Achilles Tendonitis – Causes, Symptoms, Diagnosis, Treatment

Achilles Tendonitis is one of the most frequently ankle and foot overuse injuries, which is a clinical syndrome characterized by the combination of pain, swelling, and impaired performance. The two main categories of Achilles tendinopathy are classified according to anatomical location and broadly include insertional and non insertional tendinopathy. The etiology of Achilles Tendonitis multifactorial including both intrinsic and extrinsic factors. Failed healing response and degenerative changes were found in the tendon. The failed healing response includes three different and continuous stages (reactive tendinopathy, tendon disrepair, and degenerative tendinopathy).

Causes of Achilles Tendonitis

The causes and mechanisms of Achilles Tendonitis (AT) include the following

  • 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.

Factors related to a high risk of rupture of the Achilles tendon link to advanced age due to a lack of uniformity of the tendons, slippage of the fascicles, and excessive exercise in athletes, Sports minded individuals tend to have an injury at the Achilles tendon insertion site.

Systemic Factors

Systemic diseases that may be associated with Achilles tendonitis injuries include the following

  • Chronic renal failure
  • Collagen deficiency
  • Diabetes mellitus
  • Gout
  • Infections
  • Lupus
  • Parathyroid disorders
  • Rheumatoid arthritis
  • Thyroid disorders

Foot problems that increase the risk of Achilles tendon injuries include the following

  • Cavus foot
  • Insufficient gastroc soleus flexibility and strength
  • limited ability to perform ankle dorsiflexion
  • Tibia vara
  • Varus alignment with functional hyper pronation

Symptoms of Achilles Tendonitis

  • You hear a snap, crack or popping sound when pushing off with your leg, often accompanied by a sharp pain in the back of your leg or ankle
  • Trouble moving your foot to walk or go upstairs. You’re unable to stand on your toes (“tippy-toe”)
  • Pain, bruising and swelling at the back of your leg or heel
  • Chronic, recurrent calf or Achilles tendon ̶ area pain
  • Previous rupture of the affected tendon
  • Loss of plantarflexion power in the foot
  • Swelling of the calf
  • The recent increase in physical activity/training volume
  • Recent use of fluoroquinolones, corticosteroids, or corticosteroid injections

Diagnosis of Achilles Tendonitis

Physical exploration

  • Clinical signs and symptoms of Achilles Tendonitis include localized pain, focal or diffuse sensitivity,  swelling, stiffness/morning pain, perceived rigidity in the Achilles’ tendon, positive arc sign, Royal London Hospital test, and Thompson test.

Tests used to diagnose Achilles tendinopathy

  • Lateral and axial calcaneus x-rays – 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 the 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.
  • 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.

Differential Diagnosis

  • Achilles bursitis
  • Ankle fracture
  • Ankle impingement syndrome
  • Ankle osteoarthritis
  • Ankle sprain
  • Calf injuries
  • Calcaneofibular ligament injury
  • Calcaneus fractures
  • Deep venous thrombosis (DVT)
  • Exertional Compartment Syndrome
  • Fascial tears
  • Gastrocsoleus muscle strain or rupture
  • Haglund deformity
  • Plantaris tendon tear
  • Psoriatic arthritis
  • Reiter syndrome
  • Retrocalcaneal bursitis
  • Ruptured Baker cyst
  • Syndesmosis
  • Talofibular Ligament Injury

Treatment of Achilles Tendinopathy

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.

Conservative therapy:  It is the first line of management and includes the following

  • Reduction of activity levels
  • 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, extracorporeal 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 is not a recommendation
  • Current evidence shows a lack of efficacy on the use of platelet-rich plasma for Achilles tendinopathy

Nonoperative Management

  • Braces and immobilization – with a cast or pneumatic walking boot are combined with modified activity []. Immobilization is frequently used in the acute setting to control exacerbating factors, but prolonged immobilization should be avoided[].
  • Ultrasound – is a commonly prescribed program of physical therapy. In animal studies, ultrasound could stimulate collagen synthesis in tendon fibroblasts and cell division during the period of rapid cell proliferation []. Therapeutic ultrasound has been shown to reduce the swelling in the acute inflammatory phase of soft-tissue disorders, relieve pain, and increase function in patients with chronic tendon injuries and may enhance tendon healing [, ].
  • Low-level laser therapy (LLLT) – could reduce the expression of proinflammatory markers such as IL-6 and TNF-α in gene level []. In the cellular level, LLLT may increase collagen production [], stimulate tenocyte proliferation [], downregulate MMPs, decrease the capillary flow of neovascularization, and finally preserve the resistance and elasticity of tendon [, ].
  • Extracorporeal shockwave therapy (ESWT) – How ESWT works is still poorly understood, but it is known to cause selective dysfunction of sensory unmyelinated nerve fibers, alteration in the dorsal root ganglia, and cavitation in interstitial and extracellular disruption, which could promote the healing response [].
  • Deep friction massage (DFM) – and tendon mobilization may also be helpful in the treatment of Achilles tendinopathy. DFM has been advocated for tendinopathy and para tendinopathy. Friction has been shown to increase the protein output of tendon cells []. In combination with stretching, deep friction massage helps to restore tissue elasticity and reduce the strain in the muscle-tendon unit [, ]. Future randomized comparison studies are necessary to compare DFM in isolation with other modes of treatment.
  • Cryotherapy – might play a role in reducing the increased capillary blood flow in Achilles tendinopathy, reducing the metabolic rate of the tendon, and applying for relief of pain [, ]. However, recent evidence in upper limb tendinopathy indicated that the addition of ice did not offer any advantage over an exercise program consisting of eccentric and static stretching exercises [].

Medication

  • NSAIDs – used in chronic tendinopathy is questionable because the histological examination in the tendinopathic tissue shows no inflammatory cells []. The benefits of NSAIDs use are relieving pain in the acute phase and reducing the possibility of leg stiffness []. However, there are some studies that indicated that the NSAIDs may inhibit tendon cell migration and proliferation and impair tendon healing [].
  • Corticosteroid injections – are reported to reduce pain and swelling and improve the ultrasound appearance of the tendon. The mechanism behind any positive effect of local steroids on chronic Achilles tendinopathy remains unclear. Some authors have hypothesized that any beneficial effects of corticosteroids in this condition are owed to other local steroid effects rather than suppression of inflammation, including lyses of tendon and peritendon adhesions or alteration of the function of pain generating nociceptor in the region [].
  • Platelet-rich plasma (PRP) – at the site of tendon injury is thought to facilitate healing because it contains several different growth factors and other cytokines that can stimulate the healing of soft tissue []. Animal studies indicated that PRP could increase the expression of collagen types I and III and vascular endothelial growth factor and improve the healing and remodeling process of the tendon [, ].
  • Intratendinous hyperosmolar dextrose (prolotherapy) – is thought to produce a local inflammatory response and an increase in tendon strength. Clinical results indicated that intratendinous injections of hyperosmolar dextrose could reduce the pain at rest and during tendon-loading activities in patients with chronic of the Achilles tendinopathy [, ]. Moreover, after the injection of dextrose, there were reductions in the size and severity of hypoechoic regions and intratendinous tears and improvements in neovascularity [].
  • Nitric oxide – is a small-free radical generated by a family of enzymes, the nitric oxide synthases. It can induce apoptosis in inflammatory cells and cause angiogenesis and vasodilation. Moreover, oxygen-free radicals can stimulate fibroblast proliferation []. Nitric oxide can enhance tendon healing. Inhibition of nitric oxide synthase can reduce the healing process, which resulted in a decreased cross-sectional area and reduced failure load [].
  • The sclerosing agent – that selectively targets the vascular may cause thrombosis of the vessel. As the concomitant sensory nerves have been implicated as possible pain generators, to destroy local nerves adjacent to neovessels may decrease pain []. As vessel number has been shown to correlate with tendon thickness, a treatment that decreases vessel number is likely to also affect the tendon thickness. Moreover, the sclerosing agent injected at multiple sites around the tendon and neovessels initiates a local inflammatory response, which induces the proliferation of fibroblasts and the synthesis of collagen.
  • Aprotinin – is a broad-spectrum serine protease inhibitor capable of blocking trypsin, plasmin, kallikrein, and a range of MMPs []. Most previous studies using Aprotinin injection in the management of Achilles tendinopathy showed a trend towards improved clinical results [, ]. The major potential negative of using Aprotinin is the side effect of allergy [], but the allergic reactions can be reduced by minimizing repeat injections and recommending a delay of at least 6 weeks between injections [].
  • Autologous blood injections – results have not been highly encouraging and there is little evidence for their use.[rx]

Surgery

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%.

Noninsertional Achilles Tendonitis

  • The goal of surgery is to resect degenerative tissue, stimulate tendon healing by means of controlled, low-grade trauma, and/or augment the Achilles tendon with grafts. It has been suggested that noninvasive treatment should be tried for at least 4 months prior to operative interventions []. Conventional surgical treatment has consisted of open release of adhesions with or without resection of the paratenon. If >50% of the tendon has been debrided, augmentation or reconstruction is recommended [].

Insertional Achilles Tendonitis

  • Patients who do not respond to conservative treatment may need operative management []. The operative strategy for insertional Achilles tendinopathy is the removal of the degenerative tendon and associated calcification, excision of the inflamed retrocalcaneal bursa, resection of the prominent posterior calcaneal prominence, reattachment of the insertion as required, and/or augmentation of the tendo-Achilles with a tendon transfer/graft [, ]. Calcaneoplasty and resection of the retrocalcaneal bursa can be performed endoscopically [].

Complications

Re-rupture

  • While newer level 1 evidence has reported no difference in re-rupture rates, prior studies have suggested a 10% to 40% re-rupture rate with nonoperative management (compared to 1% to 2% rate of re-rupture after surgery)

  • Lantto et al. recently demonstrated in a randomized controlled trial of 60 patients from 2009 to 2013 at 18-month follow-up: 

    • Similar Achilles tendon performance scores
    • Slightly increased calf muscle strength differences favoring the operative cohort (10% to 18% strength difference) at 18-month follow-up
    • Slightly better health-related quality of life scores in the domains of physical functioning and bodily pain favoring the operative cohort

Wound Healing Complications

  • Overall, a 5-10% risk following surgery

  • Risk factors for postoperative wound complications include:

    • Smoking (most common and most significant risk factor)
    • Female gender
    • Steroid use
    • Open technique (vs percutaneous procedures)

Sural Nerve Injury

  • Increased rate of injury associated with the percutaneous procedure (compared to open technique)

References

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