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Achilles tendonitis is seen in jumpers and correlates to risk factors of increased intensity, participation in a new activity, or new or unsuitable footwear. Injury is noted more commonly in runners, gymnasts, cyclists, and volleyball players; hyperpronation may contribute. In cyclists, low saddle height, resulting in extra dorsiflexion of the ankle with pedaling, may be a causative factor.

Achilles tendon injuries may be classified as follows:

Peritenonitis

Localized/burning pain during or following activity occurs.

As the disease progresses, onset of pain may occur earlier during activity, with decreased activity level, or even at rest.

In this condition, the paratenon itself is inflamed thickened and typically adherent to the underlying unaffected tendon. Under the microscope, there is capillary proliferation and infiltration of inflammatory cells within the paratenon.

Tendinosis

Usually, this injury is an asymptomatic, noninflammatory, degenerative disease process (mucoid degeneration).

The patient may complain of a sensation of fullness or nodule in the back of the leg.

With tendinosis, there are thickened and yellowish areas of mucoid degeneration within the tendon itself. The tendon loses its normal coloration and striation patterns.

Hypocellularity, collagen disorganization, lack of inflammatory reaction, scattered vascular ingrowth, and intermittent areas of calcification or necrosis are hallmarks of this disease process.

Pathology is usually found within the watershed area of the tendon.

Peritenonitis with tendinosis

Activity-related pain and diffuse swelling of the tendon sheath with nodularity is present.

Histologically and macroscopically, this entity combines findings found in both tendinosis and peritenonitis.

Causes:

Extrinsic causes of Achilles tendonitis include the following:
Overuse
Increased intensity of activity
Increased duration of training
Stairs
Hill climbing
Poor conditioning
Improper shoes
Improper training surfaces
Improper stretching exercises

Intrinsic causes may include the following:

Age
Tight Achilles tendon
Varus heel
Varus forefoot
Cavus foot
Tibia vara
Medical diseases that may affect tendon tissue (eg, diabetes mellitus) and diseases requiring corticosteroid treatment (eg, lupus, asthma, transplants)

Management:

Physical therapy for patients with Achilles tendonitis consists of several stages. The initial goal of physical therapy is to control the inflammation.

In the first and part of the second phase, pain is used to guide the intensity of exercise. Active ankle dorsiflexion with gentle calf stretching is performed.

In the intermediate phase, strengthening replaces active ROM, and neuromuscular control programs are initiated.

In the third phase of rehabilitation, progressive stress is applied under good control to allow the collagen to form appropriately. As pain resolves, perform aggressive stretching and active resisted motion.

Cryotherapy is useful in all of these stages. Physical modalities, such as ultrasound and electrical stimulation, also are useful to decrease pain and inflammation.

Acute Phase:

Physical Therapy:

Peritenonitis

Recommend rest and limitation of activities determined by the severity and duration of pain. Ice compresses can be used for relief of acute pain and inflammation following activities. Recommend nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce pain and inflammation. Suggest a heel lift of 1-2 cm on a temporary basis for comfort. Heel lifts on a prolonged basis may result in tendon shortening.

Instruct the patient in stretching, training modification/re-evaluation, and muscle strengthening. Stretching exercises are believed to be the key modality in treatment as they provide better flexibility to the ankle. Stretching of the posterior gastroc-soleus complex should always be slow and deliberate. Each stretch should last for 20-30 seconds, with multiple repetitions in a set.

Three possible methods of stretching the gastroc-soleus complex include 1) incline board, 2) wall leans, and 3) "foot on chair" stretching. An incline board is a fabricated ramp of 15-18° that allows the patient to gradually stretch the heel cord complex. A much simpler method is to have the patient stand and face a wall, while leaning with his knees extended and his heels planted on the ground. The "foot on chair" method requires the athlete to place his foot flat on a chair, and gradually bring his knee forward as far as possible without losing heel contact with the chair. Use orthotics to treat overpronation or heel cups to provide extra support and cushion to the tendon. Return to activities is gradual.

Tendinosis

Tendinosis alone usually is asymptomatic and is noticeable only with palpation of a nodule or fullness along the tendon. Tendinosis becomes symptomatic when coexistent peritenonitis is present and the patient complains of activity-related pain or swelling. Treatment is first conservative with methods similar to simple peritenonitis. Six to eight weeks of activity modification, orthotics (walking boot with a heel lift), anti-inflammatory analgesics, and physical therapy should be prescribed prior to any operative treatment or orthopedic referral.

Certain modalities have been used in physical therapy programs. Therapeutic ultrasound provides silent mechanical vibrations of high frequency that penetrate superficial tissue in order to generate deep heat. Ultrasound has been shown in some studies to increase the rate of collagen synthesis and the breaking strength of the tendon. Ultrasound's effectiveness as an anti-inflammatory technique remains unproven. Both phonophoresis and iontophoresis deliver topically applied anti-inflammatory medications transdermally with the aid of mechanical ultrasound energy or an electrical field gradient, respectively. Typically, because the anti-inflammatory substance is a steroid (known to weaken tendinous tissue), I do not recommend its use.

Maintenance Phase:

Physical Therapy: Achilles tendonitis is best prevented, treated, and maintained by preserving good ROM in the heel cord complex. Such motion can be gained with the use of an incline board, wall leans, or the "foot on chair" stretching exercises as described. Moist heat or compresses prior to workouts and at night are beneficial. Cold modalities should be used following strenuous activities to provide pain relief and anti-inflammatory effects.