Achilles Tendonitis

Aka: Achilles Tendonitis, Achilles Tendinitis, Achilles Peritendinitis, Achilles Tendinopathy

1. Pathophysiology
   1. Achilles tendon forms from the union of gastrocnemius and soleus tendons
   2. Achilles-calf complex responsible for Running push-off
      1. Allows for airborne phase of Running gait
   3. Mechanism of Running Injury
      1. Incorrect Running technique
      2. Poorly fitting shoes
      3. Over-pronation
      4. Running on uneven surface
   4. Rheumatologic Conditions predisposing to Tendonitis
      1. Spondyloarthropathy
      2. Rheumatoid Arthritis
   5. Exacerbating factors
      1. Inappropriate shoes for activity or high heel shoe wear in general
      2. Fluoroquinolone use
      3. Aging
      4. Poor gastrocnemius and soleus muscle flexibility
      5. Malalignment of lower extremity (e.g. Leg Length Discrepancy, sacroiliac joint dysfunction)
2. Etiology: Achilles tendon inflammation
   1. Chronic overuse of calf muscle
   2. Common overuse injury
      1. Occurs in 10% of runners
      2. New athletes to sport
      3. Dancing
      4. Gymnasts
      5. Tennis Players
3. Types
   1. Midsubstance Achilles Tendinopathy
      1. Tendinopathy superior to the insertional region
      2. Most common, and more therapy responsive, especially with Eccentric Exercises (see toe raises below)
   2. Insertional Achilles Tendinopathy
      1. Tendinopathy in the 2-3 cm region at the insertion of the achilles tendon into the calcaneous
      2. More refractory to treatment and often requires CAM Boot immobilization
4. Symptoms
   1. Sharp Heel Pain and stiffness at the mid-achilles tendon to insertion
      1. Worse with strenuous Exercise
      2. Better with walking
   2. Uneven gait may result
5. Signs
   1. Inflammation at Achilles tendon (3-5 cm above calcaneal insertion) or at calcaneal insertion itself
      1. Pain, local tenderness, and swelling (tendon thickening)
      2. Gradual onset
   2. Negative Thompson Test (differentiates from Achilles Tendon Rupture)
   3. Dry crepitus may be present on palpation
   4. Provocative maneuvers that aggravate pain
      1. Passive Stretching of tendon (ankle dorsiflexion)
      2. Lightly squeezing calf
   5. Associated: Peritendinitis
      1. Tendon sheath inflammation (2-6 cm above insertion)
      2. Pain and burning worse with Exercise
      3. Pain on rubbing tendon suggests Peritendinitis
6. Imaging
   1. Ankle XRay may show spurring at the achilles tendon insertion
   2. Ankle Ultrasound may show tendon thickening
7. Differential Diagnosis
   1. See Heel Pain
   2. Achilles Tendon Rupture
   3. Retrocalcaneal Bursitis
8. Management
   1. Relative rest (may require off sport completely)
      1. Limit runnng and other activities to flat, level ground
      2. Avoid interval training (speed work)
      3. Cross-train with non-impact actvitis (e.g. swimming, Bicycling)
   2. Gentle Stretching and strengthening (avoid worsening injury)
      1. Indicated in midsubstance Achilles Tendinopathy
      2. May also be used for insertional Achilles Tendinopathy after initial immobilization for 4-6 weeks
      3. Calf stretches and stregthening of gastrocnemius and soleus muscles with leg straight and bent
      4. Includes slow warm-up before Exercise
      5. Eccentric Exercises are most effective (muscle lengthening in response to external resistance)
      6. Toe raises
         1. Start
            1. Both feet on first, lowest step of stair case or other platform
            2. Ankles and foot start maximally plantar flexed, on tip toes
         2. Toe raises with knees straight
            1. Allow the affected foot and ankle's heel to drop below the level of the step, maximally dorsiflexing the foot and ankle
            2. Return to tip-toe position (maximally plantar flexed)
         3. Toe raises with knees bent
            1. Repeat toe raises as above, but now with knees flexed
   3. Local Ice Therapy
      1. Ice massage after activity for 20 minutes
   4. NSAIDs for 10 days at initial symptom onset
   5. Consider Orthotics or firm heel lift (1/8 to 3/8 inches)
   6. Obtain correct Running Shoe (e.g. over-pronators)
   7. Weight loss if over Ideal Weight
   8. Consider physical therapy
      1. Local Ultrasound (consider with Iontophoresis)
      2. Flexibility and Strength Training
      3. Assist with correcting biomechanics of sport
   9. Short Leg Walking Cast or CAM Boot
      1. Consider in persistent or refractory cases
      2. Consider in insertional Achilles Tendinopathy for 4-6 weeks followed by Eccentric Exercises (see toe raises as above)
   10. Avoid local Corticosteroid Injections
       1. Risk of Achilles Tendon Rupture
   11. Severe refractory cases
       1. Consider Nitroglycerin patches
       2. Consider platelet plasma injections
       3. Surgical debridement
9. Course
   1. May persist for months
   2. Athletes often require 4 weeks out of all sports
      1. Welsh (1980) Can Med Assoc 122:193-5
10. References
    1. Liu in Noble (2001) Primary Care, Mosby, p. 1262
    2. Childress (2013) Am Fam Physician 87(7): 486-90
    3. Mazzone (2002) Am Fam Physician 65(9):1805-10
    4. Paavola (2002) J Bone Joint Surg Am 84-A(11): 2062-76
    5. Simpson (2009) Am Fam Physician 80(10): 1107-13