Achilles tendonitis

Alternate names

• Achilles Tendinopathy

Definition

• The Achilles tendon ranks as the strongest tendon in the human body. This tendon connects the plantaris, gastrocnemius, and soleus to the calcaneus bone. It allows the calf muscles to act on the heel, which is necessary for walking or running. Achilles tendinopathy is a painful overuse injury of the the tendon that is extremely common in athletes, especially those who participate in running and jumping sports. In addition to pain, Achilles tendinopathy is accompanied by alterations in the tendon's structure and mechanical properties, altered lower extremity function, and fear of movement.
• It is a condition characterized by pain, inflammation, and stiffness of the Achilles tendon.

Etiology

• Intrinsic factors: This includes anatomic factors, age, sex, metabolic dysfunction,foot cavity, dysmetria, muscle weakness, imbalance, gastrocnemius dysfunction, anatomical variation of the plantaris muscle, tendon vascularization, Torsion of the Achilles tendons, slippage of the fascicle, and lateral instability of the ankle.
• Extrinsic factors: These include mechanical overload, constant effort, inadequate equipment, obesity, medications (corticosteroids, anabolic steroids, fluoroquinolones), improper footwear, insufficient warming or stretching,hard training surfaces, and direct trauma, among others.

Epidemiology

• The Achilles tendon has a cumulative lifetime injury incidence of approximately 24% in athletes.
• The overall incidence rate of Achilles tendinopathy ruptures is 2.1 per 100000 person-years, and most AT ruptures occur in males, with a 3.5 to 1 male to female ratio.

Signs and symptoms

Clinical signs and symptoms of Achilles tendinopathy include:

• pain
• focal or diffuse sensitivity
• swelling
• stiffness/morning pain
• perceived rigidity in the Achilles tendon
• positive arc sign
• Royal London Hospital test
• Thompson test

Diagnosis

Tests used to diagnose Achilles tendinopathy:

• Lateral and axial calcaneus X ray: May detect calcifications in the proximal extension of the tendon insertion or bony prominences in the upper portion of the calcaneus. Also, x-rays can help exclude pathological bone tumors.

• ultrasound: Can help assess injury to the tendon; can be used to predict the risk of tendinopathy and rupture. Ultrasound may reveal increased thickness of the Achilles tendon with hyperemia associated with hypervascularity, a decrease in the gastrocnemius-soleus rotation angle and a decrease in the length of the Kager fat pad. Ultrasound is also useful during interventional treatment.

• MRI (Magnetic resonance imaging): Provides significant information about the state of joint structures with a study in multiple planes in static and dynamic views. One study found that MRI had lower sensitivity than ultrasound in the detection of early changes of enthesopathy.. Another study found an excellent agreement between tendon thickness measurement between magnetic resonance and ultrasound.

• Computed Tomography (CT): The CT scan is useful to rule out trabecular structural alterations of the calcaneus in Achilles pathology of insertion. However, it exposes the patient to radiation.

• Victoria Institute of Sports Assessment - Achilles (VISA-A) remains the gold standard for assessing pain and function, but it requires additional studies to increase its reliability. Nevertheless, it is an essential tool for patient post-treatment follow-up.

Management

Management of Achilles tendinopathy can divide into conservative and surgical. Additionally, one must consider whether it is an acute or chronic condition. Finally, for those with a full rupture, the treatment is usually surgical.  

1. Conservative therapy: It is the first line of management and includes the following:
   • Reduction of activity levels
   • Administration of non-steroidal anti-inflammatory drugs (NSAIDS)
   • Adaptation of footwear, manual therapy directed at local sites may enhance the rehabilitation
   • Eccentric stretching exercises should comprise an integral component of physiotherapy and can achieve a 40% reduction in pain; moderate level evidence favors eccentric exercise over concentric exercise for reducing pain
   • Tendon loading exercise at short- and long-term follow-up
   • If unresponsive to initial management, extra-corporeal shock wave therapy reduces pain by 60%, with 80% patient satisfaction, improving functionality and quality of life, with a follow-up at 4 weeks; this might be the first choice because of its safety and effectiveness
   • Physiotherapy improves the pain and functionality of the Achilles tendinopathy of the middle portion; however, studies do not show preferences for any particular exercise over another - overall, use of a splint to an eccentric exercise protocol or the use of orthoses to improve pain and function are not a recommendation
2. Surgical therapy is optional for 10 to 30% of patients who fail conservative therapy after six months. The success rate is higher than 70%, but reports show complication rates of 3 to 40%. The Achilles tendon should undergo reattachment with a tendon rupture of more than 50%.

Differential Diagnosis

• Plantar Fasciitis
• Nerve entrapment or neuroma
• Heel pad syndrome
• Haglund deformity

Prognosis

• Achilles tendinopathy has a better prognosis with early and adequate initial management. Surgical intervention for Achilles tendinosis of insertion (TAI) is successful in over 80% of cases.
• As the number of risk factors increase, the possibility of failure in non-operative treatment also increases.

Complications

• Major complications: Such as ruptured AT, any reoperation, Deep vein thrombosis, reflex Dystrophy, persistent Neuralgia, deep infections, major wound problems
• Minor complications: Such as discomfort. Infections superficial, minor wound problems, scar sensitivity, hypertrophy, mild Paraesthesia, prolonged hospitalization.

References

• Miguel A. Medina Pabόn; Usker Naqvi. Achilles Tendonitis [Updated August 8,2020]. In StatPearls [Internet]. Available from : https://www.ncbi.nlm.nih.gov/books/NBK538149/
• Karin Grävare Silbernagel , Shawn Hanlon, Andrew Sprague. Conservative Management of Achilles Tendinopathy. Available from: https://pubmed.ncbi.nlm.nih.gov/32267723/

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