Question 1 of 10

    Achilles Tendinitis

    Achilles tendinitis, or tendinosis, is a condition affecting the Achilles tendon, which causes pain and discomfort at the structure's region. It is primarily caused by an inflammation of the adjacent sheath, the paratenon.

    Presentation

    Achilles tendinitis leads to a characteristic clinical picture. The primary symptom is pain and tenderness at the location of the tendon, namely at the back of the heel. Initially, pain can be felt while engaging in various types of physical activity that involve motions of the feet; as the condition remains undiagnosed or mistreated, the condition is exacerbated and may lead to symptoms experienced while resting. Pain can be felt upon awakening in the morning, typically becomes worse with movement and is accompanied by edema and tenderness at the site of the tendon. Crepitation that can be palpated may also be caused, as a result of tendon fibrosis [19] [20] [21], alongside enlarged regional lymph nodes.

    Skin
    Xanthoma
    • It should not be confused with xanthoma of the tendon , which is the accumulation of cholesterol in patients with familial hypercholesterolemia .[en.wikipedia.org]
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  • psychiatrical
    Suggestibility
    • Here are two exercises , suggested by the AAOS.[medicalnewstoday.com]
    • CAUSES AND RISK FACTORS FOR ACHILLES TENDONITIS Some common causes and risk factor that suggest you may require Achilles tendonitis treatment include: Most common in middle-aged men Conditions affecting the foot structure, such as fallen arches or flat[orthosleeve.com]
    • Surgery may also be suggested if you have a ruptured Achilles tendon.[orthogate.org]
    • Immobility and doing lower-impact activities can help heal your tendinitis. [42] If you do high-impact activities such as running, your doctor may suggest switching to lower-impact options.[wikihow.com]
    • Your doctor may suggest that you use crutches if you need to go long distances while resting your tendon.[healthline.com]
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  • musculoskeletal
    Heel Pain
    • Achilles heel pain symptoms and causes Achilles tendinitis results from overuse of the heel.[belmarrahealth.com]
    • Tendonitis is the most common cause of achilles heel pain.[foot-pain-explored.com]
    • Average 3.0 of 15 Ratings Question COMMENTS (2) (OBQ08.153) A 48-year-old male complains of 5 years of heel pain while running.[orthobullets.com]
    • Let Us help you with your Achilles Tendinitis To learn more about Achilles Tendinitis and other forms of heel pain, please contact Ankle & Foot Centers of Georgia by dialing 404-351-5015 or Contact Us .[ankleandfootcenters.com]
    • Retrocalcaneal Bursitis ILLUSTRATIVE CASE THREE A 57-year-old woman described having significant heel pain.[aafp.org]
    Tendon Disorder
    • Types of Achilles Tendon Disorders Our foot and ankle experts treat the following Achilles tendon disorders: Achilles tendinosis, insertional and non-insertional Achilles tendon rupture, chronic and acute Achilles tendinitis or tendinopathy Haglund’s[health.ucsd.edu]
    • Fluoroquinolones and risk of Achilles tendon disorders: case-control study.[hkmj.org]
    • . - Treatment of chronic achilles tendon disorders with flexor hallucis longus tendon transfer/augmentation . - Flexor hallucis longus transfer for chronic Achilles tendonosis. - Flexor Hallucis Longus Tendon Transfer in Treatment of Achilles Tendinosis[wheelessonline.com]
    • "Etiology and pathophysiology of chronic tendon disorders in sports".[en.wikipedia.org]
    Foot Pain
    • Go to Common Causes of Foot Pain or Homepage See Also Diagnose Your Foot Pain Common Causes of Foot Pain Foot & Ankle Anatomy Treatment Options for Foot Problems Visitor Comments "Thank you so much![foot-pain-explored.com]
    • Several conditions like plantar fasciitis, stress fractures, heel bursitis and arthritis may be contributing to your foot pain.[iskinstitute.com]
    • Achilles tendon bursitis (retrocalcaneal bursitis) This is another type of foot pain, more commonly found in runners.[belmarrahealth.com]
    • Including: The foot not flexing when the calf muscle is pressed ( if Achilles ruptures or tears in half) Swelling on the back of the foot Pain in the back of the foot Limited range of motion in ankle An X-ray or MRI scan can check for tendinitis.[clevelandclinic.org]
    • Just like foot pain after running isn't (for the most part) caused by a foot problem, achilles tendon pain isn't caused by the tendon.[tendonitisexpert.com]
    Calf Pain
    • Call PhysioWorks Book Online Helpful Products for Achilles Tendonitis Related Injuries General Information Calf Pain Shin Pain Achilles Injuries Achilles Tendonitis / Tendinitis Achilles Tendon Rupture Retrocalcaneal Bursitis Calf Pain Calf Muscle Tear[physioworks.com.au]
    • It took a couple of weeks (and some severe calf pain – negociating stairs and even getting out of a chair became hard!)[intelligent-triathlon-training.com]
    Knee Pain
    • Not only will this help to treat potential weak areas that may have caused altered biomechanics leading to the injury, but it will likely help to prevent the development of other orthopaedic issues (such as hip or knee pain).[marathontrainingacademy.com]
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  • respiratoric
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  • neurologic
    Confusion
    • Achilles tendon bursitis is commonly confused with Achilles tendinitis, and if both conditions are present at the same time, it is known as Haglund’s syndrome.[belmarrahealth.com]
    • This condition is often confused with Achilles Tendinosis, another type of tendinopathy.[njmetropain.com]
    • Achilles tendinitis can be confused with other injuries, such as heel problems, but the hallmark sign is “if you’re pinching the Achilles and it’s really sore,” said Uhan.[running.competitor.com]
    • The terminology can be confusing, with people and medical professionals often using terms interchangeably.[intelligent-triathlon-training.com]
    • It should not be confused with xanthoma of the tendon , which is the accumulation of cholesterol in patients with familial hypercholesterolemia .[en.wikipedia.org]
    Burning Sensation
    • Pain or burning sensation during activities Difficulty performing activities of daily living Weakness may occur as the inflammation gets worse Feeling of tightness or loss of motion due to discomfort Swelling of the tendon Loss of motion at the ankle[twinboro.com]
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  • Entire body system
    Burning Pain
    • The pain can be a shooting pain, burning pain, or even an extremely piercing pain.[foot.com]
    • It can be mild or moderate and feel like a burning pain or stiffness in that part of your leg.[webmd.com]
    • Aching and burning pain is noted especially with morning activity.[aofas.org]
    • Achilles tendonitis may be felt as a burning pain at the beginning of activity, which gets less during activity and then worsens following activity.[physioworks.com.au]
    Localized Pain
    • There are three stages of tendon inflammation : Peritenonitis Tendinosis Peritenonitis with tendinosis Peritenonitis is characterized by localized pain during or following activity.[healthcommunities.com]
    • Symptoms: • Recurring localized pain, sometimes severe, along the tendon during or a few hours after running • Morning tenderness about an inch and a half above the point where the Achilles tendon is attached to the heel bone • Sluggishness • Mild or[drmirkin.com]
    • Complications include rupture of the repair, wound healing problems, and continued local pain.[wholefoot.com]
    Weight Gain
    • Individual: Weight gain and increased age also put you at risk for Achilles tendinitis.[kintec.net]
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  • Workup

    Achilles tendinitis is mainly diagnosed clinically. There are no specific tests or pathognomonic findings: the workup procedure involves a standard complete blood count, in order to detect markers of inflammation or rule out abnormalities that may cause the same clinical picture, coagulopathy-focused tests, an ESR (erythrocyte sedimentation rate) and tests ordered to eliminate arthritis. Imaging modalities can be employed if necessary.

    Treatment

    Achilles tendinitis is a condition with no etiologic treatment, that is approached supportively in order to minimize pain, edema and inflammation of the tendon. Various methods have been proposed and are applied, depending on the particular characteristics of each case. These include:

    • Physical therapy is indubitable for the rehabilitation of Achilles tendinitis. Strengthening exercises, calf-stretching and progressive pressure are performed in order to relieve the patient of the symptoms and allow for the condition to resolve [22]. The degree of strenuous activity performed during physical therapy varies, according to the initial symptoms and progress of each individual.
    • Orthotics are mainly used to correct gait or abnormalities that may contribute to the exacerbation of the tendinitis.
    • Non-steroidal anti-inflammatory drugs are administered only in cases of confirmed inflammation.
    • Injected steroids are administered in some cases, although there have been reports of their actually contributing to the degeneration of the tendon [23].
    • Sclerotizing drugs (injected) hinder the process of neovascularization, which is believed to lead to a severer symptomatology.
    • Nitric oxide has been found to be extremely helpful in the rehabilitation of patients with Achilles tendinitis, because it boosts the production and structural organization of collagen [24] [25]. It is currently used in the form of transdermal patches and its contraindications include simultaneous ingestion of medications used for erectile problems or pulmonary hypertension.
    • Extracorporal shock-wave therapy is an option for these patients as well, because it is believed to be able to enhance circulation in the region and prove beneficial for patients who cannot be treated in more conventional ways [26].
    • Acupuncture [27].
    • Surgical procedures are reserved for patients whose injuries do not heal despite the pharmacologic or alternative treatment and whose condition is active for more than 6 months. There are various techniques that can be performed, including the resection of the damaged tendon part, the lengthening of the gastrocnemius muscle, excision of bone spurs and the replacement of the tendon with another tendon, if the healthy remaining tendon is not long enough to be functional.

    Prognosis

    Although the condition can lead to restricted mobility in its initial phase, it has a very good prognosis.

    Complications

    Achilles Tendinitis
    • Achilles tendinitis is also called Albert's Disease or Achilles tendonitis.[myfootshop.com]
    • Let Us help you with your Achilles Tendinitis To learn more about Achilles Tendinitis and other forms of heel pain, please contact Ankle & Foot Centers of Georgia by dialing 404-351-5015 or Contact Us .[ankleandfootcenters.com]
    • Part 1 Recognizing the Symptoms of Achilles Tendinitis 1 Be aware of your risk for Achilles tendinitis.[wikihow.com]
    Bursitis
    • Achilles tendinitis Approximate Synonyms Bilateral achilles bursitis Bilateral achilles tendinitis Bilateral achilles tendonitis Bursitis of bilateral achilles bursa Bursitis of right achilles bursa Right achilles bursitis Right achilles tendinitis Right[icd10data.com]
    • Achilles tendon bursitis (retrocalcaneal bursitis) This is another type of foot pain, more commonly found in runners.[belmarrahealth.com]
    • When a bursa becomes inflamed, the condition is called bursitis.[orthogate.org]
    • Introduction A family of conditions that include insertional Achilles tendonitis retrocalcaneal bursitis & Haglund deformity Achilles tendonitis Insertional Achilles tendonitis Pain and tendon thickening at insertion of Achilles tendon Epidemiology demographics[orthobullets.com]
    • Several conditions like plantar fasciitis, stress fractures, heel bursitis and arthritis may be contributing to your foot pain.[iskinstitute.com]
    Enteritis
    • Do not enter the MRI room with anything metal.[drugs.com]
    • Some of these cells come from blood vessels that enter the tendon to provide direct blood flow to increase healing.[en.wikipedia.org]
    Familial Hypercholesterolemia
    • It should not be confused with xanthoma of the tendon , which is the accumulation of cholesterol in patients with familial hypercholesterolemia .[en.wikipedia.org]
    Hypercholesterolemia
    • It should not be confused with xanthoma of the tendon , which is the accumulation of cholesterol in patients with familial hypercholesterolemia .[en.wikipedia.org]
    Osteoarthritis
    • Patients with rheumatoid or osteoarthritis may be susceptible to tendinitis Sudden increase in the amount or intensity of exercise like a change in the training regiment.[twinboro.com]
    • Differential diagnosis Achilles tendinopathy Retrocalcaneal bursitis Plantaris muscle injury Posterior ankle impingement Sural nerve entrapment Other ankle injuries Ankle osteoarthritis Ruptured Baker's cyst Deep vein thrombosis Investigations Ultrasound[patient.info]
    • Severe Achilles tendon tears, caused by things like over-exercising or osteoarthritis, can result in rupturing if trauma suddenly impacts the tendon — a common occurrence during athletic competitions, especially in football players.[draxe.com]
    Shock
    • Eccentric loading compared with shock wave treatment for chronic insertional achillestendinopathy.[footankle.com]
    • Extracorporeal shock wave therapy for chronic painful heel syndrome: a prospective, double blind, randomized trial assessing the efficacy of a new electromagnetic shock wave device.[sutterhealth.org]
    • Our insoles also have the added benefit of 44% shock absorption – more than any other insole – which reduces stress at heel impact.[enertor.com]

    Etiology

    Achilles tendinitis is not solely caused by an injury to the tendon; it involves a more complicated etiologic path, including both intrinsic factors that predispose to a tendon injury amongst others, and extrinsic factors that further stress the tendons.

    As far as the intrinsic factors are concerned, Achilles tendinitis has been associated with a plethora of other diseases, such as chronic kidney failure [1] [2], collagen deficiencies, autoimmune diseases such as systemic lupus erythematous and rheumatoid arthritis, thyroid and parathyroid dysfunction, gout, tibia vara, an O blood type and a prior family history of Achilles tendinitis [3] [4] [5] [6].

    On the other hand, various extrinsic factors contribute to the final clinical picture and morbidity. The consumption of steroid drugs are believed to render the tendon more susceptible to damage [7] [8], quinolones also have a damaging and toxic effect on the tendon's structure [9] [10] and, naturally, extreme physical activity causes excessive stress on the tendon [11] [12] [13] [14]. There are particular circumstances when physical activity actually threatens the tendon's wellbeing: inadequate warm-up prior to intense exercise, jumping, running, stair climbing, shoes that are not designed to support intense exercise and stretching beyond a reasonable extent.

    Epidemiology

    Achilles tendinitis mainly affects people who engage in frequent and excessive physical activity. Although the actual incidence of the disease has not been calculated yet, it is believed that 1 million athletes suffer from the condition annually. More specifically, this type of tendinitis is most common amongst track runners, dancers, gymnasts and tennis players (descending frequency).

    A certain geographical discrepancy has also been observed. Only 6 new cases per 100,000 individuals have been reported in Scotland, whereas in Denmark, the number is 37 new cases per 100,000 [15]. Men suffer from Achilles tendon injuries at a higher rate than women, almost 6 times more frequently. It appears that most cases of tendinitis are not diagnosed amongst professional athletes, but amongst people who engage in strenuous activity without adequate warm-up.

    Sex distribution
    Age distribution

    Pathophysiology

    Achilles tendinitis does not refer to a single condition of the respective tendon, but to a variety of conditions with different pathophysiologic background and clinical characteristics. The classification model presently followed dictates the categorization of Achilles tendinitis depending on the specific location that has sustained damage, as opposed to the exact type of damage sustained.

    In general, the aforementioned tendon can suffer various types of injuries, each of which can be outlined with the use of a different pathophysiologic route. The predominant histopathological alterations that are observed in a tendon include an elevated cellular proliferation, collagen disarray, neovascularization and an abnormally large quantity of ground substance [16] [17] [18].

    Based on the specific location on which an injury has been inflicted and the aforementioned histopathological changes, three types of Achilles tendinitis can be described:

    • Tendinosis, which leads to the structural degeneration of the tendon
    • Paratenonitis, which features hardened, fibrotic and inflamed paratenons, as well as regional sclerosis and pain
    • A combination of the above

    Prevention

    There are various measures to prevent the onset of Achilles tendinitis. If a person has never suffered from the condition before, prevention centers around strengthening the tendon and delaying its potential degeneration, which is expected to occur as a person ages. One should be physically active and follow a correct workout schedule, that involves adequate warm-up and stretching time, in order to maintain flexible tendons that can become stronger [28] [29].

    On the other hand, patients who suffer from the chronic type of Achilles tendinitis are advised to wear appropriate shoes, orthotic devices to correct gait abnormalities that may induce tendon traumatization and no high heel shoes. An exercise program that involves gradual intensity buildup is recommended [30]. Physical activity should also feature special exercises to strengthen the gastrocnemius muscles, especially when the condition has been caused by a degenerative alteration to the tendons.

    Summary

    Achilles tendinitis is a condition induced by inflammation of the paratenon next to the Achilles tendon and leads to pain at the back of the heel. It is mainly induced by strain and pressure exerted to the back of the foot when walking, running or performing any type of intense physical exercise that involves this particular region.

    The condition may manifest in two ways: the insertional type, which affects individuals who are not particularly active, and the non-insertional one. Insertional tendinitis is a result of the tendon's damage in the location where it is joined to the heel bone. Non-insertional tendinitis, on the other hand, involves the middle part of the tendon and is diagnosed in younger individuals who engage in physical activity of any type.

    Patient Information

    Achilles tendinitis is a condition that affects the Achilles tendon, namely the tendon that lies at the back of the heel and served as the lever, in order to pull the heel upwards. This tendon is involved in every movement the heel performs: walking, jumping, dancing and practically every type of physical exercise, intense or not, exerts pressure on the tendon. Although this structure is designed to bear an extreme amount of weight, its frequent use and strain can lead to damage, either in the form of inflammation or rupture.

    Achilles tendinitis is a term used to describe any type of damage the Achilles tendon may sustain. It is primarily caused by intense physical exercise, activity without the appropriate warm-up and stretching exercises or engaging in intense activity after having remained immobile for a long time. The aging process further aggravates the condition: aged tendons have degenerated fibers, something which makes it more likely for this structure to be injured.

    Tendon injuries manifest in a characteristic way. A person will feel pain at the back of the heel that worsens with exercise or may accompany them even when they rest. This location may be felt as sluggish, tender and swollen. The patients usually wake up in the morning to feel the pain present at the Achilles tendon's location. This condition is diagnosed mainly by the symptoms a patient mentions and the physical examination.

    There is no definitive answer concerning which therapeutic measure is most beneficial to the individuals affected by Achilles tendinitis; various methods are applied. These include physical therapy, which is the core of the therapeutic approach, anti-inflammatory medications, acupuncture, shock therapy and, in some extreme cases, even surgery.

    Other symptoms

    Fluoroquinolone
    • Tendon tears can occur with minimal exertion in people who have taken fluoroquinolone antibiotics.[merckmanuals.com]
    • Be aware of the risks of fluoroquinolone and exercise with caution if you’re taking this drug.[hopkinsmedicine.org]
    • You take medicines called glucocorticoids or antibiotics called fluoroquinolones.[webmd.com]
    Ciprofloxacin
    • Carpal tunnel syndrome after ciprofloxacin-induced tendinitis.[hkmj.org]
    • In 2008, the FDA asked that a boxed warning be added to the prescribing information for Cipro, or ciprofloxacin, Factive, or gemifloxacin and others.[medicalnewstoday.com]
    • It is also a known side effect of fluoroquinolone antibiotics such as ciprofloxacin , as are other types of tendinitis. [1] Swelling in a region of micro-damage or partial tear can be detected visually or by touch .[en.wikipedia.org]
    • Familial hypercholesterolaemia may present with Achilles tendon pain. [ 4 ] Insertional tendinopathy may be due to an enthesitis; ankylosing spondylitis, reactive arthritis and psoriatic arthritis should be considered. [ 5 ] Quinolone antibiotics (eg, ciprofloxacin[patient.info]
    Congenital
    • ., abnormal mechanics leading to excess motion of calcaneus, congenital deformity of calcaneus, irritation from women’s shoes known as ‘pumps’ Management Open-heeled/flat shoes, moleskin padding of calcaneus, cryomassage, orthotics to control excess motion[medical-dictionary.thefreedictionary.com]
    • […] psoriasis ( L40.5- ) certain conditions originating in the perinatal period ( P04 - P96 ) certain infectious and parasitic diseases ( A00-B99 ) compartment syndrome (traumatic) ( T79.A- ) complications of pregnancy, childbirth and the puerperium ( O00-O9A ) congenital[icd10data.com]
    • […] mainly diagnosed in runners, it does occur in basketball, volleyball, dancing, gymnastics and other athletic activities. [19] Other risk factors include gender, age, improper stretching, overuse, and conditions which the individual may be born with. [21] Congenital[en.wikipedia.org]
    Sedentary Lifestyle
    • This can affect anyone, whether they have an active or sedentary lifestyle.[foot-pain-explored.com]
    • Having rigid, inflexible leg muscles and/or joints: This can be due to arthritis, a sedentary lifestyle or aging.[draxe.com]
    Anesthetic
    • This procedure is performed in a hospital or outpatient surgery center and is typically performed under a general anesthetic.[myfootshop.com]
    • Local anesthetic is injected into the space between the tendon and its surrounding sheath to break up scar tissue.[aofas.org]
    Tendon Abnormalities
    • Abnormal tissue is excised until tissue with normal appearance appears.[aofas.org]
    • Related Reading: High cholesterol levels linked to tendon injury and pain risk Chronic low inflammation prompted by high cholesterol levels has been linked to tendon abnormalities and pain.[belmarrahealth.com]
    Gradual Progression
    • Phase 4: Restore Concentric Muscle Strength Calf strength and power should be gradually progressed from non-weight bear to partial and then full weight bear and resistance loaded exercises.[physioworks.com.au]

    Self-assessment

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    References

    1. Hofmann GO, Weber T, Lob G. Tendon rupture in chronic kidney insufficiency--"uremic tendonopathy"? A literature-supported documentation of 3 cases. Chirurg. Jun 1990; 61(6): 434-7.
    2. Spencer JD. Spontaneous rupture of tendons in dialysis and renal transplant patients. Injury. Mar 1988; 9(2): 86-8.
    3. Albers D, Hoke B. Techniques in Achilles tendon rehabilitation. Tech Foot Ankle Surg. 2003; 2(3): 208-19.
    4. Jozsa L, Balint JB, Kannus P, Reffy A, Barzo M. Distribution of blood groups in patients with tendon rupture. An analysis of 832 cases. J Bone Joint Surg Br. Mar 1989; 71(2): 272-4.
    5. Kujala UM, Järvinen M, Natri A, Lehto M, Nelimarkka O, Hurme M, et al. ABO blood groups and musculoskeletal injuries. Injury. 1992; 23(2): 131-3.
    6. Kraemer R, Wuerfel W, Lorenzen J, Busche M, Vogt PM, Knobloch K. Analysis of hereditary and medical risk factors in Achilles tendinopathy and Achilles tendon ruptures: a matched pair analysis. Arch Orthop Trauma Surg. Jun 2012; 132(6): 847-53.
    7. Shrier I, Matheson GO, Kohl HW III. Achilles tendonitis: are corticosteroid injections useful or harmful? Clin J Sport Med. Oct 1996; 6(4): 245-50.
    8. Newnham DM, Douglas JG, Legge JS, Friend JA. Achilles tendon rupture: an underrated complication of corticosteroid treatment. Thorax. Nov 1991; 46(11): 853-4.
    9. Malaguti M, Triolo L, Biagini M. Ciprofloxacin-associated Achilles tendon rupture in a hemodialysis patient. J Nephrol. Sept-Oct 2001; 14(5): 431-2.
    10. Harrell RM. Fluoroquinolone-induced tendinopathy: what do we know?. South Med J., Jun 1999; 92(6): 622-5.
    11. Asplund CA, Best TM. Achilles tendon disorders. BMJ Mar 12, 2013; 346: f1262.
    12. Diehl J. Platelet-rich plasma therapy in chronic Achilles tendinopathy, Tech Foot Ankle Surg., Mar 2011; 10(1): 2-6.
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    14. Malliou P, Rokka S, Beneka A, Gioftsidou A, Mavromoustakos S, Godolias G. (2014). Analysis of the chronic lower limb injuries occurrence in step aerobic instructors in relation to their working step class profile - A three year longitudinal prospective study. J Back Musculoskelet Rehabil. 2014; 27(3): 361-70. doi:103233/BMR-140458.
    15. de Jonge S, van den Berg C, de Vos RJ, van der Heide HJ, Weir A, Verhaar JA, et al. Incidence of midportion Achilles tendinopathy in the general population. Br J Sports Med. Oct 2011; 45(13): 1026-8.
    16. Saltzman C, Bonar S. Tendon problems of the foot and ankle. In: Lutter LD, Mizel MS, Pfeffer GB, eds. Orthopaedic Knowledge Update: Foot and Ankle. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1994: 236-73.
    17. Wheaton MT, Molnar TJ. Overuse injuries of the lower extremities. In: Griffin LY, ed. Orthopaedic Knowledge Update: Sports Medicine. Rosemont, Ill: American Academy of Orthopaedic Surgeons;1994: 225-7.
    18. De Jonge S, Warnaars JL, De Vos RJ, Weir A, van Schie HT, Bierma-Zeinstra SM, et al. Relationship between neovascularization and clinical severity in Achilles tendinopathy in 556 paired measurements. Scand J Med Sci Sports. Oct 2014; 24(5): 773-8.
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    20. Jozsa LKP. Human Tendon: Anatomy, Physiology and Pathology. Champaign: Human Kinetics; 1997.
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    24. Paoloni JA, Appleyard RC, Nelson J, Murrell GA. Topical glyceryl trinitrate treatment of chronic noninsertional achilles tendinopathy. A randomized, double-blind, placebo-controlled trial. J Bone Joint Surg Am. May 20014; 86-A(5): 916-22.
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    • Achilles Tendon Problems - AM Smith, AK Sands - Foot and Ankle: Core Knowledge in , 2007 - books.google.com
    • Achilles tendinitis - RE Leach, S James, S Wasilewski - The American journal of , 1981 - ajs.sagepub.com
    • Short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles - N Mafi, R Lorentzon, H Alfredson - Knee Surgery, Sports Traumatology, , 2001 - Springer
    • Achilles tendinitis - RE Leach, S James, S Wasilewski - The American journal of , 1981 - ajs.sagepub.com
    • Achilles tendinitis and peritendinitis: etiology and treatment - DB Clement, JE Taunton, GW Smart - The American journal of , 1984 - ajs.sagepub.com

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