Achilles Tendinopathy



Achilles Tendinopathy


Craig C. Young, MD

Mark W. Niedfeldt, MD



BASICS


DESCRIPTION



  • Achilles tendinitis is an overuse injury of the Achilles tendon 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 midportion (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%.


ETIOLOGY AND PATHOPHYSIOLOGY



  • Higher risk areas:



    • Musculotendinous junction


    • The region of distal Achilles tendon that is 2 to 6 cm proximal to insertion. This is a region with a relative lack of mesotenon and intratendinous vessels.


  • 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 and increase in sympathetic nerve ingrowth around the ventral surface of the Achilles tendon


RISK FACTORS



  • Training errors: recent increase in distance, intensity, or length of activity


  • Worn and/or old shoes


  • Inflexibility, especially tight heel cords


  • Higher body mass index (BMI)


  • Hypertension


  • Diabetes


  • Hypothyroidism


  • Older patients: decreased tensile strength and increased stiffness of tendon


  • Malalignment of the leg (excessive genu valgum, external tibial torsion) or ankle/foot (pes planus)


  • Medications:



    • Fluoroquinolones: Recent use of these antibiotics has been associated with increased risk for Achilles tendinopathy and rupture.


    • Glucocorticoids


    • Aromatase inhibitors


    • Statins have been theorized to cause tendinopathy and have been shown in some animal models.


COMMONLY ASSOCIATED CONDITIONS



  • Retrocalcaneal bursitis


  • Posterior ankle impingement syndrome


  • Superficial Achilles bursitis (“pump bump” or Haglund 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 or old shoes: Shoes need to be changed every 250 to 500 miles because of shoe padding breakdown:



    • Older shoes, even new, unused shoes, may have decreased shock absorption from age-related breakdown of the shock-absorbing materials.


  • Patients may report weakness and intermittent swelling.


PHYSICAL EXAM



  • Pain and stiffness 2 to 6 cm above Achilles tendon insertion


  • Pain with running, especially sprinting


  • Tenderness over the distal Achilles tendon (2 to 6 cm above the insertion):



    • Tenderness near insertion suggests insertional Achilles tendinopathy (enthesopathy) or bursitis.


  • Thickening of distal Achilles tendon in chronic cases


  • Tenderness with resisted plantar flexion


  • Weakness with repetitive single leg heel raises


  • 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)



DIFFERENTIAL DIAGNOSIS

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Mar 14, 2020 | Posted by in SPORT MEDICINE | Comments Off on Achilles Tendinopathy

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