Achilles tendinitis, also known as Achilles tendinopathy, is soreness of the

Achilles tendon The Achilles tendon or heel cord, also known as the calcaneal tendon, is a tendon at the back of the lower leg, and is the thickest in the human body. It serves to attach the plantaris, gastrocnemius (calf) and soleus muscles to the calcane ...

. It is accompanied by alterations in the tendon's structure and mechanical properties. The most common symptoms are pain and swelling around the back of the

ankle The ankle, the talocrural region or the jumping bone (informal) is the area where the foot and the leg meet. The ankle includes three joints: the ankle joint proper or talocrural joint, the subtalar joint, and the inferior tibiofibular joint. The ...

. 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 Running is a method of terrestrial locomotion by which humans and other animals move quickly on foot. Running is a gait with an aerial phase in which all feet are above the ground (though there are exceptions). This is in contrast to walkin ...

, a lifestyle that includes little exercise, high-heel shoes,

rheumatoid arthritis Rheumatoid arthritis (RA) is a long-term autoimmune disorder that primarily affects synovial joint, joints. It typically results in warm, swollen, and painful joints. Pain and stiffness often worsen following rest. Most commonly, the wrist and h ...

, and medications of the fluoroquinolone or

steroid A steroid is an organic compound with four fused compound, fused rings (designated A, B, C, and D) arranged in a specific molecular configuration. Steroids have two principal biological functions: as important components of cell membranes t ...

class. Diagnosis is generally based on symptoms and examination. Proposed interventions to treat tendinopathy have limited or no

scientific evidence Scientific evidence is evidence that serves to either support or counter a scientific theory or hypothesis, although scientists also use evidence in other ways, such as when applying theories to practical problems. "Discussions about empirical ev ...

to support them, such as pre-exercise stretching, strengthening calf muscles, avoiding over-training, adjustment of running mechanics, and selection of footwear. Treatment is symptomatic and non-specific such as ice,

non-steroidal antiinflammatory agents Non-steroidal anti-inflammatory drugs (NSAID) are members of a therapeutic drug class which reduces pain, decreases inflammation, decreases fever, and prevents blood clots. Side effects depend on the specific drug, its dose and duration of ...

(NSAIDs), and

physical therapy Physical therapy (PT), also known as physiotherapy, is a healthcare profession, as well as the care provided by physical therapists who promote, maintain, or restore health through patient education, physical intervention, disease preventio ...

. 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 A joint or articulation (or articular surface) is the connection made between bones, ossicles, or other hard structures in the body which link an animal's skeletal system into a functional whole.Saladin, Ken. Anatomy & Physiology. 7th ed. McGraw- ...

. 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.

Cause

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 Ciprofloxacin is a fluoroquinolone antibiotic used to treat a number of bacterial infections. This includes bone and joint infections, intra-abdominal infections, certain types of infectious diarrhea, respiratory tract infections, skin ...

, as are other types of tendinitis. 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. This lack of blood supply can lead to the degradation of collagen fibers and inflammation. Tightness in the calf muscles has also been known to be involved in the onset of Achilles tendinitis. During the loading phase of the running and walking cycle, the ankle and foot naturally

pronate Motion, the process of movement, is described using specific anatomical terms. Motion includes movement of organs, joints, limbs, and specific sections of the body. The terminology used describes this motion according to its direction relativ ...

and

supinate Motion, the process of movement, is described using specific anatomical terms. Motion includes movement of organs, joints, limbs, and specific sections of the body. The terminology used describes this motion according to its direction relativ ...

by approximately 5 degrees. Excessive pronation of the foot (over 5 degrees) in the

subtalar joint In human anatomy, the subtalar joint, also known as the talocalcaneal joint, is a joint of the foot. It occurs at the meeting point of the talus and the calcaneus. The joint is classed structurally as a synovial joint, and functionally as a pl ...

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. 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 A tendon sheath is a layer of synovial membrane around a tendon. It permits the tendon to stretch and not adhere to the surrounding fascia. It contains a lubricating fluid (synovial fluid) that allows for smooth motions of the tendon during muscl ...

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.

Diagnosis

Achilles tendinitis is usually diagnosed from a

medical history The medical history, case history, or anamnesis (from Greek: ἀνά, ''aná'', "open", and μνήσις, ''mnesis'', "memory") of a patient is a set of information the physicians collect over medical interviews. It involves the patient, and ev ...

, and

physical examination In a physical examination, medical examination, clinical examination, or medical checkup, a medical practitioner examines a patient for any possible medical signs or symptoms of a Disease, medical condition. It generally consists of a series of ...

of the tendon.

Projectional radiography Projectional radiography, also known as conventional radiography, is a form of radiography and medical imaging that produces two-dimensional images by X-ray radiation. The image acquisition is generally performed by radiographers, and the images a ...

shows calcification deposits within the tendon at its

calcaneal In humans and many other primates, the calcaneus (; from the Latin ''calcaneus'' or ''calcaneum'', meaning heel; : calcanei or calcanea) or heel bone is a bone of the tarsus of the foot which constitutes the heel. In some other animals, it is th ...

insertion in approximately 60 percent of cases.

Magnetic resonance imaging Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to generate pictures of the anatomy and the physiological processes inside the body. MRI scanners use strong magnetic fields, magnetic field gradients, and ...

(MRI) can determine the extent of tendon degeneration, and may show differential diagnoses such as bursitis.

Prevention

Performing consistent physical activity will improve the elasticity and strength of the tendon, which will assist in resisting the forces that are applied.

Stretching Stretching is a form of physical exercise in which a specific muscle or tendon (or muscle group) is deliberately expanded and flexed in order to improve the muscle's felt elasticity and achieve comfortable muscle tone. The result is a feelin ...

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 Orthotics () is a medical specialty that focuses on the design and application of orthoses, sometimes known as braces, calipers, or splints. An is "an externally applied device used to influence the structural and functional characteristics of ...

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. 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 Ultimate tensile strength (also called UTS, tensile strength, TS, ultimate strength or F_\text in notation) is the maximum stress that a material can withstand while being stretched or pulled before breaking. In brittle materials, the ultimate ...

of the tendon and lengthen the musculotendinous junction, decreasing the amount of strain experienced with ankle joint movements. 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,

(NSAIDs), and

. A heel lift or orthotics 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. 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. * This includes

corticosteroid Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex of vertebrates, as well as the synthetic analogues of these hormones. Two main classes of corticosteroids, glucocorticoids and mineralocorticoids, are invo ...

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.

Procedures

Tentative evidence supports the use of extracorporeal shockwave therapy.

Epidemiology

The

prevalence In epidemiology, prevalence is the proportion of a particular population found to be affected by a medical condition (typically a disease or a risk factor such as smoking or seatbelt use) at a specific time. It is derived by comparing the number o ...

of Achilles

tendinitis Tendinopathy is a type of tendon disorder that results in pain, swelling, and impaired function. The pain is typically worse with movement. It most commonly occurs around the shoulder ( rotator cuff tendinitis, biceps tendinitis), elbow ( tenn ...

varies among different ages and groups of people. Achilles tendinitis is most commonly found in individuals aged 30–40. Runners are susceptible, as well as anyone participating in sports, and men aged 30–39. 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. 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

External links

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