ACHILLES TENDONITIS


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related talks: torn achilles tendon; plantar fasciitis; common ankle sprain; high ankle sprain
 

What is Achilles Tendonitis?

 Achilles Tendonitis: Inflammation.

Achilles Tendonitis: Inflammation.

The Achilles tendon experiences forces 6-10 times a persons body weight during running.  It is the thickest tendon in the body, and its formed from your calf muscles and attaches into your heel bone to allow you to flex your foot downward. Over use or injury to this tendon can cause inflammation, and "tendonitis" is inflammation of the tendon.  The tendonitis can occur in 2 places along the achilles. It can occur right at the insertion on the heel bone, or it can occur in the middle portion of the tendon (usually about 2-6 cm from its insertion onto the bone).

How is Achilles Tendonitis diagnosed?

People will report significant tenderness at the heel where the tendon inserts (there is a fancy medical term for this called “enthesiopathy”).  X-rays of the heel bone (calcaneous) will often show a small bony spur within the tendon. X-rays are always a good idea to rule out other causes of heel pain, especially a calcaneus stress fracture.  

 Insertional Achilles Tendonitis: Inflammation causes calcific tendonitis (calcium formation inside the tendon).

Insertional Achilles Tendonitis: Inflammation causes calcific tendonitis (calcium formation inside the tendon).

There is another form of Achilles tendonitis, called Noninsertional Achilles tendonitis, which is inflammation of the tendon sheath (the paratenon) about 2-6 cm from the heel bone.  People with this condition will be sore along the tendon and the tendon will be very thick (but dont mistake the thickness for a strong tendon).  MRI is often ordered to evaluate how severely the tendon is affected (chronic inflammation will cause the achilles to breakdown).  Because the tendon starts to degenerate from chronic inflammation, its at a greater risk for achilles tendon rupture.  

 Non-Insertional Achilles Tendonitis: inflammation a few centimeters before the tendon inserts onto the heel.

Non-Insertional Achilles Tendonitis: inflammation a few centimeters before the tendon inserts onto the heel.

Finally, a third and common type of inflammation of the heel is called "retrocalcaneal bursitis".  This is an inflammation of the bursa (a bursa is a small fluid filled pouch that sits between the achilles tendon and the heel bone, acting as padding).  This type of inflammation often produces a small bone spur (in front of the tendon, compared to a bone spur inside the tendon with insertional tendonitis), and this bone spur is called a "Haglund deformity".    

 Achilles Buritis: A Haglund's Deformity is a bone spur that irritates the bursa causing inflammation.

Achilles Buritis: A Haglund's Deformity is a bone spur that irritates the bursa causing inflammation.

How is Achilles Tendonitis treated?

Achilles tendonitis is usually treated nonsurgically with a combination of anti-inflammatory medication, a heel lift (to take tension off the tendon) and heel stretching exercises. Heel pads are also useful.

Sometimes, if nonoperative treatment fails, then surgery can be performed to remove the small bone spur that has developed (haglund deformity) which may be causing irritation at the insertion of the tendon.  But the inflammation is a classic "chicken or the egg" debate: chronic inflammation can lead to a bone spur formation, but maybe the bone spur causes irritation by rubbing the tendon during ankle motion.  

Noninsertional achilles tendonitis will often respond to a specific therapy called eccentric strenghtening.  More severe disease may require surgery to remove the degenerative portion of the tendon. If more than 50% of the tendon has degenerated, then another tendon (like the tendon that flexes our big toe) is used to strengthen the achilles.

Tendon inflammation in other parts of the body (like in tennis elbow, see talk) is commonly treated with a steroid injection.  This is not done with the Achilles tendonitis because there is a very high risk that it will cause tendon rupture.  While there is a risk of tendon rupture will all steroid injections, the risk is much higher here. 

Reference

1) Shalabi A et al. Eccentric training of the gastrocnemius-soleus complex in chronic Achilles tendinopathy results in decreased tendon volume and intratendinous signal as evaluated by MRI. Am J Sports Med 2004; 32: 1286-96. full article. eccentric improves healing on mri.

2) Kingma JJ et al. Eccentric overload training in patients with chronic Achilles tendinopathy: a systemic review. Br J Sports Med 2007. 41: e3. full article. eccentric best rehab.

3) Den Hartog BD. Flexor hallucis longus transfer for chronic Achilles tendonosis. Foot Ankle Int. 2003; 24: 23307. full article. good/excellent in 26/29 pt.

4) McGarvey WC et al. Insertional Achilles tendinosis: surgical treatment through a central tendon splitting approach. Foot Ankle Int 2002; 23: 19-25. full article. 82% success.

5)  Roche AJ, Calder JD. Achilles tendinopathy: A review of the current concepts of treatment. Bone Joint J 2013; 95B: 1299-307. full article. review.

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