Achilles Tendinopathy

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Achilles tendon injuries are a common problem in both active and sedentary individuals of all ages.

Classification

Insertional (within first 2cm of attachment) versus midportion (>2cm) Achilles tendinopathy.[1]

There are two location-based patterns of Achilles tendionpathy

  • Mid-portion Achilles tendinopathy - the pain occurs between 2-7cm above the superior aspect of the calcaneum
  • Insertional Achilles tendinopathy - the pain occurs within the first 2cm of the insertion point on the calcaneum. There may be a tendinopathy of the Achilles tendon insertion, and associated Haglund deformity and/or an associated retrocalcaneal bursitis.

Clinical Features

In general, history and physical exam features are better at ruling in, rather than ruling out achilles tendinopathy. Self reported morning stiffness is the only feature with a moderate negative likelihood ratio.

Test Sens. Spec. LR+ LR- K
Palpation (tenderness) 64% 81% 3.15 0.48  
Arc Sign 42% 88% 3.24 0.68  
Royal London Hospital Test
54% 86% 3.84 0.54  
Morning stiffness 89% 58% 2.12 0.19  
Palpation thickening 59% 90% 5.9 0.46  
Crepitus 3% 100% inf 0.97  
Stretch on passive dorsiflexion
with knee joint in flexion
13% 87% 1.00 1.00  
Single legged heel raise 22% 93% 3.14 0.95  
Hop test 43% 87% 3.31 0.66  
Thompson test (for rupture)          
  • Palpation: Palpate midportion and insertion
  • Royal London Hospital Test: Pain on palpation disappears on maximal dorsiflexion compared to plantarflexion in achilles tendinopathy
  • Arc test: palpate for thickened part/nodule, then have patient move ankle. In achilles tendinopathy the nodule should move, if it does not move then consider paratendonitis. Paratendonitis may show swelling.
  • Modified straight leg raise for assessing sural nerve neuropathy: bring ankle into dorsiflexion and inverison, then flex the hip.
  • Posterior impingement: passively hyperplantarflex the ankle looking for pain provocation.
  • Plantaris tendinopathy: medial pain as the plantaris compresses against the medial achilles tendon
  • Accessory/low soleus: can lead to compartment syndrome like symptoms e.g. symptoms settle quickly after the patient stops running

Diagnosis

Diagnosing achilles tendinopathy follows the same overarching assessment principles as other lower limb tendinopathies.

  1. Localised symptoms at relevant portion (insertion or midportion)
  2. Proportional pain-load relationship
    • Pain onset 24 hours after high and fast load activities
    • Every stage perform a couple of repetitions and gauge pain. Start with walking or running to assess the pain, double calf raises on the ground, double calf raises on a step, single leg calf raises, single leg knee bent calf raises, add load if required, add speed to calf raises with knee bent, hopping double leg, hopping single leg, hopping forward, backwards, sideways, jumps for maximal height with single leg.
  3. Local thickening of the relevant portion.
  4. Pain on local palpation of the relevant portion.
  5. Hallmark signs
    • Morning stiffness, this is the most sensitive sign.
    • Often have pain after arising from sitting.
  6. Muscle Wasting.

Differential Diagnosis

Differential Diagnosis of Posterior Heel Pain

Imaging

Plain films in insertional Achilles tendinopathy may show calcification or Haglund deformity.

Ultrasound is the preferred imaging modality which has the following typical findings, but may not be correlated with symptoms:

  • Tendon thickening (increased AP diameter)
  • Altered tendon pattern (altered echogenicity)
  • Neovascularisation

MRI is usually not done but can be used if there is a discrepancy between the ultrasound results and the clinical findings, or if an additional specific diagnosis is suspected which can't be detected on ultrasound.

Imaging cannot give information related to response to treatment or prognosis.

Treatment

Progressive calf muscle strengthening

First Line

Education: that it is a degenerative condition that will take many months to resolve but a significant portion of patients will have long term symptoms. Address psychosocial factors.

Loading advice: temporary avoidance of painful sporting activities. Encourage non-provocative replacement activities for example cycling, walking, swimming, or low-impact aerobic gym activities. The patient should start slowly and build up gradually. They can adjust activities based on pain.

Progressive calf muscle strengthening: Graded loading programme based around calf muscle strengthening for 12 weeks. Insertional Achilles tendinopathy exercises can be done on a flat surface to avoid compressing the anterior surface of the distal Achilles against the posterior calcaneum. Be guided by pain levels, if pain is more than 5/10 go back a level, if it is less than 5/10 progress.

  1. Isometric exercises (5 x 45 seconds)
  2. Isotonic exercises (4 x 15 reps)
  3. Isotonic exercises with added weight (4 x 6 reps)
  4. Plyometric exercises
  5. Return to sport

Second Line

If there is no improvement after three months of patient education, structured exercise therapy, and loading advice then discuss other options. However explain that the evidence is very poor.

  • Night splint
  • Orthotics or heel raise
  • Injections (lidocaine, autologous blood, PRP, hyaluronic acid, prolotherapy). Avoid corticosteroid injections.
  • Extracorporeal shockwave therapy
  • Surgery

Prognosis

The majority of patients recover, But 23-37% have persisting pain for at least 10 years despite treatment.[1]

Resources

See Also

References

  1. 1.0 1.1 1.2 de Vos RJ, van der Vlist AC, Zwerver J, Meuffels DE, Smithuis F, van Ingen R, van der Giesen F, Visser E, Balemans A, Pols M, Veen N, den Ouden M, Weir A. Dutch multidisciplinary guideline on Achilles tendinopathy. Br J Sports Med. 2021 Oct;55(20):1125-1134. doi: 10.1136/bjsports-2020-103867. Epub 2021 Jun 29. PMID: 34187784; PMCID: PMC8479731.