Special Interest
What is Achilles Tendonitis?

Achilles tendonitis is a common disorder of the lower leg. Achilles tendonitis is an overuse type injury, which causes irritation to the tendon. Researchers have documented that 11% of all running injuries can be attributed to Achilles tendonitis.

Anatomy

The Achilles tendon is the common tendon of the soleus and gastrocnemius muscles. Its primary function is to point your foot downward (plantarflexion) or raise your heel. The Achilles tendon plays a functional role in push-off during your gait cycle, jogging and running.

Etiology

There are two types of Achilles tendonitis; one is insertional and the other is non-insertional. Insertional Achilles tendonitis is distinguished by a localization of the patient’s symptoms to the insertion point of the tendon into the calcaneus. The signs and symptoms are pain during or after exercise and an erythema to the Achilles.

Non-insertional tendonitis is classified by pain 2-6 cm. above the Achilles tendon insertion. Signs and symptoms include pain after exercise, pain and stiffness is present in the early morning (first steps out of bed). If symptoms persist, pain may become constant. There is also a thickening of the tendon and surrounding swelling.

Achilles tendonitis can further be broken down into two subsets: Paratenonitis and Tendinosis.

  • Paratenonitis is when there is a pathologic change to the matrix of the tendon.
  • Tendinosis is classified as a damaged paratenonitis; the tendon has now become degenerated. You now have chronic pain, which has been present for at least sixteen weeks.

Risk Factors

  • Decreased flexibility of Achilles tendon (Gastrocnemius/Soleus muscles)
  • Foot Biomechanics (Forefoot Varus)
  • Poor joint Arthrokinematics (Decreased subtalar ROM)
  • Footwear
  • Decreased Strength
  • Decreased endurance of muscle
  • Training errors
  • Poor treatment of early signs

Evaluation/ Physical Exam

  • Point tenderness along Achilles tendon
  • Thickening of actual tendon
  • Positive crepitus with active movement of ankle along tendon
  • Loss of motion in ankle
  • Poor flexibility and palpable tightness of gastrocnemius/soleus complex

Treatment Protocol
Phase I – First 24 to 72 Hours

  • Identify etiological factors; biomechanical connection (Heel lift orthotics)
  • Ice (cryotherapy)
  • Rest
  • Anti-inflammatory medications

Phase II – 3 Days to 3-4 Weeks

  • Cryotherapy
  • Gentle, passive stretching (Both soleus and gastrocnemius muscles). I.e. Bent and straight leg
  • Ultrasound
  • Iontophoresis
  • Strengthening
  • Eccentric training program

Phase III – 4 Weeks to Return to Activity

  • Continuous stretching program
  • Progress with strengthening program
  • Begin plyometric program
  • Progress to running program
  • Cryotherapy after activity
  • Gradually return to full activity

 
Samir Fanous, FRCS 18 Antikhana Street, Kasr El Nil, Cairo, EGYPT.
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