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Achilles Tendinopathy

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Other Names

  • Achilles tendinosis
  • Achilles tendinopathy

Background

History

Epidemiology

  • General
    • Degeneration of the tendon has been found in 34% of individuals at autopsy[1]
    • In one study, sonographic evidence of degeneration was seen in 32% of asymptomatic individuals[2]
    • Insertional Achilles tendonitis accounts for 20-25% of Achilles tendinopathies[3]
  • Incidence
    • Approximately 2–3 per 1000 patients in general medicine practice[4]
  • Prevalence
    • Affects 9% of recreational runners and may end up to 5% of professional athletic careers [5]
    • During one study, achilles tendinopathy was found in 5.6% of 1394 nonathletes [6]

Pathophysiology

  • See: Tendinopathies (Main)
  • General
    • Overuse injury of the Achilles tendon that causes pain in the posterior calf and heel
    • Most commonly at the midportion of the tendon
  • Pathophysiology
    • Failed healing response leading to a degeneration of the tendon (tendinosis), rather than inflammatory response[7]
    • Increased number of tenocytes and concentration of glycosaminoglycans with disorganized and fragmented collagen, and neovascularization [8]
    • Increased tenocyte irregularities leads to apoptosis [7]
  • 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 [7]
  • Insertional
    • Anterior aspect more common than posterior
    • Retrocalcaneal impingement may exacerbate symptoms

Associated Conditions

Pathoanatomy

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 [9]
  • Behavioral
    • Moderate alcohol use (7–13 drinks/week for men and 4–6 drinks/week for women)[10]
  • Orthopedic
    • Prior lower limb tendinopathy or fracture [11]
  • Biomechanical leg abnormalities including [12]
    • 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 [14]
  • Mechanical overload and training errors [7] [12]
    • 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

Clinical Features

  • History
    • Pain, swelling, burning, and decreased mobility of the posterior heel
    • Pain worsened by exercise, walking upstairs
  • 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
  • Specialty Test
    • Thompson Test: squeeze calf to reproduce passive plantarflexion (excludes tear)

Evaluation

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 [12]

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 [15]

MRI

  • General
    • Not generally required
    • Provide the most information regarding Achilles tendinopathy
    • Used for classifying the degree of degeneration [12]
    • May show intrasubstance abnormalities, increased signal and enlarged retrocalcaneal bursa

Classification

  • Insertional [7]
    • Injury occurs at the calcaneus-Achilles tendon junction
  • Non-Insertional [7]
    • Injury occurs 2 to 6 cm proximal to the insertion of the Achilles tendon into the calcaneus

Management

Prognosis

  • Patients can expect their symptoms to improve between 3 and 12 months after commencing treatment, but not beyond 12 months[16]
  • 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[17]

Nonoperative

  • Indications
    • Vast majority of cases
    • Non-insertional tendinopathy
  • Activity modification
  • Physical Therapy
    • Emphasis on eccentric exercises[18]
    • 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[19]
    • In one study, a stretching program resulted in 88% of patients being satisfied with the results[20]
  • NSAIDS
    • In one RCT comparing Piroxicam to placebo, there was no benefit[21]
    • Some authors have suggested that due to inhibition of tendon cell migration and proliferation, NSAIDS may contribute to development of Achilles tendinopathy[22]
  • 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[23]
    • 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[24]
    • RCT reported improved scores after ESWT, particularly in women[25]
    • ESWT in refractory nonoperative cases showed benefit in a case control study[26]
    • Saxena found 78% of patients improved at 1 year after 3 weeks of ESWT in a single arm study[27]
  • Topical Glyceryl Trinitrate
    • One RCT showed benefit for non-insertional tendinopathy compared to control group up to 3 years after treatment[28]
  • Platelet Rich Plasma
    • RCT by Kearney et al showed no benefit[29]
    • RCT compared PRP to placebo showed no benefit when combined with eccentric exercises[30]
    • Meta-analysis showed no benefit to treatment of achilles tendinopathy[31]
  • High Volume Injection
    • A few small studies with limited follow up showed benefit when injecting 10 mL Bupivicaine combined with 40 mL normal saline into the paratenon[32][33]
  • Dextrose Prolotherapy
    • Maxwell et al: small study demonstrated reduction in achilles pain at rest, with activity[34]
    • Yelland et al: demonstrated improvement in outcome scores when combined with eccentric exercises[35]

Additional Considerations

Recommend Avoiding

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) [38]:
    • 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

Rehabilitation

  • Exercise Rehabilitation - 4 Phases [39] [40]
    • 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 [40]
      • Goal is return patient to activity and performance

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 [40]
  • Various factors must be considered when returning to sport:[40]
    • 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

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 [41]

See Also

References

  1. ↑ 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.
  2. ↑ 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.
  3. ↑ Kvist M. Achilles tendon injuries in athletes. Ann Chir Gynaecol 1991;80:188–201.
  4. ↑ de Jonge, Suzan, et al. "Incidence of midportion Achilles tendinopathy in the general population." British journal of sports medicine 45.13 (2011): 1026-1028.
  5. ↑ Lysholm J, Wiklander J. Injuries in runners. Am J Sports Med. 1987 Mar-Apr;15(2):168-71. doi: 10.1177/036354658701500213. PMID: 3578639
  6. ↑ 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.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 7.5 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
  8. ↑ 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.
  9. ↑ Kvist M. Achilles tendon injuries in athletes. Ann Chir Gynaecol. 1991;80(2):188-201. PMID: 1897886.
  10. ↑ 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
  11. ↑ 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
  12. ↑ 12.0 12.1 12.2 12.3 12.4 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.
  13. ↑ 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
  14. ↑ 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
  15. ↑ 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.
  16. ↑ 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).
  17. ↑ 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.
  18. ↑ Magnussen RA, Dunn WR, Thomson AB. Nonoperative treatment of midportion Achilles tendinopathy: a systematic review. Clin J Sport Med 2009;19:54–64.
  19. ↑ 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.
  20. ↑ Rosenbaum D, Hennig EM. The influence of stretching and warm-up exercises on Achilles tendon reflex activity. J Sport Sci 1995;13:481–490.
  21. ↑ Aström M, Westlin N. No effect of piroxicam on Achilles tendinopathy: a randomized study of 70 patients. Acta Orthop Scand 1992;63:631–634.
  22. ↑ 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.
  23. ↑ 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.
  24. ↑ 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.
  25. ↑ 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.
  26. ↑ Furia JP. High-energy extracorporeal shock wave therapy as a treatment for chronic noninsertional Achilles tendinopathy. Am J Sports Med 2008;36:502–508.
  27. ↑ 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.
  28. ↑ 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.
  29. ↑ 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.
  30. ↑ 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.
  31. ↑ 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.
  32. ↑ Chan O, O’Dowd D, Padhiar N, et al. High volume image guided injections in chronic Achilles tendinopathy. Disabil Rehabil 2008;30:1697–1708.
  33. ↑ 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.
  34. ↑ 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.
  35. ↑ 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.
  36. ↑ Hart L. Corticosteroid and other injections in the management of tendinopathies: a review. Clin J Sport Med 2011;21:540–541.
  37. ↑ Shrier I, Matheson GO, Kohl HW 3rd. Achilles tendonitis: are corticosteroid injections useful or harmful? Clin J Sport Med 1996;6:245–250.
  38. ↑ 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
  39. ↑ 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.
  40. ↑ 40.0 40.1 40.2 40.3 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.
  41. ↑ 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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