." Knee Surgery, Sports Traumatology, Arthroscopy 19.5 (2011): 835-841.
  15. ↑ Uquillas, Carlos A., et al. "Everything Achilles: knowledge update and current concepts in management: AAOS exhibit selection." JBJS 97.14 (2015): 1187-1195.
  16. ↑ Kvist M. Achilles tendon injuries in athletes. Ann Chir Gynaecol. 1991;80(2):188-201. PMID: 1897886.
  17. ↑ Owens BD, Wolf JM, Seelig AD, et al. . Risk factors for lower extremity tendinopathies in military personnel. Orthop J Sports Med 2013;1:232596711349270 10.1177/2325967113492707
  18. ↑ van der Vlist AC, Breda SJ, Oei EHG, Verhaar JAN, de Vos RJ. Clinical risk factors for Achilles tendinopathy: a systematic review. Br J Sports Med. 2019;53(21):1352-1361. doi:10.1136/bjsports-2018-099991
  19. ↑ 19.0 19.1 19.2 19.3 19.4 Irwin TA. Current concepts review: insertional achilles tendinopathy. Foot Ankle Int. 2010 Oct;31(10):933-9. doi: 10.3113/FAI.2010.0933. PMID: 20964977.
  20. ↑ van der Linden PD, van de Lei J, Nab HW, et al. . Achilles tendinitis associated with fluoroquinolones. Br J Clin Pharmacol 1999;48:433–7. 10.1046/j.1365-2125.1999.00016.x
  21. ↑ Milgrom C, Finestone A, Zin D, et al. . Cold weather training: a risk factor for Achilles paratendinitis among recruits. Foot Ankle Int 2003;24:398–401
  22. ↑ Pearce, Christopher J., and Audrey Tan. "Non-insertional Achilles tendinopathy." EFORT Open Reviews 1.11 (2016): 383-390.
  23. ↑ Thompson TC, Doherty JH. Spontaneous rupture of tendon of Achilles: a new clinical diagnostic test. J Trauma. 1962; 2: 126-129.
  24. ↑ 24.0 24.1 Hutchison, Anne-Marie, et al. "What is the best clinical test for Achilles tendinopathy?." Foot and ankle surgery 19.2 (2013): 112-117.
  25. ↑ Szaro, Pawel, Katarina Nilsson-Helander, and Michael Carmont. "MRI of the Achilles tendon–a comprehensive pictorial review. Part two." European journal of radiology open 8 (2021): 100343.
  26. ↑ Image courtesy of ankleandfootcenter.com.au
  27. ↑ Leung JL, Griffith JF. Sonography of chronic Achilles tendinopathy: a case-control study. J Clin Ultrasound. 2008 Jan;36(1):27-32. doi: 10.1002/jcu.20388. PMID: 17721925.
  28. ↑ Malanga, Gerard A., and Kenneth R. Mautner. " Atlas of ultrasound-guided musculoskeletal injections." (No Title) (2014)
  29. ↑ Magnussen RA, Dunn WR, Thomson AB. Nonoperative treatment of midportion Achilles tendinopathy: a systematic review. Clin J Sport Med 2009;19:54–64.
  30. ↑ Alfredson H, Pietilä T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med 1998;26:360–366.
  31. ↑ Rosenbaum D, Hennig EM. The influence of stretching and warm-up exercises on Achilles tendon reflex activity. J Sport Sci 1995;13:481–490.
  32. ↑ Aström M, Westlin N. No effect of piroxicam on Achilles tendinopathy: a randomized study of 70 patients. Acta Orthop Scand 1992;63:631–634.
  33. ↑ Tsai WC, Hsu CC, Chou SW, et al. Effects of celecoxib on migration, proliferation and collagen expression of tendon cells. Connect Tissue Res 2007;48:46–51.
  34. ↑ Rabusin, Chantel L., et al. "Efficacy of heel lifts versus calf muscle eccentric exercise for mid-portion Achilles tendinopathy (the HEALTHY trial): study protocol for a randomised trial." Journal of foot and ankle research 12.1 (2019): 1-12.
  35. ↑ Rompe JD, Furia J, Maffulli N. Eccentric loading versus eccentric loading plus shock-wave treatment for midportion achilles tendinopathy: a randomized controlled trial. Am J Sports Med 2009;37:463–470.
  36. ↑ Rasmussen S, Christensen M, Mathiesen I, Simonson O. Shockwave therapy for chronic Achilles tendinopathy: a double-blind, randomized clinical trial of efficacy. Acta Orthop 2008;79:249–256.
  37. ↑ Furia JP. High-energy extracorporeal shock wave therapy as a treatment for chronic noninsertional Achilles tendinopathy. Am J Sports Med 2008;36:502–508.
  38. ↑ Saxena A, Ramdath S, O’Halloran P, Gerdesmeyer L, Gollwitzer H. Extra-corporeal pulsed-activated therapy (“EPAT” sound wave) for Achilles tendinopathy: a prospective study. J Foot Ankle Surg 2011;50:315–319.
  39. ↑ Kane TP, Ismail M, Calder JD. Topical glyceryl trinitrate and noninsertional Achilles tendinopathy: a clinical and cellular investigation. Am J Sports Med 2008;36:1160–1163.
  40. ↑ Hart L. Corticosteroid and other injections in the management of tendinopathies: a review. Clin J Sport Med 2011;21:540–541.
  41. ↑ Shrier I, Matheson GO, Kohl HW 3rd. Achilles tendonitis: are corticosteroid injections useful or harmful? Clin J Sport Med 1996;6:245–250.
  42. ↑ Chan O, O’Dowd D, Padhiar N, et al. High volume image guided injections in chronic Achilles tendinopathy. Disabil Rehabil 2008;30:1697–1708.
  43. ↑ Humphrey J, Chan O, Crisp T, et al. The short-term effects of high volume image guided injections in resistant non-insertional Achilles tendinopathy. J Sci Med Sport 2010;13:295–298.
  44. ↑ Maxwell NJ, Ryan MB, Taunton JE, Gillies JH, Wong AD. Sonographically guided intratendinous injection of hyperosmolar dextrose to treat chronic tendinosis of the Achilles tendon: a pilot study. Am J Roentgenol 2007;189:W215–W220.
  45. ↑ Yelland MJ, Sweeting KR, Lyftogt JA, et al. Prolotherapy injections and eccentric loading exercises for painful achilles tendinosis: a randomised trial. Br J Sports Med 2011;45:421–428.
  46. ↑ Kearney RS, Ji C, Warwick J, et al. Effect of Platelet-Rich Plasma Injection vs Sham Injection on Tendon Dysfunction in Patients With Chronic Midportion Achilles Tendinopathy: A Randomized Clinical Trial. JAMA. 2021;326(2):137–144.
  47. ↑ de Vos RJ, Weir A, van Schie HT, et al. Platelet-rich plasma injection for chronic Achilles tendinopathy: a randomized controlled trial. JAMA 2010;303:144–149.
  48. ↑ Sadoghi P, Rosso C, Valderrabano V, Leithner A, Vavken P. The role of platelets in the treatment of achilles tendon injuries. J Orthop Res 2013;31:111–118.
  49. ↑ DeOrio MJ, Easley ME. Surgical strategies: insertional achilles tendinopathy. Foot Ankle Int. 2008 May;29(5):542-50. doi: 10.3113/FAI-2008-0542. PMID: 18510913
  50. ↑ Image courtesy of verywellhealth.com
  51. ↑ Ganderton, Charlotte, et al. "Achilles tendinopathy: Understanding the key concepts to improve clinical management." Australasian Musculoskeletal Medicine 19.2 (2015): 12-18.
  52. ↑ Silbernagel KG, Hanlon S, Sprague A. Current Clinical Concepts: Conservative Management of Achilles Tendinopathy. J Athl Train. 2020 May;55(5):438-447. doi: 10.4085/1062-6050-356-19. Epub 2020 Apr 8. PMID: 32267723; PMCID: PMC7249277.
  53. ↑ 53.0 53.1 53.2 53.3 Silbernagel KG, Crossley KM. A proposed return-to-sport program for patients with midportion Achilles tendinopathy: rationale and implementation. J Orthop Sports Phys Ther. 2015;45(11):876–886.
  54. ↑ Lagas, I. F., J. L. Tol, and A. Weir. "One in four patients with midportion achilles tendinopathy has persisting symptoms after 10 years: a prospective cohort study." Am J Sports Med (2019).
  55. ↑ Paavola M, Kannus P, Paakkala T, Pasanen M, Järvinen M. Long-term prognosis of patients with achilles tendinopathy: an observational 8-year follow-up study. Am J Sports Med 2000;28:634–642.
  56. ↑ Paavola M, Orava S, Leppilahti J, Kannus P, Järvinen M. Chronic Achilles tendon overuse injury: complications after surgical treatment. An analysis of 432 consecutive patients. Am J Sports Med. 2000 Jan-Feb;28(1):77-82. doi: 10.1177/03635465000280012501. PMID: 10653548.
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