ACHILLES

TENDINITIS
DEFINITION
• Achilles tendinitis is an overuse injury of the Achilles tendon, the
band of tissue that connects calf muscles at the back of the lower
leg to heel bone.

• Athletes, joggers and hikers often develop pain and swelling

around the tendon Achilles, due to local irritation of the tendon
sheath or the paratenon.
ANATOMY

• The Achilles tendon ranks as the strongest tendon in the human body connecting the

plantaris, gastrocnemius, and soleus to the calcaneus bone.

• A sheath-like structure comprised of a single layer of cells surrounds the tendon; this is

called the paratenon. The paratenon supplies a significant portion of the blood supply to
the tendon.

•  The Achilles tendon allows the calf muscles to act on the heel, which is necessary for
walking or running.
PATHOLOGY
• The condition usually affects the ‘watershed’ area about 4 cm above the insertion of the
tendon, an area where the blood supply to the tendon is poorer than elsewhere.

• The tendon sheath or the flimsy tissue around it may become inflamed.

• In a minority of cases the changes appear at the tendon insertion, or there may be
inflammation of the retro calcaneal bursa just above the calcaneum and deep to the
tendon; anatomical deformity of the posterior part of the calcaneum may contribute to
the pathogenesis.
AETIOLOGY
• The effects of overuse, poor circulation, lack of flexibility, gender, endocrine, or
metabolic factors can lead to tendinopathies.

• Straining the tendon during physical exercise has been seen as one of the biggest
pathological stimuli and systematic overloading of the Achilles tendon above the
physiological limit can cause a micro-trauma.  

• Repetitive micro-traumas that are linked with a non-uniform tension between the
gastrocnemius and soleus, cause frictional forces between the fibers and abnormal
concentrations of the loading in the Achilles tendon
• This has consequences such as the inflammation of the tendon sheath,
degeneration, or a combination of both. Without the minimum time for recovery,
this can lead to tendinopathy
• The most common and perhaps the most important malalignment is one of the
ankles caused by over pronation of the foot. Increased foot pronation has been
proposed to be associated with Achilles tendinopathy.
 RISK FACTORS
• Obesity

• High blood pressure

• Type II Diabetes

• Prolonged steroid use

• Family history of tendinopathy

• Other factors include inappropriate footwear and the elderly population.

CLINICAL PRESENTATION
• Morning pain is a hallmark symptom because the Achilles tendon must tolerate a full
range of movement including stretch immediately after getting up in the morning.
Symptoms are typically localized to the tendon and the immediate surrounding area.

• With people who have tendinopathy of the Achilles tendon that has a sensitive zone,
combined with intra-tendinous swelling, that moves along with the tendon and of
which sensitivity increases or decreases when the tendon is put under pressure, there
will be a high predictive value that in this situation there is a case of tendinosis. 

• The affected side of the tendon shows a larger diameter, higher stiffness, and lower
strain in comparison to the non-affected side
TREATMENT
• If the condition starts acutely, it will often settle within about 6 weeks if treated
appropriately. Referral for early physiotherapy is important. In the interim, advice on
rest, ice, compression and elevation (RICE) and the use of an NSAID (oral or topical)
are helpful.

• Corticosteroid injection (CSI) appears to have short ‐term pain ‐relieving effects

• When the symptoms improve, stretching exercises, followed by a muscle strengthening

programme, should be advised. The use of a removable in-shoe heel-raise might be
helpful. If there is a plano-valgus hindfoot, correction with orthotics will often bring
about improvement and reduce the risk of recurrence.
Operative treatment is seldom necessary but if symptoms fail to settle with
physiotherapy then surgery may be appropriate
The aim of surgical treatment for tendinopathy is to irritate the tendon to initiate a
chemically mediated reaction response. Surgery may consist of simple procedures,
percutaneous tenotomy, open procedures, and removal of the infected tendon part.