Achilles tendinitis

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Achilles tendinitis
Other namesAchilles tendinopathy, Achilles tendonitis, Achilles tenosynovitis
Achilles tendonitis.svg
Drawing of Achilles tendinitis with the affected part highlighted in red
Specialty Rheumatology
Symptoms Pain, swelling around the affected tendon [1]
Usual onsetGradual [1]
DurationMonths [2]
TypesNoninsertional, insertional [2]
CausesOveruse [2]
Risk factors Trauma, lifestyle that includes little exercise, high-heel shoes, rheumatoid arthritis, medications of the fluoroquinolone or steroid class [1]
Diagnostic method Based on symptoms and examination [3]
Differential diagnosis Achilles tendon rupture [3]
TreatmentRest, ice, non-steroidal antiinflammatory agents (NSAIDs), physical therapy [1] [2]
FrequencyCommon [2]

Achilles tendinitis, also known as Achilles tendinopathy, is soreness the Achilles tendon. It is accompanied by alterations in the tendon's structure and mechanical properties. [2] The most common symptoms are pain and swelling around the back of the ankle. [1] The pain is typically worse at the start of exercise and decreases thereafter. [3] Stiffness of the ankle may also be present. [2] Onset is generally gradual. [1]

Contents

It commonly occurs as a result of overuse such as running, [2] [3] but also occurs due to injury. Other risk factors include trauma, a lifestyle that includes little exercise, high-heel shoes, rheumatoid arthritis, and medications of the fluoroquinolone or steroid class. [1] Diagnosis is generally based on symptoms and examination. [3]

There are several simple actions that individuals can take to prevent or reduce tendinitis. Though commonly used, some of these have limited or no scientific evidence to support them, namely pre-exercise stretching. Strengthening calf muscles, avoiding over-training, and selecting more appropriate footwear are more well-regarded options. [4] [5] [6] Running mechanics can be improved with simple exercises that will help runners avoid Achilles injury. [7] Treatment typically involves rest, ice, non-steroidal antiinflammatory agents (NSAIDs), and physical therapy. [1] [2] In those whose symptoms last more than six months despite other treatments, surgery may be considered. [2] Achilles tendinitis is relatively common. [2]

Signs and symptoms

Symptoms can vary from an ache or pain and swelling in the local area of one or both ankles, or a burning that surrounds the whole joint. With this condition, the pain is usually worse during and after activity, and the tendon and joint area can become stiff the following day, as swelling impinges on the movement of the tendon.

Achilles tendon injuries can be separated into insertional tendinopathy (20%–25% of the injuries), midportion tendinopathy (55%–65%), and proximal musculotendinous junction (9%–25%) injuries, according to the location of pain. [8]

Cause

Demonstration of the right foot in pronation, neutral and supinated subtalar joint placements. Over-pronation (excessive pronation) occurs when the ankle begins to roll inward by more than 5 degrees, demonstrated with the arrows. Ankle Pronation Position.png
Demonstration of the right foot in pronation, neutral and supinated subtalar joint placements. Over-pronation (excessive pronation) occurs when the ankle begins to roll inward by more than 5 degrees, demonstrated with the arrows.
Walking gait cycle starting with the left leg demonstrated. The loading cycle is where foot pronation naturally occurs. Walking gait cycle.png
Walking gait cycle starting with the left leg demonstrated. The loading cycle is where foot pronation naturally occurs.

Achilles tendinitis is a common injury, particularly in sports that involve lunging and jumping, occurs both laterally and bilaterally, and is often induced in a single ankle by trauma. It is also a known side effect of fluoroquinolone antibiotics such as ciprofloxacin, as are other types of tendinitis. [9]

Achilles tendinitis is thought to have physiological, mechanical, or extrinsic (i.e. footwear or training) causes. The Achilles tendon has a generally poor blood supply throughout its length, as measured by the number of vessels per cross-sectional area. Blood is supplied via the synovial sheaths that surround it. [10] This lack of blood supply can lead to the degradation of collagen fibers and inflammation. [11] Tightness in the calf muscles has also been known to be involved in the onset of Achilles tendinitis. [12]

During the loading phase of the running and walking cycle, the ankle and foot naturally pronate and supinate by approximately 5 degrees. [13] Excessive pronation of the foot (over 5 degrees) in the subtalar joint is a type of mechanical mechanism that can lead to tendinitis. [12] [13]

An overuse injury refers to repeated stress and strain, which is likely the case in endurance runners. [14] [15] Overuse can simply mean an increase in running, jumping or plyometric exercise intensity too soon. Another consideration would be the use of improper or worn-down footwear, which lack the necessary support to maintain the foot in the natural/normal pronation. [15]

Pathophysiology

Because the Achilles tendon does not have good blood supply, injuries can be slow to heal. The tendon receives nutrients from the tendon sheath or paratendon. When an injury occurs to the tendon, cells from surrounding structures migrate into the tendon to assist in repair. Some of these cells come from blood vessels that enter the tendon to provide direct blood flow to increase healing. With the blood vessels come nerve fibers. Researchers including Alfredson and his team in Sweden believe these nerve fibers to be the cause of the pain - they injected local anaesthetic around the vessels and this decreased significantly the pain in the Achilles tendon. [16]

Diagnosis

Calcification deposits forming an enthesophyte within the Achilles tendon at its calcaneal insertion. The Achilles tendon is wider than normal, further suggesting inflammation. Achilles insertional calcific tendinosis (labeled).jpg
Calcification deposits forming an enthesophyte within the Achilles tendon at its calcaneal insertion. The Achilles tendon is wider than normal, further suggesting inflammation.

Achilles tendinitis is usually diagnosed from a medical history, and physical examination of the tendon. Projectional radiography shows calcification deposits within the tendon at its calcaneal insertion in approximately 60 percent of cases. [17] Magnetic resonance imaging (MRI) can determine the extent of tendon degeneration, and may show differential diagnoses such as bursitis. [17]

Prevention

This photo demonstrates a calf raise exercise that can be performed to strengthen two of the major ankle plantar flexor muscles, the gastrocnemius and the soleus. This exercise can be performed with minimal to no equipment. A step can be added under the foot to enhance range of motion and weights can be added to increase the resistance Eccentric Exercise.png
This photo demonstrates a calf raise exercise that can be performed to strengthen two of the major ankle plantar flexor muscles, the gastrocnemius and the soleus. This exercise can be performed with minimal to no equipment. A step can be added under the foot to enhance range of motion and weights can be added to increase the resistance

Performing consistent physical activity will improve the elasticity and strength of the tendon, which will assist in resisting the forces that are applied. [19]

Stretching before beginning an exercise session is often recommended, however evidence to support this practice is limited. [4] [5] Prevention of recurrence includes following appropriate exercise habits and wearing low-heeled shoes. In the case of incorrect foot alignment, orthotics can be used to properly position the feet. [19] Footwear that is specialized to provide shock-absorption can be utilized to defend the longevity of the tendon. [20] Achilles tendon injuries can be the result of exceeding the tendon's capabilities for loading, therefore it is important to gradually adapt to exercise if someone is inexperienced, sedentary, or is an athlete who is not progressing at a steady rate. [20]

Eccentric strengthening exercises of the gastrocnemius and soleus muscles are utilized to improve the tensile strength of the tendon and lengthen the musculotendinous junction, decreasing the amount of strain experienced with ankle joint movements. [21] This eccentric training method is especially important for individuals with chronic Achilles tendinosis which is classified as the degeneration of collagen fibers. [20]

Treatment

Treatment typically involves rest, ice, non-steroidal antiinflammatory agents (NSAIDs), and physical therapy. [1] [2] A heel lift [22] or orthotics [23] may also be helpful, [3] [2] but evidence for either is limited. Foam rolling may increase range of motion, but there is only weak evidence for the direct treatment of stiffness. [24] Other treatments include:

Injections

The evidence to support injection therapies is poor. [25]

Procedures

Tentative evidence supports the use of extracorporeal shockwave therapy. [28]

Epidemiology

The prevalence of Achilles tendinitis varies among different ages and groups of people. Achilles tendinitis is most commonly found in individuals aged 30–40 [29] Runners are susceptible, [29] as well as anyone participating in sports, and men aged 30–39. [30]

Risk factors include participating in a sport or activity that involves running, jumping, bounding, and change of speed. Although Achilles tendinitis is mostly likely to occur in runners, it also is more likely in participants in basketball, volleyball, dancing, gymnastics and other athletic activities. [29] Other risk factors include gender, age, improper stretching, and overuse. [31] Another risk factor is any congenital condition in which an individual's legs rotate abnormally, which in turn causes the lower extremities to overstretch and contract; this puts stress on the Achilles tendon and will eventually cause Achilles tendinitis. [31]

Related Research Articles

<span class="mw-page-title-main">Tendon</span> Type of tissue that connects muscle to bone

A tendon or sinew is a tough band of dense fibrous connective tissue that connects muscle to bone. It sends the mechanical forces of muscle contraction to the skeletal system, while withstanding tension.

<span class="mw-page-title-main">Tendinopathy</span> Inflammation of the tendon

Tendinopathy is a type of tendon disorder that results in pain, swelling, and impaired function. The pain is typically worse with movement. It most commonly occurs around the shoulder, elbow, wrist, hip, knee, or ankle.

<span class="mw-page-title-main">Shoulder problem</span> Medical condition

Shoulder problems including pain, are one of the more common reasons for physician visits for musculoskeletal symptoms. The shoulder is the most movable joint in the body. However, it is an unstable joint because of the range of motion allowed. This instability increases the likelihood of joint injury, often leading to a degenerative process in which tissues break down and no longer function well.

<span class="mw-page-title-main">Achilles tendon</span> Tendon at the back of the lower leg

The Achilles tendon or heel cord, also known as the calcaneal tendon, is a tendon at the back of the lower leg, and is the thickest in the human body. It serves to attach the plantaris, gastrocnemius (calf) and soleus muscles to the calcaneus (heel) bone. These muscles, acting via the tendon, cause plantar flexion of the foot at the ankle joint, and flexion at the knee.

<span class="mw-page-title-main">Sprain</span> Damage to one or more ligaments in a joint

A sprain is a soft tissue injury of the ligaments within a joint, often caused by a sudden movement abruptly forcing the joint to exceed its functional range of motion. Ligaments are tough, inelastic fibers made of collagen that connect two or more bones to form a joint and are important for joint stability and proprioception, which is the body's sense of limb position and movement. Sprains may be mild, moderate, or severe, with the latter two classes involving some degree of tearing of the ligament. Sprains can occur at any joint but most commonly occur in the ankle, knee, or wrist. An equivalent injury to a muscle or tendon is known as a strain.

<span class="mw-page-title-main">Plantar fasciitis</span> Connective tissue disorder of the heel

Plantar fasciitis or plantar heel pain is a disorder of the plantar fascia, which is the connective tissue that supports the arch of the foot. It results in pain in the heel and bottom of the foot that is usually most severe with the first steps of the day or following a period of rest. Pain is also frequently brought on by bending the foot and toes up towards the shin. The pain typically comes on gradually, and it affects both feet in about one-third of cases.

<span class="mw-page-title-main">Tennis elbow</span> Condition in which the outer part of the elbow becomes sore and tender

Tennis elbow, also known as lateral epicondylitis or enthesopathy of the extensor carpi radialis origin, is an enthesopathy of the origin of the extensor carpi radialis brevis on the lateral epicondyle. The outer part of the elbow becomes painful and tender. The pain may also extend into the back of the forearm. Onset of symptoms is generally gradual, although they can seem sudden and be misinterpreted as an injury. Golfer's elbow is a similar condition that affects the inside of the elbow.

A soft tissue injury is the damage of muscles, ligaments and tendons throughout the body. Common soft tissue injuries usually occur from a sprain, strain, a one-off blow resulting in a contusion or overuse of a particular part of the body. Soft tissue injuries can result in pain, swelling, bruising and loss of function.

<span class="mw-page-title-main">Rotator cuff tear</span> Shoulder injury

Rotator cuff tendinopathy is a process of senescence. The pathophysiology is mucoid degeneration. Most people develop rotator cuff tendinopathy within their lifetime.

Prolotherapy, also called proliferation therapy, is an injection-based treatment used in chronic musculoskeletal conditions. It has been characterised as an alternative medicine practice.

<span class="mw-page-title-main">Achilles tendon rupture</span> Medical condition where the tendon at the back of the ankle breaks

Achilles tendon rupture is when the Achilles tendon, at the back of the ankle, breaks. Symptoms include the sudden onset of sharp pain in the heel. A snapping sound may be heard as the tendon breaks and walking becomes difficult.

<span class="mw-page-title-main">Patellar tendinitis</span> Human disease

Patellar tendinitis, also known as jumper's knee, is an overuse injury of the tendon that straightens the knee. Symptoms include pain in the front of the knee. Typically the pain and tenderness is at the lower part of the kneecap, though the upper part may also be affected. Generally there is no pain when the person is at rest. Complications may include patellar tendon rupture.

<span class="mw-page-title-main">Golfer's elbow</span> Tendon inflammation disease of the elbow

Golfer's elbow, or medial epicondylitis, is tendinosis of the medial common flexor tendon on the inside of the elbow. It is similar to tennis elbow, which affects the outside of the elbow at the lateral epicondyle. The tendinopathy results from overload or repetitive use of the arm, causing an injury similar to ulnar collateral ligament injury of the elbow in "pitcher's elbow".

<span class="mw-page-title-main">Calcific tendinitis</span> Disorder characterized by calcium deposits in a tendon

Calcific tendinitis is a common condition where deposits of calcium phosphate form in a tendon, sometimes causing pain at the affected site. Deposits can occur in several places in the body, but are by far most common in the rotator cuff of the shoulder. Around 80% of those with deposits experience symptoms, typically chronic pain during certain shoulder movements, or sharp acute pain that worsens at night. Calcific tendinitis is typically diagnosed by physical exam and X-ray imaging. The disease often resolves completely on its own, but is typically treated with non-steroidal anti-inflammatory drugs to relieve pain, rest and physical therapy to promote healing, and in some cases various procedures to breakdown and/or remove the calcium deposits.

<span class="mw-page-title-main">Extracorporeal shockwave therapy</span> Ultrasonic, non-invasive, outpatient treatment

Extracorporeal shockwave therapy (ESWT) is a treatment using powerful acoustic pulses which is mostly used to treat kidney stones and in physical therapy and orthopedics.

<span class="mw-page-title-main">Platelet-rich plasma</span> Blood product used in transfusion medicine

Platelet-rich plasma (PRP), also known as autologous conditioned plasma, is a concentrate of plasma protein derived from whole blood, centrifuged to remove red blood cells but retaining platelets. Though promoted for treating various medical conditions, evidence of its benefits was mixed as of 2020, showing effectiveness in certain conditions and ineffectiveness in others.

<span class="mw-page-title-main">Volleyball injuries</span>

Volleyball is a game played between two opposing sides, with six players on each team, where the players use mainly their hands to hit the ball over a net and try to make the ball land on the opposing team's side of the court. Volleyball is played by over 800 million people worldwide, making it one of the most popular sports in the world. Volleyball has some risks involved with it because there are some injuries which occur to players that are quite common; these include ankle injuries, shoulder injuries, foot injuries and knee injuries.

Running injuries affect about half of runners annually. The frequencies of various RRI depend on the type of running, such as speed and mileage. Some injuries are acute, caused by sudden overstress, such as side stitch, strains, and sprains. Many of the common injuries that affect runners are chronic, developing over longer periods as the result of overuse. Common overuse injuries include shin splints, stress fractures, Achilles tendinitis, Iliotibial band syndrome, Patellofemoral pain, and plantar fasciitis.

<span class="mw-page-title-main">Ankle problems</span> Medical condition

Ankle problems occur frequently, having symptoms of pain or discomfort in the ankles.

<span class="mw-page-title-main">Karim M. Khan</span> Canadian/Australian sport and exercise medicine physician

Karim M. Khan is a former sport and exercise medicine physician who served as editor in chief of the British Journal of Sports Medicine from 2008-2020. He was awarded the Officer of the Order of Australia in 2019 for "distinguished service to sport and exercise medicine and to the promotion of physical activity for community health" and an Honorary Fellowship of the Faculty of Sport and Exercise Medicine (UK) in 2014.

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