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.

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.

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.

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References

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