Achilles Tendonitis

KEY FEATURES

• The Achilles tendon

  • The body's thickest and strongest tendon

  • Remains mostly hypovascular, especially in the classic watershed area

  • Along with the gastrocnemius and soleus muscles, crosses three joints in the lower extremity

  • Participates in knee flexion, ankle flexion, and subtalar inversion

  • Subjected to a high load, up to 12.5 times a person's body weight during running, putting it at risk for injury

• Achilles tendon pathology can occur in both athletes and less active individuals, with obesity being a major contributor

• Common Achilles tendon conditions include insertional Achilles tendinopathy, Achilles paratenonitis, and retrocalcaneal bursitis

CLINICAL FINDINGS

• Pain or swelling along the Achilles tendon

• Pain increased with physical activity (eg, climbing stairs or sprinting)

• Pain when wearing shoes

DIAGNOSIS

• Lateral foot radiograph can show posterior bone spurs or calcifications within the Achilles tendon

• MRI and ultrasonography provide more information about the level of disease within the tendon

TREATMENT

• Conservative care

  • Nonsteroidal anti-inflammatory drugs, ice, rest, or activity modification

  • Orthosis and shoe modification to control hyperpronation

  • Friction-reducing shoes for insertional Achilles tendinopathy

  • Physical therapy including strengthening, stretching, proprioception, and anti-inflammatory modalities

  • Heel lifts to reduce load on the Achilles tendon during daily activity

  • Short-term immobilization with a boot or cast for nonresponsive or noncompliant patients

  • Controversial options: Corticosteroid injections, platelet-rich plasma, and sclerosing agents

• Surgery

  • Insertional tendinopathy: Removal of the prominent bone (Hagland deformity) and debridement of the Achilles tendon; reattachment of the Achilles tendon may be necessary

  • Tendon debridement when the insertion site is not the source of pain

  • Other options: Tendon transfers or augmentation (eg, flexor digitorum longus)

  • Percutaneous options (Tenex and Topaz procedures) to break up scar tissue and stimulate vasculature

• Limited data are available to validate these treatment modalities