Achilles Tendinopathy

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Clinically Relevant Anatomy

The Achilles tendon is the single tendon of the soleus and gastrocnemius muscles, inserting into the calcaneus.

Mechanism of Injury / Pathological Process

Achilles tendonitis is commonly seen in athletes who sustain an increase in training load, and is most often due to overuse. Tendons respond poorly to overuse, therefore healing is slow. This can leave a tendon pathologically substantially defective, which decreases tendon strength and leaves it less able to tolerate load, thus vulnerable to further injury. Extrinsic factors contributing to this condition include training errors and inappropriate footwear. Intrinsic factors include inflexibility, weakness and malalignment.

Clinical Presentation

Morning pain is a hallmark symptom because the Achilles tendon must tolerate full range of movement including stretch immediately on rising in the morning. Symptoms are typically localized to the tendon and immediate surrounding area. Swelling and pain at the attachment are less common. The tendon can appear to have subtle changes in outline, becoming thicker in the A-P and M-L planes.

Diagnostic Procedures

Imaging studies are not necessary to diagnose Achilles tendonitis, but may be useful with differential diagnosis. US is the imaging modality of first choice as it provides a clear indication of tendon width, changes of water content within the tendon and collagen integrity, as well as bursal swelling. MRI may be indicated if diagnosis is unclear or symptoms are atypical. MRI may show increased signal within the Achilles.

Outcome Measures

Robinson et al recommend the VISA-A scale. This is a subjective rating scae that quantifies the symptoms and dysfunction in the Achilles tendon. It is very useful to rate Achilles tendons and to assess progress of recovery during rehabilitation.

Management / Interventions

Treatment of Achilles tendinopathy is initially non-operative, including rest, equipment changes, strength and flexibility exercises, anti-inflammatory agents and corticosteroids. The effects of physical therapy on Achilles tendonitis is poorly understood, although musculotendinous strengthening appears essential. Eccentric exercises have been shown to have positive effects of Achilles tendonitis, and remains the gold standard for rehabiliation of this condition. A study by Roos et al concluded that eccentric exercises improve function and reduce pain and effects were apparent after 6 weeks of treatment, lasting for 1 year.

Differential Diagnosis

Posterior ankle impingement, medial tendinopathy, retrocalcaneal bursitis, sural nerve, lumbar radiculopathy, ankle OA, DVT, Haglund deformity, partial Achilles tendon rupture.

References

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