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Achilles Tendinitis

Achilles tendinitis, also known as Achilles tendinopathy, occurs when the Achilles tendon at the back of the ankle becomes sore and exhibits structural alterations. This condition is common and primarily affects those involved in sports requiring lunging and jumping, but can also be seen in sedentary individuals, those with high-heel shoe usage, and those taking certain medications such as fluoroquinolones or steroids.

Signs and Symptoms

Achilles tendinitis typically presents with pain and swelling around the affected tendon, often worse at the start of exercise and decreasing thereafter. Stiffness in the ankle may also be noted, particularly the day after activity. Symptoms can range from localised ache and swelling to a burning sensation encompassing the entire joint. The condition can be classified based on the location of the pain: insertional tendinopathy, midportion tendinopathy, and proximal musculotendinous junction injuries.

Drawing of Achilles tendonitis with the affected part highlighted in red
Drawing of Achilles tendonitis with the affected part highlighted in red

Causes

Achilles tendinitis is commonly due to overuse, particularly in sports involving repetitive stress on the tendon. Risk factors include trauma, lack of exercise, high-heel shoes, rheumatoid arthritis, and certain medications. Physiological factors such as poor blood supply to the tendon and mechanical factors like excessive foot pronation can also contribute.

Demonstration of the right foot in pronation, neutral, and supinated subtalar joint placements
Demonstration of the right foot in pronation, neutral, and supinated subtalar joint placements
Walking gait cycle starting with the left leg
Walking gait cycle starting with the left leg

Pathophysiology

The Achilles tendon connects the calf muscles to the heel bone, facilitating foot extension. Due to its poor blood supply, injuries to the tendon can be slow to heal. When injured, cells from surrounding structures, including blood vessels and nerve fibres, migrate to the tendon to aid in repair. The presence of nerve fibres around these blood vessels is believed to contribute to pain.

Diagnosis

Achilles tendinitis is diagnosed through medical history and physical examination. Radiography may show calcification deposits in the tendon, while MRI can assess the extent of tendon degeneration and rule out other conditions like bursitis.

Calcification deposits forming an enthesophyte within the Achilles tendon at its calcaneal insertion
Calcification deposits forming an enthesophyte within the Achilles tendon at its calcaneal insertion

Prevention

Preventative measures include consistent physical activity to improve tendon elasticity and strength, proper exercise habits, and appropriate footwear. Eccentric strengthening exercises for the gastrocnemius and soleus muscles are particularly beneficial for individuals with chronic Achilles tendinosis.

Calf raise exercise to strengthen the gastrocnemius and soleus muscles
Calf raise exercise to strengthen the gastrocnemius and soleus muscles

Treatment

Treatment involves rest, ice, NSAIDs, and physical therapy. Measures such as heel lifts or orthotics may be helpful, though evidence is limited. Other treatments include:

  • Eccentric exercise routines designed to strengthen the tendon.
  • Application of a boot or cast.

Injections

Evidence supporting injection therapies is poor, including corticosteroid injections, which may increase the risk of tendon rupture, and autologous blood injections, which show limited efficacy.

Procedures

Extracorporeal shockwave therapy has some tentative evidence supporting its use in treating Achilles tendinitis.

Epidemiology

Achilles tendinitis is most common in individuals aged 30–40, particularly runners and participants in sports involving running, jumping, bounding, and changes of speed. Risk factors include gender, age, improper stretching, overuse, and congenital conditions affecting lower extremity alignment.


Self-assessment MCQs (single best answer)

Achilles tendinitis is primarily associated with which type of activity?



What is a common symptom of Achilles tendinitis?



Which anatomical structure is primarily involved in Achilles tendinitis?



Which of the following can be a risk factor for developing Achilles tendinitis?



What is a key preventative measure for Achilles tendinitis?



Which imaging modality can show calcification deposits in the Achilles tendon?



What is a common initial treatment for Achilles tendinitis?



Which of the following is a less recommended treatment option due to the potential risk of tendon rupture?



In which age group is Achilles tendinitis most commonly observed?



Which of the following conditions is NOT a contributing factor to Achilles tendinitis?



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