Introduction to Achilles Tendinitis
As one of the most common ankle and foot over-use injuries, Achilles tendinitis or tendinopathy is a syndrome that is characterized by a combination of pain, swelling and sub-optimal performance. Achilles tendinitis arises from a failed healing response, resulting in degenerative changes within the tendon itself. This failed healing response has 3 stages – reactive tendinitis, tendon disrepair and finally, degenerative tendinitis. Broadly speaking, Achilles tendinitis can be further sub-classified into insertional and non-insertional tendinitis. Insertional tendinitis affects the part of the Achilles tendon which inserts onto the ankle bone (calcaneum), whereas non-insertional tendinitis affects the part of the Achilles tendon that is roughly 2 to 6 cm above the insertion.
Achilles tendinitis is not uncommon – it affects up to 10% of recreational runners and has been reported to cause 5% of professional athletes to suffer a premature end to their careers. A study that looked at 1,400 athletes found that 4% of them had insertional tendinitis, 3.6% had non-insertional tendinitis and 1.9% had both forms.
Risk Factors for Achilles Tendinitis
The main risk factors for Achilles tendinitis are biomechanical variations of the lower limbs, such as discrepancies of leg length, Varus (inward angulation) deformities of the forefoot and pes cavus (high arched foot). Other general risk factors include increasing age, hypertension, diabetes mellitus, gout, inflammatory joint disease (e.g. rheumatoid arthritis) and the use of certain antibiotics (i.e. quinolones).
Diagnosis of Achilles Tendinitis
The main symptoms of Achilles tendinitis are that of localized pain, swelling, stiffness and perceived rigidity that is typically worse in the morning. Lateral and axial x-rays are useful in detecting calcifications or bony prominences that emerge from the tendon. They can also be used to exclude bony tumours in the region of the calcaneum (ankle bone). Ultrasound is used to assess the degree of injury to the tendon as well as the thickness and vascularity of the tendon. Occasionally, MRI is used to assess these parameters as well.
Management of Achilles Tendinitis
The management of Achilles tendinitis can be classified into conservative and interventional management. Conservative management includes rest and avoidance of strenuous activity, non-steroidal anti-inflammatory drugs (NSAIDs) such as Ibuprofen or Arcoxia, tendon-loading exercises and physiotherapy with adjuncts such as braces, insoles and pneumatic walking boots. Interventional treatment options include corticosteroid injections, platelet-rich plasma injections as well as intratendinous hyperosmolar dextrose injections.
Surgical therapy is typically reserved for patients in whom most forms of conventional therapy has failed, or in patients who have sustained a complete (rupture) or partial tear of their Achilles tendon. During surgery, the degenerative tendon is removed together with any associated calcifications and the insertion of the remaining tendon is re-attached to the calcaneum using suture anchors. As complications are common in this approach (about 11%), patients are advised to adopt conservative measures and less invasive procedural interventions (i.e. injections) prior to considering surgery.
- Alfredson, H. and Cook, J. (2007) ‘A treatment algorithm for managing Achilles tendinopathy: new treatment options’, British journal of sports medicine, 41(4), pp. 211-216.
- Li, H.-Y. and Hua, Y.-H. (2016) ‘Achilles Tendinopathy: Current Concepts about the Basic Science and Clinical Treatments’, BioMed research international, 2016, pp. 6492597-6492597.
- Lopez, R. G. L. and Jung, H.-G. (2015) ‘Achilles tendinosis: treatment options’, Clinics in orthopedic surgery, 7(1), pp. 1-7.