Achilles Tendinitis

What is it?

Achilles tendinitis implies an inflammatory response, but this is very limited because there is little blood supply to the Achilles tendon. More appropriate descriptions are inflammation of the surrounding sheath (paratenonitis), degeneration within the substance of the tendon (tendinosis) or a combination of the two. ​

Symptoms and Clinical Presentation

​Paratenonitis presents in younger people. Symptoms start gradually and spontaneously. Aching and burning pain is noted especially with morning activity. It may improve slightly with initial activity, but becomes worse with further activity. It is aggravated by exercise. Over time less exercise is required to cause the pain.

The Achilles tendon is often enlarged, warm and tender approximately 1 to 4 inches above its heel insertion. Sometimes friction is noted with gentle palpation of the tendon during ankle motion.

Tendinosis presents similarly but typically in middle-aged people. If severe pain and limited walking ability are present, it may indicate a partial tear of the tendon.

Cause (including risk factors)

Cause​The cause of paratenonitis is not well understood although there is a correlation with a recent increase in the intensity of running or jumping workouts. It can be associated with repetitive activities which overload the tendon structure, postural problems such as flatfoot or high-arched foot, or footwear and training issues such as running on uneven or excessively hard ground or running on slanted surfaces. Tendinosis is also associated with the aging process.

Anatomy

The Achilles tendon is the largest tendon in the body. It is formed by the merging together of the upper calf muscles and inserts into the back of the heel bone. Its blood supply comes from the muscles above and the bony attachment below. The blood supply is limited at the “watershed” zone approximately 1 to 4 inches above the insertion into the heel bone.  Paratendonitis and tendinosis develop in the same area.

Diagnosis

There is enlargement and warmth of the tendon 1 to 4 inches above its heel insertion. Pain and sometimes a scratching feeling may be created by gently squeezing the tendon between the thumb and forefinger during ankle motion. There may be weakness in push-off strength with walking.  Magnetic resonance imaging (MRI) can define the extent of degeneration, the degree to which the tendon sheath is involved and the presence of other problems in this area, but the diagnosis is mostly clinical.

Treatment Options

​Nonsurgical Treatment Options

Most cases are successfully treated non-surgically although this is time-consuming and frustrating for active patients. Treatment is less likely to be successful if symptoms have been present more than six months. Nonsurgical management includes nonsteroidal anti-inflammatory medications, rest, immobilization, limitation of activity, ice, contrast baths, stretching and heel lifts. If symptoms fail to resolve after two to three months, a formal physical therapy (PT) program may be of benefit.  An arch support may help if there is an associated flatfoot.  A cast or brace to completely rest this area may be necessary. Extracorporeal shockwave therapy (ESWT) and platelet rich plasma (PRP) injections have variable reports of success.  Nitroglycerin medication applied to the overlying skin may be of benefit.

Surgical Treatment Options

For paratenonitis, a technique called brisement is an option. Local anesthetic is injected into the space between the tendon and its surrounding sheath to break up scar tissue. This can be beneficial in earlier stages of the problem 30 to 50 percent of the time, but may need to be repeated two to three times.

Surgery consists of cutting out the surrounding thickened and scarred sheath. The tendon itself is also explored and any split tears within the tendon are repaired. Motion is started almost immediately to prevent repeat scarring of the tendon to the sheath and overlying soft tissue, and weight-bearing should follow as soon as pain and swelling permit, usually less than one to two weeks. Return to competitive activity takes three to six months.
 
Since tendinosis involves changes in the substance of the tendon, brisement is of no benefit. Surgery consists of cutting out scar tissue and calcification deposits within the tendon. Abnormal tissue is excised until tissue with normal appearance appears. The tendon is then repaired with suture. In older patients or when more than 50 percent of the tendon is removed, one of the other tendons at the back of the ankle is transferred to the heel bone to assist the Achilles tendon with strength as well as provide better blood supply to this area.

Recovery

Recovery from symptoms with both non-surgical and surgical management may take up to one to two years. At least three to six months of non-surgical treatment is recommended before considering surgery. A cast, splint or brace is used for four to eight weeks following surgery, although early range of motion exercises will be started earlier.

Outcome

​Non-surgical management of paratenonitis may take several months but results in resolution and return to pre-injury activities in 90 percent of cases. In those patients that fail nonsurgical management, surgical treatment will result in resolution of symptoms in 75 to 100 percent of cases.

Results of nonsurgical and surgical treatment for tendinosis are less predictable, with surgery success reported from 36 to 100 percent. Better results are associated with shorter duration of symptoms and amount of tendon involvement, younger age and whether a tendon transfer was performed.

Complications

The risk of Achilles tendon rupture is small but present. Return to normal running and jumping athletic activities is usually avoided until the pain is completely resolved and the involved area is no longer tender to touch. As with any surgery, there are risks of infection and wound problems, although these are uncommon.

Frequently Asked Questions

Would a cortisone injection help?

Cortisone injections are not recommended for the treatment of these types of problems because they can lead to death of the tendon and make it much easier to rupture.

Additional Resources

Brisement

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