(Redirected from Achilles Tendonitis)
- 1 Other Names
- 2 Background
- 3 Pathophysiology
- 4 Risk Factors
- 5 Differential Diagnosis
- 6 Clinical Features
- 7 Evaluation
- 8 Classification
- 9 Management
- 10 Rehab and Return to Play
- 11 Complications
- 12 See Also
- 13 References
- Achilles tendinosis
- Achilles tendinopathy
- This page refers to tendinopathies of the Achilles Tendon
- Achilles Tendon Rupture is discussed separately
- Approximately 2–3 per 1000 patients in general medicine practice
- See: Tendinopathies (Main)
- Overuse injury of the Achilles tendon that causes pain in the posterior calf and heel
- Most commonly at the midportion of the tendon
- Failed healing response leading to a degeneration of the tendon (tendinosis), rather than inflammatory response
- Increased number of tenocytes and concentration of glycosaminoglycans with disorganized and fragmented collagen, and neovascularization 
- Increased tenocyte irregularities leads to apoptosis 
- 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 
- Anterior aspect more common than posterior
- Retrocalcaneal impingement may exacerbate symptoms
- Achilles Tendon
- Retrocalcaneal Bursa
- 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 
- Moderate alcohol use (7–13 drinks/week for men and 4–6 drinks/week for women)
- Prior lower limb tendinopathy or fracture 
- Biomechanical leg abnormalities including 
- 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
- Cold weather training 
- Mechanical overload and training errors  
- 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)
- Fractures & Dislocations
- Muscle and Tendon Injuries
- Ligament Injuries
- Nerve Injuries
- 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)
- Standard Radiographs Ankle
- Weightbearing AP view and Lateral views
- Lateral view are useful for measuring Achilles shadow
- Often normal
- Calcifications may be noted in lateral view 
- Imaging modality of choice
- 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 
- Not generally required
- Provide the most information regarding Achilles tendinopathy
- Used for classifying the degree of degeneration 
- May show intrasubstance abnormalities, increased signal and enlarged retrocalcaneal bursa
- Insertional 
- Injury occurs at the calcaneus-Achilles tendon junction
- Non-Insertional 
- Injury occurs 2 to 6 cm proximal to the insertion of the Achilles tendon into the calcaneus
- Patients can expect their symptoms to improve between 3 and 12 months after commencing treatment, but not beyond 12 months
- 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
- Vast majority of cases
- Non-insertional tendinopathy
- Activity modification
- Physical Therapy
- Emphasis on eccentric exercises
- 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
- In one study, a stretching program resulted in 88% of patients being satisfied with the results
- Extracorporeal Shockwave Therapy
- RCT demonstrated significant improvement when this was combined with eccentric exercises compared with eccentric exercises alone
- RCT reported improved scores after ESWT, particularly in women
- ESWT in refractory nonoperative cases showed benefit in a case control study
- Saxena found 78% of patients improved at 1 year after 3 weeks of ESWT in a single arm study
- Topical Glyceryl Trinitrate
- One RCT showed benefit for non-insertional tendinopathy compared to control group up to 3 years after treatment
- Platelet Rich Plasma
- High Volume Injection
- Dextrose Prolotherapy
- Corticosteroid Injection
- 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) :
- 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
- Exercise Rehabilitation - 4 Phases  
- 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 
- Goal is return patient to activity and performance
- 1) Symptom management and load reduction
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 
- Various factors must be considered when returning to sport:
- Level of pain
- Tendon recovery, healing, and load
- Strength of athlete
- Range of motion of joint
- Demands of the specific sport
- Exercises include: sport specific movements, running, heel rises, plyometrics
- Achilles Rupture
- Study of 432 patients showed wound necrosis in 3%, superficial infection in 2.5%, and sural nerve injury in 1% following surgery 
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