Achilles tendon (Achilles tendonopathy)


The Achilles tendon is a band of tissue that runs down the back of the lower leg and connects the calf muscle to the heel bone.

Pain in the middle portion of the Achilles tendon, and is off and severe when initiating activity from rest.

The Achilles tendon facilitates walking by helping to raise the heel off the ground.

Two common disorders that occur in the heel cord are Achilles tendonitis and Achilles tendonosis.

Chronic Achilles tendon disorders may affect is in the insertion of the tendon on the calcaneus, or the mid portion of the Achilles.

Achilles tendonopathy causes pain approximately 2 to 6 cm above the Achilles insertion on the heel and is more amenable to nonoperative treatment than other types of Achilles tendonopathy.

Achilles tendonopathy is a degenerative condition due to abnormal healing responses due to repetitive microtrauma in which there is loss of collagen fiber organization, as well as increase and type III collagen compared with normal tendon tissue.

Achilles tendonopathy is approximately 1.85 per thousand adult patients and the prevalence in physically active exercising individuals at 6%.

Pain often improves with light activity, but worsens with intense or prolonged activity.

Clinically the mid portion of the Achilles tendon is tender to palpation, along with palpable thickening of this portion of the tendon compared with the unaffected side.

Achilles tendinitis is associated with older age, with its highest rate of 8% in individuals older than 45 years.

Running is the most common inciting activity.

The relative risk of Achilles tendinitis in fluoroquinolone users is about 3.7%.

The use of glucocorticoids and fluoroquinolones is associated with a greater risk of Achilles tendonopathy..

It’s incidence is estimated at approximately two per 1000 in the Netherlands.

Achilles tendonitis is an inflammation of the Achilles tendon, which is usually short lived.

If tendinitis is not resolved, the condition may progress to a degeneration of the tendon.

With degeneration, the tendon loses its organized structure and is likely to develop microscopic tears.

Rarely, chronic degeneration may result in rupture of the tendon.

The risk of Achilles tendon rupture following the diagnosis of Achilles tendon is approximately 4%: the highest risk in patients 50 to 59 years.

Tendonitis and tendonosis of the Achilles are usually caused by a sudden increase of a repetitive activity involving the Achilles tendon.

Too much stress on the tendon too quickly, leading to micro-injury of the tendon fibers, and due to this ongoing stress on the tendon, the body is unable to repair the injured tissue.

Athletes are at high risk for developing disorders of the Achilles tendon.

Achilles tendonitis/tendonosis are common in individuals whose work puts stress on their ankles and feet, and those who are less conditioned and participate in athletics only on weekends or infrequently.

Individuals with excessive pronation have a tendency to develop Achilles tendonitis and tendonosis due to the greater demands placed on the tendon when walking.

If individuals with flat feet wear shoes without adequate stability, their overpronation could further aggravate the Achilles tendon.

Patients present with pain, aching, stiffness, soreness or tenderness within the tendon.

Symptoms may occur anywhere along the tendon’s path, beginning with the tendon’s attachment directly above the heel upward to the region just below the calf muscle.

Pain often appears upon arising in the morning or after periods of rest.

Pain often improves somewhat with motion but later worsens with increased activity.

Tenderness, or pain occur when the sides of the tendon are squeezed.

There is less tenderness present when pressing directly on the back of the tendon.

With degeneration, the tendon may become enlarged and may develop nodules.

Diagnosis involves evaluating the range of motion and condition of the tendon.

The extent of the condition can be further assessed with x-rays or other imaging modalities.

Treatment approaches for Achilles tendonitis or tendonosis is based on how long the injury has been present and the degree of damage to the tendon.

In the early stages of inflammation, one or more of the following options may be recommended:



Nonsteroidal anti-inflammatory drugs (NSAIDs).


Night splints.

Physical therapy.

If nonsurgical approaches fail to restore the tendon to its normal condition, surgery may be necessary.

To prevent Achilles tendonitis or tendonosis from recurring strengthening and stretching of the calf muscles through daily exercises.

Wearing proper shoes for the foot type and activity is also important in preventing recurrence of the condition.

Injuries in sports participants and inactive middle-aged individuals is frequent.

Distance runners have a lifetime risk of 52% more injury (Zsfar MS).

Injuries to this tendon interfere with subsequent sporting activities and activities of daily living.

Injuries lead to surgery up in 25-45% of patients.

Conservative therapy is often inadequate.

Chronic tendon disorders are referred to as a tendinopathy and is associated with pain, swelling and decreased activity.

Exercise promotes collagen synthesis and may result in decreased pain.

Eccentric strengthening is considered for patients with Achilles tendonopathy.

Eccentric exercises allows the muscle to undergo controlled lengthening, under a load, while the muscle is contracting.

Extracorporeal shockwave therapy may be beneficial.

Nonsteroidal, anti-inflammatory drugs may provide temporary pain relief but no significant benefit compared with placebo, when added to physical therapy.

Topical , anti-inflammatory drugs have shown no benefit.

Platelet rich plasma does not result in pain reduction or increase function compared to saline injections (de Vos RJ) in Achilles tendinitis.

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