Tendinopathy, achilles

• Achilles tendinitis
• Achilles tendonitis
• Achilles paratenonitis

• 726.71 Achilles bursitis or tendonitis

• M76.60 Achilles tendinitis, unspecified leg

• 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Localized Inflammation

Description

• Insertional Achilles tendinitis: fibers in middle portion of the tendon breakdown, degenerate, swell, thicken
• Noninsertional Achilles tendonitis: pain in lower portion of heel at tendon attachment
• Pain common at midportion of Achilles tendon
• Typically lacks presence of inflammatory cells, probably more tendonosis then tendonitis
• Typically associated with tissue degeneration
  • Two types
    • Lipoid: fatty tissue deposited in the tendon
    • Mucoid: conversion of tendon in softer material with gray or brown appearance
  • Thickening of tendon
  • Neovascularization
  • Increased presence of varicose nerve fibers
    • Most likely source of pain

Essentials of Diagnosis

• Patient history and clinical examination
• Ultrasound or MRI imaging

General Considerations

• Address training errors and biomechanics deficits to prevent recurrence

Demographics

• People participating in athletic activity; condition can also occur in sedentary individuals
  • Runners: 7 to 9% prevalence4
• Age: between 30 to 50 years of age (median)4
• Sex: Males more than females4
• Onset more common during training vs. competitive event

Signs and Symptoms

• Pain with palpation of tendon 2 to 6 cm proximal to the insertion
• Pain back of the heel
• Tenderness changes position with tendon movement during dorsiflexion and plantarflexion (arc sign)
• Increased swelling throughout the day
• Thickening of the tendon
• Decreased dorsiflexion range of motion (ROM)
• Decreased gastrocnemius strength
• Greater pronation/calcaneal varus and faster rate of max. pronation
• Decreased plantar flexion strength and endurance verse uninvolved side

Functional Implications

• Inability to climb stairs or ladder
• Inability to push-off during ambulation
• Decreased stride length during ambulation

Possible Contributing Causes

• Intrinsic risk factors
  • Decreased dorsiflexion ROM
  • Decreased gastrocnemius strength
  • Greater pronation/Calcaneal varus and faster rate of max. pronation
  • Comorbidities
  • Obesity
  • Diabetes
  • Hyperlipidemia
  • Hypertension
• Extrinsic risk factors
  • Training errors
    • Sudden increase in mileage or intensity or incline
    • Return from inactivity
  • Environmental factors
    • High incidence with training in cold weather
  • Faulty equipment

Differential Diagnosis

• Achilles tendon rupture
• Achilles tendon partial tear
• Bone spur
• Sural nerve pathology
• Retrocalcaneal bursitis
• Posterior ankle impingement
• Accessory soleus muscle
• S1 radiculopathy
• Achilles tendon ossification
• Achilles enthesopathy
• Os trigonum
• Systemic inflammatory disease
• Xanthoma of the tendon: accumulation of cholesterol in patients with familial hypercholesterolemia

Imaging

• Ultrasonography: (sn=85%, sp=49%)
• MRI: (sn=95%, sp=50%)1
• X-ray

• Hypertrophic tendon
• Hyperechoic mass at midtendon
• Irregular tendon structure

• Medication
  • NSAIDs
  • Prolotherapy: sclerosant injection (most common dextrose)

Medical Procedures

• Tendon ...