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Achilles Tendonitis
Article Last Updated: Jun 29, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 10  
Author: Henry Marano, MD, Director, Department of Orthopedic Surgery, Associate Professor, St Joseph's Hospital, Albert Einstein College of Medicine
Henry Marano is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, and Medical Society of the State of New York
Coauthor(s):
David Y Lin, MD, Fellow, Department of Orthopedic Surgery, Section of Pediatrics, University of Tennessee Campbell Clinic;
Evan Schwartz, MD, Director of Orthopedic Surgery, New York Medical College; Assistant Professor, St John's Queens Hospital, Department of Surgery, Albert Einstein School of Medicine
Editors: David T Bernhardt, MD, Director of Adolescent and Sports Medicine Fellowship, Department of Pediatrics, Associate Professor, University of Wisconsin; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Marlene DeMaio, MD, Consulting Staff, Department of Orthopedic Surgery, Assistant Professor, Bone & Joint/Sports Medicine Institute, Naval Medical Center; Jon Whitehurst, MD, Consulting Staff, Rockford Orthopedic Associates; Sherwin SW Ho, MD, Section of Orthopedic Surgery and Rehabilitation Medicine, Associate Professor, Department of Surgery, University of Chicago
Author and Editor Disclosure
Synonyms and related keywords:
Achilles peritenonitis, Achilles peritendinitis, Achilles tendinitis, Achilles tendinosis, Achilles rupture, Achilles tendo calcaneitis
Background
The Achilles tendon, named after the seemingly indestructible mythologic Greek warrior, is the largest and strongest tendon in the human body. Achilles tendonitis was the term originally used to describe the spectrum of tendon injuries, ranging from inflammation to tendon rupture. Recently, a histopathologically determined nomenclature has evolved to classify this range of tendon inflammation and degeneration into 3 stages: (1) peritenonitis, (2) peritenonitis with tendinosis, and (3) tendinosis.
Partial or full tendon ruptures may result from end-stage peritenonitis. Causes of tendon ruptures are associated with overuse and host susceptibility with both extrinsic and intrinsic factors playing a role. Athletes who are poorly conditioned, overtrained, or insufficiently prepared are at the highest risk for this disease process. Repetitive stresses to the tendon, such as prolonged jumping or running, result in chronic pain and tightness along the tendon. Tendonitis usually develops insidiously after sudden changes in activity or training level, use of inappropriate footwear, or training on poor running surfaces, especially if high risk factors are present (eg, age, cavus feet, tibia vara, heel and forefoot varus deformities).
Frequency
United States
True incidence of Achilles tendonitis is unknown, although there is a reported incidence of 6.5-18% in runners.
Functional Anatomy
The Achilles tendon (tendo calcaneus) is formed from the tendinous contributions of the gastrocnemius and soleus muscles, coalescing approximately 15 cm proximal to its insertion. Along its course in the posterior aspect of the leg, the tendon spirals 30-150° until inserting into the calcaneal tuberosity. The tendon's ability to glide is facilitated by the presence of a thin paratenon sheath, which is composed of both a visceral layer and parietal layer, rather than simply a true synovial sheath. The tendon's blood supply arises from the osseous insertion, the musculotendinous junction, and multiple infiltrating mesotenon vessels, which cross the layers of the anterior paratenon.
Various injection and nuclear medicine studies have demonstrated a paucity of mesotenon and intratendinous vessels 2-6 cm proximal to the heel insertion known as the watershed area. Due to the relative lack of blood supply in the watershed area, this area of the tendon is less resilient to repetitive microtrauma and has a higher tendency for irritation, degeneration, and possible rupture.
Sport Specific Biomechanics
The entire gastrocnemius/soleus musculotendinous unit spans the knee joint, tibiotalar (ankle) joint, and talocalcaneal (subtalar) joint. Contracture of this complex flexes the knee, plantar flexes the ankle, and supinates the subtalar joint. During running, forces equaling 10 times the body weight have been measured within the tendon.
History
- Achilles tendon injuries often occur in older recreational athletes (eg, athletes who usually are sedentary and deconditioned) but may occur in younger well-conditioned athletes.
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- Determine any recent changes in activity level, training duration, running surface, or footwear.
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- Ask for previous history of calf pain or weakness.
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- Achilles tendon injuries may be classified as follows:
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- Peritenonitis
- Localized/burning pain during or following activity occurs.
- As the disease progresses, onset of pain may occur earlier during activity, with decreased activity level, or even at rest.
- In this condition, the paratenon itself is inflamed thickened and typically adherent to the underlying unaffected tendon. Under the microscope, there is capillary proliferation and infiltration of inflammatory cells within the paratenon.
- Tendinosis
- Usually, this injury is an asymptomatic, noninflammatory, degenerative disease process (mucoid degeneration).
- The patient may complain of a sensation of fullness or nodule in the back of the leg.
- With tendinosis, there are thickened and yellowish areas of mucoid degeneration within the tendon itself. The tendon loses its normal coloration and striation patterns.
- Hypocellularity, collagen disorganization, lack of inflammatory reaction, scattered vascular ingrowth, and intermittent areas of calcification or necrosis are hallmarks of this disease process.
- Pathology is usually found within the watershed area of the tendon.
- Peritenonitis with tendinosis
- Activity-related pain and diffuse swelling of the tendon sheath with nodularity is present.
- Histologically and macroscopically, this entity combines findings found in both tendinosis and peritenonitis.
Physical
- Palpate the entire gastroc-soleus complex for tenderness, nodules, swelling, warmth, atrophy, and tendon defects with the patient in a prone position with feet off the table. Localization of the tenderness should be differentiated between musculotendinous (tennis leg), intrasubstance (Achilles tendon injury), and insertional (eg, Haglund deformity, pump bump). Nodules should be palpated for tenderness, boundaries, mobility, and size. Calf atrophy, determined by calf circumference as compared to the contralateral side, may provide information as to the chronicity of the disease process (acute versus chronic). "Gaps" or areas of tendon discontinuity are often signs of partial or complete tendon rupture.
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- Patients with peritenonitis typically present with warmth, swelling, and diffuse tenderness localized 2-6 centimeters proximal to the tendon's insertion. Crepitation also may be felt if peritenonitis presents acutely. As the condition becomes more chronic, symptoms may be provoked by decreased amounts of physical activity.
- Tendinosis is often pain free. Typically, the only sign may be a palpable intratendinous nodule that accompanies the tendon as the ankle is placed through ROM. Occasionally, a thickening along the entire tendon may develop in chronic conditions.
- Peritenonitis with tendinosis is diagnosed in patients with activity-related pain and swelling of the tendon sheath with tendon nodularity.
- Perform a Thompson test to check for Achilles tendon rupture.
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- With the patient prone and the knee flexed, the calf is squeezed proximal to the affected area. If passive plantar flexion of the foot is achieved with this maneuver, the test is negative and the Achilles tendon is at least partially intact. If no motion at the ankle is generated, the Thompson test is positive and a complete rupture of the tendon has occurred.
- This test is important to perform as incomplete or complete ruptures may occur in patients with a history of peritonitis with or without tendinosis. With acute partial or complete tendon ruptures, patients often relate focal pain and swelling at the sight of injury.
- Ascertain active and passive range of motion of the knee, ankle, and subtalar joints. Patients with overuse Achilles tendon injuries typically have decreased motion in the ankle and/or subtalar joints.
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- Note resting alignment and motion of the forefoot and ankle. Forefoot and heel varus, pronated feet, cavus feet, and tibia vara are known predisposing risk factors for this disease process.
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- Determine if evidence of neurovascular compromise is present.
Causes
- Extrinsic causes of Achilles tendonitis include the following:
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- Overuse
- Increased intensity of activity
- Increased duration of training
- Stairs
- Hill climbing
- Poor conditioning
- Improper shoes
- Improper training surfaces
- Improper stretching exercises
- Intrinsic causes may include the following:
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- Age
- Tight Achilles tendon
- Varus heel
- Varus forefoot
- Cavus foot
- Tibia vara
- Medical diseases that may affect tendon tissue (eg, diabetes mellitus) and diseases requiring corticosteroid treatment (eg, lupus, asthma, transplants)
Achilles Tendon Rupture
Ankle Fracture
Ankle Impingement Syndrome
Ankle Sprain
Athletic Foot Injuries
Calcaneofibular Ligament Injury
Compartment Syndromes
Retrocalcaneal Bursitis
Talofibular Ligament Injury
Other Problems to be Considered
Calf injuries and syndromes
Achilles bursitis (ie, pump bump)
Haglund deformity
Deep venous thrombosis
Tendinous xanthomas (eg, hyperbetalipoproteinemia, hyperlipoproteinemias)
Inflammatory arthropathies (eg, Reiter syndrome, psoriatic arthritis)
Lab Studies
- No lab studies typically are necessary to diagnose this condition.
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- In patients with no history of overuse or who do not fit the typical profile, appropriate lab work and medical referral should be ordered in those suspicious of having an underlying systemic disorder (eg, diabetes mellitus, hyperlipidemia, inflammatory arthropathy).
Imaging Studies
- Ultrasound is a relatively inexpensive, fast, and repeatable modality. Use of ultrasound permits dynamic assessment of the tendon and determines degree of thickening but requires technical expertise.
- MRI is an expensive adynamic test that is superior in detecting incomplete tendon ruptures and chronic degenerative changes. MRI detects fluid, peritenonitis, bursitis, tendon thickening, tendon signal, and tendon rupture.
- Radiographs are usually nondiagnostic but may show soft tissue swelling, calcifications, calcaneal avulsion fractures, increased dorsiflexion, Haglund deformity, and bony metaplasia.
Acute Phase
Rehabilitation Program
Physical Therapy
Peritenonitis Recommend rest and limitation of activities determined by the severity and duration of pain. Ice compresses can be used for relief of acute pain and inflammation following activities. Recommend nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce pain and inflammation. Suggest a heel lift of 1-2 cm on a temporary basis for comfort. Heel lifts on a prolonged basis may result in tendon shortening. Instruct the patient in stretching, training modification/re-evaluation, and muscle strengthening. Stretching exercises are believed to be the key modality in treatment as they provide better flexibility to the ankle. Stretching of the posterior gastroc-soleus complex should always be slow and deliberate. Each stretch should last for 20-30 seconds, with multiple repetitions in a set. Three possible methods of stretching the gastroc-soleus complex include 1) incline board, 2) wall leans, and 3) "foot on chair" stretching. An incline board is a fabricated ramp of 15-18° that allows the patient to gradually stretch the heel cord complex. A much simpler method is to have the patient stand and face a wall, while leaning with his knees extended and his heels planted on the ground. The "foot on chair" method requires the athlete to place his foot flat on a chair, and gradually bring his knee forward as far as possible without losing heel contact with the chair. Use orthotics to treat overpronation or heel cups to provide extra support and cushion to the tendon. Return to activities is gradual. Tendinosis Tendinosis alone usually is asymptomatic and is noticeable only with palpation of a nodule or fullness along the tendon. Tendinosis becomes symptomatic when coexistent peritenonitis is present and the patient complains of activity-related pain or swelling. Treatment is first conservative with methods similar to simple peritenonitis. Six to eight weeks of activity modification, orthotics (walking boot with a heel lift), anti-inflammatory analgesics, and physical therapy should be prescribed prior to any operative treatment or orthopedic referral. Certain modalities have been used in physical therapy programs. Therapeutic ultrasound provides silent mechanical vibrations of high frequency that penetrate superficial tissue in order to generate deep heat. Ultrasound has been shown in some studies to increase the rate of collagen synthesis and the breaking strength of the tendon. Ultrasound's effectiveness as an anti-inflammatory technique remains unproven. Both phonophoresis and iontophoresis deliver topically applied anti-inflammatory medications transdermally with the aid of mechanical ultrasound energy or an electrical field gradient, respectively. Typically, because the anti-inflammatory substance is a steroid (known to weaken tendinous tissue), we do not recommend its use.
Medical Issues/Complications
Steroid injections into and around the tendon are not advised because they have been shown to weaken the tendon.
Surgical Intervention
Operative treatment is indicated in athletes with peritonitis and/or tendinosis after a comprehensive conservative treatment program has failed and who are unwilling to modify or stop their activity. Although there are no absolute indications, relative contraindications include noncompliant patients, active infection site, and patients with potential wound healing problems (eg, diabetes mellitus, peripheral vascular disease, smokers). Lysis of adhesions through release of the Achilles tendon from the inflamed paratenon is the mainstay procedure for unrelieved peritonitis. Release is performed on the dorsal, medial, and lateral aspects of the tendon. Circumferential dissection to include the anterior sheath may jeopardize the vascular supply to the tendon and cause excessive scarring. This surgery is followed immediately with passive range of motion (PROM) and progressive weight bearing and strengthening for 2-3 weeks. When ambulating without pain, the patient may begin closed chain activities, such as biking or stair climbing. Running may begin at 6-10 weeks after surgery. Participation in competitive sports can start after 3-6 months. For people with tendinosis, failure of nonoperative treatment often requires excision or splitting of the paratenon, debridement, and repair of the degenerated tendon with side-to-side repair. Following the operation, a period of protected weight bearing, ROM, and strengthening is advised until return to full activities is achieved.
Other Treatment
Operative brisement (ie, injection of dilute anesthetic into the paratenon sheath under ultrasound guidance to break up adhesions) may be useful in patients with peritenonitis or tendinosis with peritenonitis.
Recovery Phase
Rehabilitation Program
Physical Therapy
See Physical Therapy above.
Medical Issues/Complications
Tendonitis may go onto rupture. Steroid injections, especially multiple injections, may weaken the tendon leading to tendon rupture.
Maintenance Phase
Rehabilitation Program
Physical Therapy
Achilles tendonitis is best prevented, treated, and maintained by preserving good ROM in the heel cord complex. Such motion can be gained with the use of an incline board, wall leans, or the "foot on chair" stretching exercises as described. Moist heat or compresses prior to workouts and at night are beneficial. Cold modalities should be used following strenuous activities to provide pain relief and anti-inflammatory effects.
No medical therapy of choice exists. Most patients are treated symptomatically with acetaminophen or NSAIDs as determined by the patient's medical condition and physician's preferences.
Drug Category: Analgesics/antipyretics
Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties, which are beneficial for patients who have sustained trauma or have sustained injuries.
| Drug Name | Acetaminophen (Tylenol, Feverall, Tempra) |
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| Description | DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants. |
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| Adult Dose | 650 mg PO q4h prn |
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| Pediatric Dose | 10-15 mg/kg PO q4h prn |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
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| Precautions | Hepatotoxicity possible in patients with chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; APAP is contained in many OTC products and combined use with these products may result in cumulative APAP doses exceeding recommended maximum dose |
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Drug Category: Nonsteroidal anti-inflammatory drugs (NSAIDs)
Have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but may inhibit cyclo-oxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.
| Drug Name | Ibuprofen (Motrin, Advil) |
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| Description | DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis. |
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| Adult Dose | 200-600 mg PO q8h prn |
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| Pediatric Dose | 10 mg/kg PO q6-8h prn |
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| Contraindications | Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding |
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| Interactions | Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
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| Pregnancy | D - Unsafe in pregnancy
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| Precautions | Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy |
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Complications
Patients with long-standing tendonitis or tendinosis may progress to complete rupture of the tendon.
Prevention
A key to the prevention of Achilles tendonitis is maintaining good flexibility and strength of the heel cord complex and ankle. Proper warm-up is necessary before activity. In individuals with faulty foot biomechanics (eg, overpronation), custom orthotics, heel cups, or arch supports may be recommended to prevent development of tendonitis.
Prognosis
In general, the prognosis is quite good for individuals with Achilles tendonitis who comply with a period of relative rest and conservative treatment.
Education
Patients need to have a good understanding of the importance of proper warm-up techniques before participating is activities that may cause repetitive stress to the Achilles tendon. Wearing proper footwear in important, as well as periodic changing of training surfaces. If athletes do demonstrate faulty foot biomechanics that may place them at risk, recommend that they consult with an orthotist and/or physical therapist for an evaluation and recommendation of proper orthotics.
For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center. Also, see eMedicine's patient education articles Tendinitis, Ruptured Tendon, and Achilles Tendon Rupture.
Medical/Legal Pitfalls
- Risk of tendon rupture, especially with multiple steroid injections
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Achilles Tendonitis excerpt Article Last Updated: Jun 29, 2006
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