High Yield Topics

Achilles Tendinitis

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Ovid: 5-Minute Sports Medicine Consult, The


Achilles Tendinitis
Craig C. Young
Mark W. Niedfeldt
Basics
Description
  • Achilles tendinitis is an overuse injury of the Achilles tendon (from the musculotendinous junction of the gastrocnemius/soleus complex proximally to its insertion on the calcaneous) that causes pain in the posterior calf and heel.
  • Synonym(s): Achilles tendinosis; Achilles tendinopathy
Epidemiology
  • Accounts for 6.5–18% of injuries in runners
  • Accounts for up to 4% of patients in sports medicine clinics
  • Most common site is mid-portion (80–90%); pure insertional is rare (5%)
Incidence
Lifetime incidence in competitive athletes is estimated to be 24%:
  • Athletes in running and jumping sports are especially at risk; lifetime incidence in competitive runners may be as high as 50%.
Risk Factors
  • Training errors: Recent increase in distance, intensity, or length of activity
  • Worn, old shoes
  • Inflexibility, especially tight heel cords
  • Obesity
  • Hypertension
  • Malalignment of the leg (excessive genu valgum, external tibial torsion) or ankle/foot (pes planus)
  • Fluoroquinolones: Recent use of these antibiotics has been associated with increased risk for Achilles tendinopathy and rupture (1)[B].
  • Estrogen exposure from hormone replacement therapy and oral contraceptives may cause changes in microvascularity that may predispose a woman to Achilles tendinopathy (2)[C].
Etiology
  • Tendinosis: Chronic degenerative condition is more common than tendinitis, which is an inflammatory condition.
  • Disruption of normal tendon architecture:
    • Chronic intratendinous degeneration, collagen disorientation, and increases in mucoid ground substance
    • Neovascularization
Commonly Associated Conditions
  • Retrocalcaneal bursitis
  • Posterior ankle impingement syndrome
  • Superficial Achilles bursitis (“pump bump” or Haglund's deformity)
  • Achilles tendon rupture: Chronic changes in tendon may predispose to rupture.
Diagnosis
History
  • Pain that initially subsides with use but returns with continued use or after use suggests an overuse injury.
  • Morning stiffness is a hallmark of Achilles tendinitis.
  • Training errors are a factor in a large percentage of cases.
  • Worn shoes: Shoes need to be changed every 250–500 miles because of shoe padding breakdown.
  • Patients may report weakness and intermittent swelling.
Physical Exam
  • Pain and stiffness 2–6 cm above Achilles tendon insertion
  • Pain with running, especially sprinting
  • Tenderness over the distal Achilles tendon (2–6 cm above the insertion):
    • Tenderness near insertion suggests insertional Achilles tendinopathy (enthesopathy) or bursitis.
  • Thickening of the distal Achilles tendon (chronic injury)
  • Tenderness with resisted plantar flexion
  • Crepitus with ankle motion
  • Negative Simmonds-Thompson test: Compression of the calf will cause normal passive plantar flexion of the foot:
    • A positive test (absence of plantar flexion with calf compression) suggests complete Achilles tendon rupture.
  • Decreased ankle dorsiflexion (from tight heel cord)
Diagnostic Tests & Interpretation
Imaging
  • Not usually needed for initial evaluation. X-rays should be obtained if other potential injuries are suspected (eg, fracture or tumor) or if injury is not responding to appropriate treatment.
  • Standard ankle series (anteroposterior, lateral, and mortise) may show calcification of tendon; however, presence of calcification does not affect initial treatment.
  • US (3)[C]:
    • Hypoechoic regions, intratendinous calcifications, disorganization of fibers, fusiform expansion, intrasubstance/partial-thickness tears, and neovascularization may be seen with Achilles tendinopathy:
      • Degenerative changes may be seen in ∼60% of healthy uninjured persons.
      • Individuals who were more active are more likely to have changes.
      • Neovascularization at baseline does not predict clinical outcome of nonoperative treatment.
  • MRI shows thickening of the tendon with intratendinous changes.
Differential Diagnosis
  • Retrocalcaneal bursitis
  • Superficial Achilles bursitis
  • Calcaneal apophysitis (Sever's condition) in adolescents
  • Haglund deformity: Prominent superior tuberosity of calcaneus
  • Achilles tendon rupture
  • Gastroc-soleus tear
  • Overuse myositis
  • Chronic exertional compartment syndrome
  • Os trigonum irritation or posterior ankle impingement syndrome
  • Vascular/neurogenic claudication
  • Deep venous thrombosis
  • Hematoma
  • Infection

P.5


Treatment
  • Acute tendinopathy (4,5,6,7,8)[C]:
    • Ice after activity; proper warm-up prior to activity
    • NSAIDs: May be useful as an adjunct for pain control and in cases of acute injury
    • Modalities: Consider the use of US or phonophoresis. Although some studies have shown that these modalities are useful in returning an athlete to activity sooner, they also show no long-term benefit.
    • Short-term immobilization (7–10 days) with walking boot for severe acute symptoms or recalcitrant symptoms
    • Heel lift (or high-heeled shoes)
  • Chronic tendinopathy (4,5,6,7,8)[C]:
    • Hamstring and calf stretching and strengthening program:
      • Progression to eccentric exercise programs has been shown to shorten time to return to full activity. Results of randomized, controlled trials have not consistently shown short- or long-term benefit, though.
    • Orthotics or arch supports may be useful in patients with pes planus and those who overpronate.
    • Short-term use of night splints or walking boots may be useful in patients with recalcitrant symptoms.
    • Nitric oxide via topical nitroglycerin particularly for noninsertional chronic Achilles tendinopathy (9)[C]
    • Autologous blood or platelet-rich plasma injections: Theoretically make the environment of fibroblasts more conducive to healing (10)[C]
    • Injection of sclerosing agents to destroy the sensory nerves that travel with the blood vessels of neovascularization
    • Avoid injection of cortisone into the Achilles tendon because of risk of rupture.
    • Extracorporeal shock wave therapy: Thought to induce neovascularization and a new inflammatory process that leads to tissue healing (11)[C]
    • Low-level laser therapy: Thought to modulate inflammation and regeneration of collagen (12)[C]
    • Surgery for recalcitrant cases
Additional Treatment
Referral
Consider referral for surgical debridement for individuals whose symptoms have not responded to 3–6 or more months of nonoperative treatment.
Additional Therapies
  • Stretching: Ensure athlete is on appropriate conditioning program, pre-activity warm-up, and post-activity cool-down programs.
  • Strengthening: Including a gastrocnemius and soleus strengthening program with emphasis on eccentric exercises
Ongoing Care
Follow-Up Recommendations
  • Relative rest: Especially eliminate sprinting, speed work, and running hills or stairs. Overall decrease in running intensity, duration, and/or frequency.
  • New shoes: Avoid shoes with high heel counters or other structures that place pressure over irritated area. Running shoes should be changed every 250–500 miles.
  • Use of heel lifts or high heels often can acutely decrease symptoms.
References
1. Sode J, Obel N, Hallas J, et al. Use of fluroquinolone and risk of Achilles tendon rupture: a population-based cohort study. Eur J Clin Pharmacol. 2007;63:499–503.
2. Holmes GB, Lin J. Etiologic factors associated with symptomatic achilles tendinopathy. Foot Ankle Int. 2006;27:952–959.
3. Nicol AM, McCurdie I, Etherington J. Use of ultrasound to identify chronic Achilles tendinosis in an active asymptomatic population. J R Army Med Corps. 2006;152:212–216.
4. Gottschlich LM, Eerkes KJ, Lin D, et al. Achilles tendonitis. http://emedicine.medscape.com/article/85115-overview, 2009.
5. Ham P, Maughan KL. Achilles tendinopathy and tendon rupture. http://www.uptodate.com/online/content/topic.do?topicKey=ad_orth/11653, 2009.
6. Magnussen RA, Dunn WR, Thomson AB. Nonoperative treatment of midportion Achilles tendinopathy: a systematic review. Clin J Sport Med. 2009;19:54–64.
7. Marks RM. Achilles tendinopathy: peritendinitis. Foot Ankle Clin. 1999;4(4):789–809.
8. Solan M, Davies M. Management of insertional tendinopathy of the Achilles tendon. Foot Ankle Clin. 2007;12:597–615.
9. Paoloni JA, Murrell GA. Three-year followup study of topical glyceryl trinitrate treatment of chronic noninsertional Achilles tendinopathy. Foot Ankle Int. 2007;28:1064–1068.
10. Mishra A, Woodall J, Vieira A. Treatment of tendon and muscle using platelet-rich plasma. Clin Sports Med. 2009;28:113–125.
11. Furia JP. High-energy extracorporeal shock wave therapy as a treatment for insertional Achilles tendinopathy. Am J Sports Med. 2006;34:733–740.
12. Stergioulas A, Stergioula M, Aarskog R, et al. Effects of low-level laser therapy and eccentric exercises in the treatment of recreational athletes with chronic Achilles tendinopathy. Am J Sports Med. 2008;36:881–887.
Codes
ICD9
726.71 Achilles bursitis or tendinitis
ICD10
M76.6 Achilles tendinitis
Clinical Pearls
Because of the high stresses placed upon the Achilles tendon with weight-bearing activities and the risk of rupture, corticosteroid injection into the Achilles tendon should be avoided.


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