Background

The Achilles tendon, named after the seemingly indestructible mythologic Greek warrior, is the largest and strongest tendon in the human body. Achilles tendinitis was the term originally used to describe the spectrum of tendon injuries ranging from inflammation to tendon rupture. Despite this spectrum, through extensive study of the histopathology of Achilles tendinitis, it has been determined that there is no evidence to support primary prostaglandin-mediated inflammation. There are, however, signs of "neurogenic inflammation with presence of neuropeptides like substance P and calcitonin gene related peptide." Tendon histopathology has been divided into 4 categories[1, 2, 3, 4] : (1) Cellular activation and increase in cell numbers, (2) increase in ground substance, (3) collagen disarray, and (4) neovascularization. Using this as a guide, a histopathologically determined nomenclature has evolved to classify this range of Achilles tendon pathology into 3 stages: (1) paratenonitis, (2), tendinosis, and (3) paratenonitis with tendinosis. Partial or full tendon ruptures may result from end-stage paratenonitis. Causes of tendon ruptures are associated with multiple factors including overuse, with both extrinsic and intrinsic factors playing a role in increasing susceptibility.[3, 5, 6, 7, 8, 9, 10, 11] 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. [12] Tendinitis 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). For patient education resources, see the Foot, Ankle, Knee, and Hip Center, as well as Tendinitis, Ruptured Tendon, and Achilles Tendon Rupture.

Epidemiology
Frequency
United States The true incidence of Achilles tendinitis 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 it inserts 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 region of the tendon is less resilient to repetitive microtrauma and has a higher tendency for irritation, degeneration, and possible rupture than the calcaneal insertion site.[13]

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 are usually sedentary and deconditioned) but may also occur in younger well-conditioned athletes. Determine any recent changes in activity level, training duration, running surface, or footwear. Ask for previous history of calf pain or weakness. If there is clinical suspicion of a partial or complete tear, inquire if there has been any history of quinolone use. Achilles tendon injuries may be classified as follows:

Paratenonitis
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 and thickened and is typically adherent to the underlying unaffected tendon. Under the microscope, there is capillary proliferation and infiltration of inflammatory cells within the paratenon.[14]

Tendinosis
Usually, this injury is an asymptomatic, noninflammatory, degenerative disease process (mucoid degeneration). The patient may complain of a sensation of fullness or a 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. [14, 15] Pathology is usually found within the watershed area of the tendon.

Paratenonitis 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 paratenonitis.[14, 15]

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 with the contralateral side, may provide information as to the chronicity of the disease process (acute vs chronic). "Gaps" or areas of tendon discontinuity are often signs of partial or complete tendon rupture. Patients with paratenonitis typically present with warmth, swelling, and diffuse tenderness localized 2-6 cm proximal to the tendon's insertion. Crepitation may also 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 its range of motion (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 and tendon nodularity. Perform a Thompson test to check for Achilles tendon rupture. 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 because incomplete or complete ruptures may occur in patients with a history of paratenonitis, 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 ROM and strength of the knee, ankle, and subtalar joints. Patients with overuse Achilles tendon injuries typically have decreased motion and strength in the ankle and/or subtalar joints. Note the 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. Determine if evidence of neurovascular compromise is present.

Causes
Extrinsic causes of Achilles tendinitis include the following: [1, 2] Overuse Increased intensity of activity Increased duration of training Stairs Hill climbing Poor conditioning Improper shoes Improper training surfaces Improper stretching exercises Intrinsic Achilles tendinitis causes may include the following: [1, 2] 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)

Laboratory Studies
Laboratory studies are usually not necessary

In patients with who do not fit the typical profile of those with Achilles tendinitis or who have systemic or bilateral symptoms, appropriate laboratory workup and medical referral may be carried out to evaluate for possible autoimmune disorder.

Imaging Studies
X-rays are usually not useful in the diagnosis of Achilles tendinitis. There may be tendon calcifications in tendinosis or spurs at the calcaneal insertion site, but neither are diagnostic for Achilles tendinitis. Magnetic resonance imaging (MRI) can provide useful information in refractory cases and in patients being considered for surgery.[16] In paratenonitis, fluid may be seen in and around the tendon. In chronic paratenonitis, the paratenon may be thicken and fibrotic. In tendinosis, increased MRI signal is evident in the tendon and degenerative changes, and occasionally partial tears may be seen. Keep in mind that these MRI findings may also be present in asymptomatic individuals. Ultrasound is a relatively inexpensive, fast, and repeatable modality. Use of ultrasound permits dynamic assessment of the tendon and determines the degree of thickening but requires technical expertise. [16, 17] Ultrasound does not distinguish a partial tear from tendinosis as MRI can. In a small study, De Zordo et al compared a newly introduced ultrasound technique, real-time sonoelastography, with clinical examination and conventional ultrasound in differentiating Achilles tendon tendinopathy changes between symptomatic patients and healthy volunteers.[18] Relative to 93% of healthy volunteers, who had hard tendons, 57% of the symptomatic patients demonstrated distinct softening of the Achilles tendon on sonoelastography, with more frequent involvement in the distal and middle thirds than the proximal third of the tendon. Seven percent of the volunteers and 11% of the patients had mild tendon softening.[18] Using clinical examination as the reference standard, De Zordo et al found that sonoelastography had a mean 94% sensitivity, 99% specificity, and 97% accuracy, with a 0.89 correlation to ultrasound. [18] The investigators concluded that this imaging modality was comparable to clinical examination and ultrasound findings only with distinct softening of the Achilles tendon, but very early changes in tissue elasticity in Achilles tendinopathy may cause mild softening, which should be assessed in follow-up studies.[18]

Acute Phase
Paratenonitis
Relative rest from activities that involve forceful and repetitive ankle plantarflexion are recommended. In athletes wishing to maintain conditioning while waiting for the injury to heal, cross training with activities that dont involve forceful plantarflexion can be employed. Examples of these exercises are swimming, biking (with the pedal on the heel), and aqua jogging. In mild cases, a runner may continue to run and still allow their injury to heal by simply reducing their mileage and eliminating hills for a while. In severe cases, complete rest with crutches or a walking cast or boot may be needed for a short time. Icing to reduce inflammation and pain is often helpful. Nonsteroidal anti-inflammatory drugs (NSAIDs) can also reduce inflammation and pain. Heel lifts of 10-15 mm for short-term use my reduce symptoms by reducing the stress and excursion of the tendon. Fluoroquinolones should be stopped, as these agents have been associated with Achilles tendinitis and rupture.

Tendinosis

The initial treatment for tendinosis is similar to paratenonitis (above), although tendinosis tends to less responsive to NSAIDs and ice, unless there is concomitant paratenonitis. Some clinicians feel patients with Achilles tendinosis are predisposed to rupture and should be protected, but this is controversial.

Physical therapy
Correcting strength and flexibility deficits of the muscle-tendon unit in Achilles tendinitis can commence when the acute pain subsides. This can be done under the supervision of a physical therapist or from instructions or handouts from the physician. Calf stretches should be done with the knee in both extension (to stretch the gastrocnemius muscle) and flexion (to stretch the soleus muscle). Strengthening usually starts with isometric exercises, and progresses to isotonic and, finally, isometric exercises. As with stretching, strengthening should be done with the knee in extension and flexion. A heavy-load, eccentric, calf strengthening program has been show to be highly beneficial for treating resistant tendinosis in runners and for getting them back to full activity. [19, 20] Cross training with low-impact exercises can begin during this phase. If pain develops, the athlete should decrease the amount of activity one level to alleviate the pain. If the individual is pain free with low-impact activity, the athlete can begin sport-specific training. If pain develops as activity is escalated, the patient should decrease the level of activity to one that doesnt cause pain. Care must be taken to not commit another training error if that is what initially caused the tendinitis. The patient should warm up the muscle-tendon unit well before engaging in vigorous activity, such as sprinting and jumping. In chronic, refractory cases of paratenonitis and tendinosis with a tight heel cord despite stretching, a night splint can be used.[21] This orthosis is similar to an orthopedic boot and is worn at night keeping the ankle at 5 dorsiflexion. In refractory cases with hyperpronation, a custom orthotic with a medial heel posting may be tried. In chronic cases of paratenonitis, some authors have advocated bupivacaine injection into the sheath to disrupt adhesions. Others have suggested that 2 cm of saline injection to the sheath may lift the paratenon off the tendon and lead to improvement.

Medical issues/complications
Steroid injections into and around the tendon are not advised because they have been shown to weaken the tendon. Achilles tendinitis may progress to rupture. Steroid injections, especially multiple injections, may weaken the tendon, leading to tendon rupture.

Surgical intervention
Operative treatment may be indicated if there are disabling or unacceptable symptoms despite 6-12 months of nonoperative treatment.[22, 23] . MRI is obtained before surgery to better define the pathology. Although there are no absolute indications to surgery, relative contraindications include noncompliant patients, an active infection site, and patients with potential wound-healing problems (eg, diabetes mellitus,peripheral vascular disease, smokers).

In paratenonitis, fibrotic adhesions and nodules are excised, freeing up the tendon. Longitudinal tenotomies may be performed to decompress the tendon. Satisfactory results have been obtained in 75100% of cases. In tendinosis, in addition to the above procedures, the degenerated portions of the tendon and any osteophytes are excised. Haglunds deformity, if present, is removed. If the remaining tendon is too thin and weak, the plantaris or flexor hallucis longus tendons can be weaved through the Achilles tendon to provide more strength. The outcome is generally less favorable than surgery for paratenonitis. Twentyfive percent of patients were unable to return to preinjury level of activity Surgery is followed immediately with passive ROM and progressive weight bearing and strengthening for 2-3 weeks. When the patient is able to ambulate without pain, he or she 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.

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. Platelet-rich plasma (PRP) injections have become popular recently for refractory tendinosis, particularly chronic lateral epicondylitis. Results of studies on the effectiveness of PRP injections have been mixed. With regard to Achilles tendinosis, recent study results indicated no difference in outcome between intratendinous PRP injections and saline injections at 1 year. [24]

Maintenance Phase
The athlete must be sure that the underlying cause of the tendinitis has been corrected. If it was a training error, the athlete must be educated on importance of starting a new activity slowly and to increase activity gradually, including allowing rest days. If hyperpronation was hypothesized as the cause, orthotics could be considered. The athlete should remain on a maintenance program of daily stretching after activity and every-other-day strengthening. If the activity of choice is a high impact one such as running or jumping, it is advised that the athlete start with low-impact activity. If symptoms dont return, gradual progression to higher impact and sport-specific activity can be carried out. Sport-specific activity can subsequently be introduced.

Physical therapy
Achilles tendinitis 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. Application of moist heat or compresses before workouts and at night are beneficial. Cold modalities should be used following strenuous activities to provide pain relief and anti-inflammatory effects.

Medication Summary
No medical therapy of choice exists. Most patients are treated symptomatically with acetaminophen or NSAIDs as determined by the patient's medical condition and the physician's preferences.

Analgesics/Antipyretics

Class Summary
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 who have sustained injuries.
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Acetaminophen (Tylenol, Feverall, Tempra)

DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

Class Summary
NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. The mechanism of action of these agents is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well; these may include inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.
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Ibuprofen (Motrin, Advil)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Complications
Patients with long-standing Achilles tendinitis or tendinosis may have their conditions progress to complete rupture of the tendon.

Prevention
The keys to prevention of Achilles tendinitis are not committing a training error, introducing new activities slowly, continuing on a maintenance program of stretching and strengthening, and warming up well before subjecting the tendon to heavy loads.

Prognosis
The recovery time is generally weeks to months. There is a longer recovery time with tendinosis. Recurrences are common.