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Achilles Tendinopathy as a Chronic Overuse Injury

Achilles tendon disorders represent a major lower extremity injury in the general population, with a reported annual incidence of 6% to 18%. More on diagnosis, management, and prevention of recurrence.

This overview is part of a Chronic Overuse Injuries Primer. View the introduction.
 

History/Pathogenesis

Chronic Achilles tendinopathy is an injury common among athletes, often resulting from repetitive stress and overuse. Pain typically presents on the posterior aspect of the ankle and may be related to the gastrocnemius/soleus muscles.

Recent literature as well as histological studies suggest that Achilles tendinopathy is primarily a degenerative, non-inflammatory condition. However, evidence indicates that other potential etiologic factors may influence the development of this condition; further research is needed.1-5

Prevalence/Epidemiology

General Achilles tendon disorders are a major lower extremity injury in the general population, with a reported annual incidence of 6% to 18%. Although all age groups are affected by Achilles tendonitis, it most commonly seen in the middle aged (45 to 65 years old), “weekend warrior” population.

Runners are specifically at risk, with reports of a 10-times greater likelihood of Achilles tendon injury in comparison to age-matched controls. Despite the commonality of this occurrence in athletes, nonathletes are also affected, with 31% of Achilles tendinopathy patients reporting that they did not engage in physical exercise. The majority of reported Achilles tendinopathy cases refer to either the midportion (55% to 65%) or the insertion (20 to 25%) of the tendon.5-9

 

Image: iStock (gilaxia)Chronic Achilles tendinopathy is an injury common among athletes, often resulting from repetitive stress and overuse. Pain typically presents on the posterior aspect of the ankle and may be related to the gastrocnemius/soleus muscles.

Signs/Symptoms

Pain/tenderness 2 cm to 6 cm above the Achilles tendon insertion on the calcaneus, but also along the length of the tendon, and occasionally with warmth/swelling with crepitus and tendon nodule present. Pain with running (especially sprinting) and standing heel raise activities. Pain with early pre-activity maneuvers and morning stiffness.

Predisposing Conditions

  • Achilles tendon tightness
  • Cavus foot
  • Functional talipes equines
  • Protonated foot secondary to forefoot, hindfoot, or tibial varus

High Risk Activities for Developing Achilles Tendinitis

Activities involving forceful and repetitive plantar flexion, such as running and jumping (especially on uneven terrain and/or hills). The condition is also associated with excessive training overload progression in frequency, intensity, duration, etc.

Associated Risk Factors

  • 45- to 65-year-old “weekend warriors”
  • Gender (males are at a higher risk)
  • Obesity
  • Steroid use
  • Diabetes
  • Other inflammatory arthropathies1,4,10,11

Physical Exam 

Clinicians should look for tenderness to palpation 2 cm to 6 cm above the Achilles tendon insertion (thickening of the tendon is often noted); increased pain with associated mild myofascial weakness with resisted plantar flexion and walking on toes; and decreased ankle dorsiflexion. Often, patients will present with increased subtalar pronation. If chronic, may see mild calf muscular atrophy noted.

Diagnostic Tests

  • If indicated, evaluate with baseline x-rays, MRI, musculoskeletal diagnostic U/S testing, bone scan testing, or EMG/NCS testing.

Differential Diagnosis

  • Posterior tibialis ligament injury or Achilles tendon avulsion
  • Inflammatory arthritis
  • Plantar fasciitis syndrome
  • Occult lesion
  • Stress fracture of calcaneus
  • Sural neuritis

Prevention

  • Dynamic stretching/warmup prior to activity
  • Progress training gradually (intensity, duration, frequency, etc.)
  • Running on level ground opposed to uneven ground when possible
  • Proper footwear

Acute Treatment

Advise patients on relative rest (decrease speedwork, running hills or stairs, general decrease in overall intensity, duration, and/or frequency) and shoes to control excessive motion if present.

Treatments may include:

  • Heel lift
  • Analgesia through appropriate doses of NSAIDs together with physical modalities such as ice, ultrasound, iontophoresis, phonophoresis, topical anesthetic skin refrigerants, and electrical stimulation
  • Gentle calf stretching.
  • Prescribed orthotics or arch supports if significant hyper-pronator; or night splints or walking boot (if severe).

Long-Term Treatment/Rehab

Conservative treatment is the initial treatment method for both insertional and non-insertional chronic Achilles tendinopathies. Typical treatment plans will begin with activity modification, gait analysis, footwear evaluation, and orthotic intervention if necessary; and gastrocnemius and soleus stretching and strengthening. Strengthening methods should focus on eccentric loading of musculature, eventually progressing to loading in a sport-specific manner.

However, caution must be used in insertional pathologies, as eccentric exercises often irritate the injury. If symptoms have not improved following six months of conservative treatment, surgical intervention may be indicated.

It has been shown that upwards of 88% of patients who adhere to their prescribed daily home stretching regimen, while also participating in supervised physical therapy, statistically see a significantly improvement in their condition.

Regenerative medicine techniques, such as platelet-rich plasma and stem cell injection options, are now on the of forefront research and for potential treatments for chronic overuse MSK/sports injuries. These techniques should be considered on a case-by-case setting for Achilles tendinopathy. 1,5,6,12-14

Practical Takeaways

  • Chronic Achilles tendinopathy is an injury common among athletes, often resulting from repetitive stress and overuse. Pain typically presents on the posterior aspect of the ankle and may be related to the gastrocnemius/soleus muscles.
  • Tenderness is noted in palpation 2 cm to 6 cm above the Achilles tendon insertion (thickening of the tendon is often noted).
  • Conservative treatment is the initial treatment method for both insertional and non-insertional chronic Achilles tendinopathies. Typical treatment plans will begin with activity modification, gait analysis, footwear evaluation, and orthotic intervention if necessary; and gastrocnemius and soleus stretching and strengthening.
  • More than of 88% of patients who adhere to their prescribed daily home stretching regimen, while also participating in supervised physical therapy, statistically see a significant improvement in their condition.
Additional chronic overuse injuries in this primer:
Last updated on: May 29, 2020
Continue Reading:
Patellar Tendinopathy as a Chronic Overuse Injury
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