Achilles Tendinopathy

Achilles tendinopathy is a common problem, especially in running and jumping athletes. The Achilles tendon consists of the distal ends of the gastrocnemius and soleus muscles and attaches broadly across the posterior aspect of the calca-neus. Contraction of the Achilles results in plantar flexion of the ankle. Activities that cause eccentric loading of the tendon may result in tendonitis. Achilles tendonitis is considered an overuse injury.

Patients present with pain in the posterior aspect of the distal lower leg or heel. Pain is worsened with push-off activities, such as walking up hills or stairs, running, or jumping. Examination reveals tenderness to palpation of the distal portion of the tendon. A palpable area of swelling and firmness may be noted as well as "wet crepitus" from fluid in the peritenon. Strength may be limited because of discomfort. This can be assessed by direct manual testing or by having the patient perform repeated single-foot toe-raise exercises.

Assessment of the integrity of the Achilles tendon is essential and best done by the Thompson test. Asking the patient simply to plantar-flex the ankle actively is not sufficient because there are several secondary plantar flexors. Lay the patient prone on the examination table with the knee flexed to 90 degrees and the ankle in neutral position. Squeeze the midgastrocnemius area and observe for passive ankle plantar flexion. If the Achilles is intact, the ankle will plantar-flex (negative test). If the Achilles is torn, the ankle will remain in neutral position (positive test).

Radiographs generally are not necessary to make an accurate diagnosis of Achilles tendinopathy or to initiate treatment. X-ray films are considered in chronic cases, primarily to rule out calcific tendinopathy and Haglund deformity (bump on back of calcaneus near Achilles insertion).

Ultrasound and MRI are not routinely needed early on but may be used to assess for partial tears, as well as assess the vascular integrity of the injured area. Ultrasound and MR changes in the tendon can persist even after functional recovery (Khan et al., 2003).

Treatment of Achilles tendinopathy is similar to that for other forms of tendinopathy and includes ice treatment, relative rest, NSAIDs, stretching and strengthening programs, and proprioception exercises. An exercise program focused on eccentric training has been described and renders promising results in many cases (Alfredson et al., 1998). Most experts agree that corticosteroid injection should not be considered due to the risk of tendon rupture. For recalcitrant cases, treatments such as prolotherapy and extracorporeal shock wave therapy have been studied, but short-term follow-up and isolated reports of effectiveness are mixed. Platelet-rich plasma injections for chronic Achilles tendinopathy have no benefit over saline injections. Surgical debridement is reserved for chronic cases and involves debridement of the diseased tendon and may require tendon transfers for grafting.

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