Current And Emerging Conservative Modalities For Achilles Tendonitis

Ryan Fitzgerald, DPM, FACFAS

   In contrast to Achilles tendonitis, Achilles tendinosis is a chronic degenerative process that occurs when acute inflammation about the tendon is allowed to progress unchecked.14,15 Achilles tendinosis is commonly associated with long-term repetitive actions such as running, heavy lifting and excessive training. These injuries are chronic in nature and are commonly recalcitrant to many of the more conservative treatment modalities.16

Reviewing The Possible Etiologies For Achilles Tendonitis

As I noted previously, the Achilles tendon forms from the distal slips of aponeurosis from two muscles, the gastrocnemius and the soleus. These muscles play an important role in both the swing and stance phase of the gait cycle.4,5,17 Virtually all cases of Achilles tendon injury appear to result from anatomic, structural or dynamic disturbances in normal lower leg mechanics, and require active treatment regimens that attempt to establish normal function to prevent recurrence of injury.

   Microtrauma produced by the eccentric loading of fatigued muscle and vascular blanching of the Achilles tendon produced by conflicting internal and external rotatory forces impart to the tibia by simultaneous pronation and by knee extension with running.18 This pronation can exacerbate a preexisting anatomic or structural equinus deformity, creating increased tension along the triceps surae complex. Sports that require jumping — like basketball — can further increase the level of tension along the Achilles tendon and these activities are commonly associated with the development of Achilles tendonitis. However, even patients who are participating in lower impact activities such as walking develop inflammation, particularly in the context of biomechanical instability.19

   In addition to the underlying biomechanical etiology, Achilles tendonitis can occur as a consequence of an overuse injury, particularly in younger patient populations. Tendinopathy is likely to develop in those patients who have sudden increases in the amount or intensity of activity. For example, tendinopathy may occur when one increases a distance run every day by a few miles without allowing the body a chance to adjust to the new distance. Additionally, patients who demonstrate posterior soft tissue equinus are prone to develop Achilles tendonitis due to the chronic tightness in the triceps surae during the gait cycle, leading to increased stress forces being transmitted throughout the Achilles tendon and the subsequent development of inflammation.20,21

   Apart from biomechanical and activity-related causes of Achilles tendinopathy, several studies have also demonstrated the development of Achilles inflammation associated with arthritis and infection.22-25 Tendonitis associated with concomitant arthritic conditions is more common in middle-aged and elderly patients, and is often associated with the development of enthesopathy.26

Key Symptoms And Characteristics Of Achilles Tendonitis

Patients suffering from Achilles tendonitis commonly complain of pain and stiffness along the posterior aspect of the ankle and along the heel in the area of the Achilles insertion. This pain can be worse in the morning and following activity. As this disease process progresses, one may observe fusiform thickening along the Achilles tendon and often this area is focally tender to palpation.27

   During the physical exam, there is commonly pain with resisted plantarflexion, particularly in the later stages of Achilles tendonitis. Swelling can be present and authors have noted that it often increases throughout the day with activity.28 Occasionally, one may note palpable enthesopathy with the presence of Haglund’s deformities and retrocalcaneal spur formation.26,29

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