Achilles tendinitis
{{Short description|Medical condition of the ankle and heel}}
{{Infobox medical condition (new)
| name = Achilles tendinitis
| synonyms = Achilles tendinopathy, Achilles tendonitis, Achilles tenosynovitis
| image = Achilles tendonitis.svg
| caption = Drawing of Achilles tendinitis with the affected part highlighted in red
| pronounce =
| field = Rheumatology
| symptoms = Pain, swelling around the affected tendon
| complications =
| types = Noninsertional, insertional
| risks = Trauma, lifestyle that includes little exercise, high-heel shoes, rheumatoid arthritis, medications of the fluoroquinolone or steroid class
| diagnosis = Based on symptoms and examination
| differential = Achilles tendon rupture
| prevention =
| treatment = Rest, ice, non-steroidal antiinflammatory agents (NSAIDs), physical therapy
| medication =
| prognosis =
| deaths =
}}
Achilles tendinitis, also known as Achilles tendinopathy, is soreness of the Achilles tendon. It is accompanied by alterations in the tendon's structure and mechanical properties.{{Cite journal|last=Silbernagel|first=Karin|date=2020|title=Current Clinical Concepts: Conservative Management of Achilles Tendinopathy|journal=Journal of Athletic Training|volume=55|issue=5|pages=0–0000|doi=10.4085/1062-6050-356-19|pmid=32267723|pmc=7249277}} The most common symptoms are pain and swelling around the back of the ankle. The pain is typically worse at the start of exercise and decreases thereafter. Stiffness of the ankle may also be present. Onset is generally gradual.
Achilles tendinopathy is idiopathic, meaning the cause is not well understood. Theories of causation include overuse such as running,{{cite web |title=Achilles Tendinitis |url=https://www.msdmanuals.com/en-gb/professional/injuries-poisoning/sports-injury/achilles-tendinitis |website=MSD Manual Professional Edition |access-date=27 June 2018 |date=March 2018}} a lifestyle that includes little exercise, high-heel shoes, rheumatoid arthritis, and medications of the fluoroquinolone or steroid class.{{cite journal |last1=Hubbard |first1=MJ |last2=Hildebrand |first2=BA |last3=Battafarano |first3=MM |last4=Battafarano |first4=DF |title=Common Soft Tissue Musculoskeletal Pain Disorders. |journal=Primary Care |date=June 2018 |volume=45 |issue=2 |pages=289–303 |doi=10.1016/j.pop.2018.02.006 |pmid=29759125|s2cid=46886582 }} Diagnosis is generally based on symptoms and examination.
Proposed interventions to treat tendinopathy have limited or no scientific evidence to support them, such as pre-exercise stretching, strengthening calf muscles, avoiding over-training, adjustment of running mechanics, and selection of footwear.{{cite journal |last1=Park |first1=DY |last2=Chou |first2=L |title=Stretching for prevention of Achilles tendon injuries: a review of the literature. |journal=Foot & Ankle International |date=December 2006 |volume=27 |issue=12 |pages=1086–95 |doi=10.1177/107110070602701215 |pmid=17207437|s2cid=8233009 }}{{cite journal |last1=Peters |first1=JA |last2=Zwerver |first2=J |last3=Diercks |first3=RL |last4=Elferink-Gemser |first4=MT |last5=van den Akker-Scheek |first5=I |title=Preventive interventions for tendinopathy: A systematic review. |journal=Journal of Science and Medicine in Sport |date=March 2016 |volume=19 |issue=3 |pages=205–211 |doi=10.1016/j.jsams.2015.03.008 |pmid=25981200|doi-access=free }}{{cite web |title=Achilles tendinitis - Symptoms and causes |url=https://www.mayoclinic.org/diseases-conditions/achilles-tendinitis/symptoms-causes/syc-20369020 |website=Mayo Clinic |access-date=27 June 2018 |language=en}} Treatment is symptomatic and non-specific such as ice, non-steroidal antiinflammatory agents (NSAIDs), and physical therapy. People who are not satisfied with symptomatic treatment may be offered surgery. Achilles tendinitis is relatively common.
Signs and symptoms
Symptoms can vary from an ache or pain and swelling in the local area of one or both ankles, or a burning that surrounds the whole joint. With this condition, the pain is usually worse during and after activity, and the tendon and joint area can become stiff the following day, as swelling impinges on the movement of the tendon.
Achilles tendon injuries can be separated into insertional tendinopathy (20%–25% of the injuries), midportion tendinopathy (55%–65%), and proximal musculotendinous junction (9%–25%) injuries, according to the location of pain.{{Cite journal|last=Kvist|first=M|date=1991|title=Achilles tendon injuries in athletes|url=|journal=Ann Chir Gynaecol|volume=80|issue=2|pages=188–201|pmid=1897886}}
Cause
File:Ankle Pronation Position.png
Achilles tendinitis is a common injury, particularly in sports that involve lunging and jumping, occurs both laterally and bilaterally, and is often induced in a single ankle by trauma. It is also a known side effect of fluoroquinolone antibiotics such as ciprofloxacin, as are other types of tendinitis.{{Cite news|url=http://www.cnn.com/2008/HEALTH/07/08/antibiotics.risk/index.html|title=FDA orders 'black box' label on some antibiotics |access-date=8 July 2008 |work=CNN | date=8 July 2008}}
Achilles tendinitis is thought to have physiological, mechanical, or extrinsic (i.e. footwear or training) causes. The Achilles tendon has a generally poor blood supply throughout its length, as measured by the number of vessels per cross-sectional area. Blood is supplied via the synovial sheaths that surround it.{{Cite journal |last1=Kader |first1=D. |last2=Saxena |first2=A. |last3=Movin |first3=T. |last4=Maffulli |first4=N. |date=2002-08-01 |title=Achilles tendinopathy: some aspects of basic science and clinical management |journal=British Journal of Sports Medicine |language=en |volume=36 |issue=4 |pages=239–249 |doi=10.1136/bjsm.36.4.239 |issn=0306-3674 |pmid=12145112|pmc=1724537 |doi-access=free }} This lack of blood supply can lead to the degradation of collagen fibers and inflammation.{{cite journal |author1=Fenwick S. A. |author2=Hazleman B. L. |author3=Riley G. P. | year = 2002 | title = The vasculature and its role in the damaged and healing tendon | journal = Arthritis Research | volume = 4 | issue = 4| pages = 252–260 |doi=10.1186/ar416 |pmid=12106496 | pmc = 128932 |doi-access=free }} Tightness in the calf muscles has also been known to be involved in the onset of Achilles tendinitis.{{cite journal |author1=Maffulli N. |author2=Sharma P. |author3=Luscombe K. L. | year = 2004 | title = Achilles tendinopathy: aetiology and management | journal = Journal of the Royal Society of Medicine | volume = 97 | issue = 10| pages = 472–476 | doi=10.1177/0141076809701004|pmid=15459257 |pmc=1079614}}
During the loading phase of the running and walking cycle, the ankle and foot naturally pronate and supinate by approximately 5 degrees.{{cite journal | author = Hintermann B., Nigg B. M. | year = 1998 | title = Pronation in runners | journal = Sports Medicine | volume = 26 | issue = 3| pages = 169–176 | doi=10.2165/00007256-199826030-00003 | pmid=9802173| s2cid = 24812917 }} Excessive pronation of the foot (over 5 degrees) in the subtalar joint is a type of mechanical mechanism that can lead to tendinitis.
An overuse injury refers to repeated stress and strain, which is likely the case in endurance runners.{{cite journal | author = Kannus P | year = 1997 | title = Etiology and pathophysiology of chronic tendon disorders in sports | journal = Scandinavian Journal of Sports Medicine | volume = 7 | issue = 2| pages = 78–85 | doi = 10.1111/j.1600-0838.1997.tb00123.x | pmid = 9211608 | s2cid = 664841 }}{{cite journal |author1=McCrory J. L. |author2=Martin D. F. |author3=Lowery R. B. |author4=Cannon D. W. |author5=Curl W. W. |author6=Read Jr H. M. |author7=Hunter D.M. |author8=Craven T. |author9=Messier S. P. |s2cid=25204643 | year = 1999 | title = Etiologic factors associated with Achilles tendinitis in runners | journal = Medicine and Science in Sports and Exercise | volume = 31 | issue = 10| pages = 1374–1381 | doi=10.1097/00005768-199910000-00003|pmid=10527307 |doi-access=free }} Overuse can simply mean an increase in running, jumping or plyometric exercise intensity too soon. Another consideration would be the use of improper or worn-down footwear, which lack the necessary support to maintain the foot in the natural/normal pronation.
Pathophysiology
Because the Achilles tendon does not have good blood supply, injuries can be slow to heal. The tendon receives nutrients from the tendon sheath or paratendon. When an injury occurs to the tendon, cells from surrounding structures migrate into the tendon to assist in repair. Some of these cells come from blood vessels that enter the tendon to provide direct blood flow to increase healing. With the blood vessels come nerve fibers. Researchers including Alfredson and his team in Sweden believe these nerve fibers to be the cause of the pain - they injected local anaesthetic around the vessels and this decreased significantly the pain in the Achilles tendon.{{Cite journal | last1 = Alfredson | first1 = H. | last2 = Ohberg | first2 = L. | last3 = Forsgren | first3 = S. | title = Is vasculo-neural ingrowth the cause of pain in chronic Achilles tendinosis? An investigation using ultrasonography and colour Doppler, immunohistochemistry, and diagnostic injections. | journal = Knee Surg Sports Traumatol Arthrosc | volume = 11 | issue = 5 | pages = 334–8 |date=Sep 2003 | doi = 10.1007/s00167-003-0391-6 | pmid = 14520512 | s2cid = 12264939 }}
Diagnosis
File:Achilles insertional calcific tendinosis (labeled).jpg within the Achilles tendon at its calcaneal insertion. The Achilles tendon is wider than normal, further suggesting inflammation.]]
Achilles tendinitis is usually diagnosed from a medical history, and physical examination of the tendon. Projectional radiography shows calcification deposits within the tendon at its calcaneal insertion in approximately 60 percent of cases. Magnetic resonance imaging (MRI) can determine the extent of tendon degeneration, and may show differential diagnoses such as bursitis.{{cite web|url=http://www.aofas.org/footcaremd/conditions/ailments-of-the-ankle/Pages/Insertional-Achilles-Tendinitis.aspx|title=Insertional Achilles Tendinitis|website=American Orthopaedic Foot & Ankle Society|access-date=2017-01-17}}
Prevention
Performing consistent physical activity will improve the elasticity and strength of the tendon, which will assist in resisting the forces that are applied.{{cite journal | author = Hess G.W. | year = 2009 | title = Achilles Tendon Rupture: A Review of Etiology, Population, Anatomy, Risk Factors, and Injury Prevention | journal = Foot & Ankle Specialist| volume = 3 | issue = 1| pages = 29–32 | doi = 10.1177/1938640009355191 | pmid = 20400437 | s2cid = 19237310 }}
Stretching before beginning an exercise session is often recommended, however evidence to support this practice is limited. Prevention of recurrence includes following appropriate exercise habits and wearing low-heeled shoes. In the case of incorrect foot alignment, orthotics can be used to properly position the feet. Footwear that is specialized to provide shock-absorption can be utilized to defend the longevity of the tendon.{{cite journal|author=Alfredson H., Lorentzon R.|year=2012|title=Chronic Achilles Tendinosis: Recommendations for Treatment and Prevention|url=http://www.peakxvfitness.com/achilles-tendinopathy/ |journal=Sports Medicine|volume=29|issue=2|pages=135–146|doi=10.2165/00007256-200029020-00005 |pmid=10701715|s2cid=36957036}} Achilles tendon injuries can be the result of exceeding the tendon's capabilities for loading, therefore it is important to gradually adapt to exercise if someone is inexperienced, sedentary, or is an athlete who is not progressing at a steady rate.
Eccentric strengthening exercises of the gastrocnemius and soleus muscles are utilized to improve the tensile strength of the tendon and lengthen the musculotendinous junction, decreasing the amount of strain experienced with ankle joint movements.G T Allison, C Purdam. Eccentric loading for Achilles tendinopathy — strengthening or stretching? Br J Sports Med 2009;43:276-279 This eccentric training method is especially important for individuals with chronic Achilles tendinosis which is classified as the degeneration of collagen fibers.
Treatment
Treatment typically involves rest, ice, non-steroidal antiinflammatory agents (NSAIDs), and physical therapy. A heel lift{{cite web |last1=Munteanu |first1=Shannon |title=Customised foot orthoses for Achilles tendinopathy RCT: responding to the critics |url=https://blogs.bmj.com/bjsm/2014/11/03/customised-foot-orthoses-for-achilles-tendinopathy-rct-responding-to-the-critics/ |website=British Journal of Sports Medicine|date=3 November 2014 }} or orthotics {{cite journal |last1=Munteanu |first1=Shannon |title=Effectiveness of customised foot orthoses for Achilles tendinopathy: a randomised controlled trial |url=https://pubmed.ncbi.nlm.nih.gov/25246441/ |journal=British Journal of Sports Medicine|year=2015 |volume=49 |issue=15 |pages=989–994 |doi=10.1136/bjsports-2014-093845 |pmid=25246441 |s2cid=5588570 }} may also be helpful, but evidence for either is limited. Foam rolling may increase range of motion, but there is only weak evidence for the direct treatment of stiffness.{{cite journal |last1=Baumgart |first1=Christian |title=Foam Rolling of the Calf and Anterior Thigh: Biomechanical Loads and Acute Effects on Vertical Jump Height and Muscle Stiffness |journal=Sports |year=2019 |volume=7 |issue=1 |page=27 |doi=10.3390/sports7010027 |pmid=30669477 |pmc=6359537 |doi-access=free }} Other treatments include:
- An eccentric exercise routine designed to strengthen the tendon.
- Application of a boot or cast.
=Injections=
The evidence to support injection therapies is poor.{{cite journal |last1=Kearney |first1=RS |last2=Parsons |first2=N |last3=Metcalfe |first3=D |last4=Costa |first4=ML |title=Injection therapies for Achilles tendinopathy. |journal=The Cochrane Database of Systematic Reviews |date=26 May 2015 |issue=5 |pages=CD010960 |doi=10.1002/14651858.CD010960.pub2 |pmid=26009861|url=http://wrap.warwick.ac.uk/100504/1/WRAP-injection-therapies-Achilles-tendinopathy-Kearney-2015.pdf }}
- This includes corticosteroid injections. These can also increase the risk of tendon rupture.
- Autologous blood injections - results have not been highly encouraging and there is little evidence for their use.{{cite web |url=http://www.jbjs.org/article.aspx?articleid=35811 |title=JBJS | Limited Evidence Supports the Effectiveness of Autologous Blood Injections for Chronic Tendinopathies |work=jbjs.org |year=2012 |access-date=February 12, 2012 |archive-url=https://web.archive.org/web/20120329045939/http://www.jbjs.org/article.aspx?articleid=35811 |archive-date=March 29, 2012 |url-status=dead }}{{cite web |url= http://bmb.oxfordjournals.org/content/95/1/63.full |archive-url= https://archive.today/20130415144101/http://bmb.oxfordjournals.org/content/95/1/63.full |url-status= dead |archive-date= April 15, 2013 |title=Autologous growth factor injections in chronic tendinopathy: a systematic review |vauthors=de Vos RJ, van Veldhoven PL, Moen MH, Weir A, Tol JL, Maffulli N |work=bmb.oxfordjournals.org |year=2012 |access-date=February 12, 2012}}
=Procedures=
Tentative evidence supports the use of extracorporeal shockwave therapy.{{cite journal |last1=Korakakis |first1=V |last2=Whiteley |first2=R |last3=Tzavara |first3=A |last4=Malliaropoulos |first4=N |title=The effectiveness of extracorporeal shockwave therapy in common lower limb conditions: a systematic review including quantification of patient-rated pain reduction. |journal=British Journal of Sports Medicine |date=March 2018 |volume=52 |issue=6 |pages=387–407 |doi=10.1136/bjsports-2016-097347 |pmid=28954794|doi-access=free }}
Epidemiology
The prevalence of Achilles tendinitis varies among different ages and groups of people. Achilles tendinitis is most commonly found in individuals aged 30–40{{cite journal |author1=Leach R. E. |author2=James S. |author3=Wasilewski S. | year = 1981 | title = Achilles tendinitis | journal = The American Journal of Sports Medicine | volume = 9 | issue = 2| pages = 93–98 | doi=10.1177/036354658100900204|pmid=7223927 |s2cid=10111816 }} Runners are susceptible, as well as anyone participating in sports,
Risk factors include participating in a sport or activity that involves running, jumping, bounding, and change of speed. Although Achilles tendinitis is mostly likely to occur in runners, it also is more likely in participants in basketball, volleyball, dancing, gymnastics and other athletic activities. Other risk factors include gender, age, improper stretching, and overuse.{{Cite journal | pmid = 8820370| year = 1996| last1 = Kainberger| first1 = F| title = Differential diagnosis of diseases of the Achilles tendon. A clinico-sonographic concept| journal = Der Radiologe| volume = 36| issue = 1| pages = 38–46| last2 = Fialka| first2 = V| last3 = Breitenseher| first3 = M| last4 = Kritz| first4 = H| last5 = Baldt| first5 = M| last6 = Czerny| first6 = C| last7 = Imhof| first7 = H| doi = 10.1007/s001170050037| s2cid = 25971164}} Another risk factor is any congenital condition in which an individual's legs rotate abnormally, which in turn causes the lower extremities to overstretch and contract; this puts stress on the Achilles tendon and will eventually cause Achilles tendinitis.
References
{{Reflist}}
External links
{{Medical resources
| DiseasesDB = 31726
| ICD10 = {{ICD10|M|76|6|m|70}}
| ICD9 = {{ICD9|726.71}}
| ICDO =
| OMIM =
| MedlinePlus = 001072
| eMedicineSubj = sports
| eMedicineTopic = 2
| MeshID =
}}
{{Soft tissue disorders}}
{{DEFAULTSORT:Achilles Tendonitis}}