Achilles tendinopathy

Findings

Typically, there appears to be a history of pain, increasing with activity and better is rest. Active and passive stretching of the gastrocnemius( knee straight, dorsiflexed ankle) or soleus( knee bent, dorsiflexed ankle) is painful and limited. Resisted plantar flexion, which may require testing by a one-leg heel raise, or hopping, is painful. Passive whipped plantarflexion, tested by calcaneotibial compression, is pain-free. There may be a palpable swelling in the tendon that moves with the tendon. It is locally tender to compression. The attitude and Simonds’/Thompson’s test is normal.

Cause

Partial tear, myeloid, myxoaid, hyaline degeneration of collagen fibres or cystic degeneration. Ageing could be a factor, but the cause is possibly attritional, from vibration shock at impact, overpronation or incoordination between the quadriceps and calf muscle. EMG studies shown that the quadriceps straightens the knee before the calf plantar flexes the foot, and movements that stress this mechanism or that encourage plantar flexion, whilst the knee is bent, may promote Achilles attrition.

Treatment

a)      A heel raise in the shoes will reduce the load on the Achilles tendon.

b)      Orthotics, if overpronation is contributing to a “side to side” distortion during movement.

c)      Achilles ladder, and/or repetition of eccentric “heel drops”.

d)     A cyst, sometimes called “red degeneration”, which can be seen on scanning should be curetted out.

e)      Surgery or percutaneous needling to longitudinally split the tendon fibres and encourage vascular neogenesis.

f)       Sclerosis or disruption of new vessels under Doppler ultrasound guidance.

Sports

a)      Athletics – a sudden increase in speed, or distance, may create too much load for the tendon. Camber running encourages lateral movement of the calcaneum and bowing of the tendon. Repetition sprints, with too little recovery time, can fatique the quadriceps, causing an upset in calf/quadriceps coordination. Uphill running may produce overload of the Achilles.

b)      Hill walking and climbing – when climbing using the forefoot, the heel may drop too low, increasing the forces on the Achilles. However, by using “high heels”, i.e. finding a rock to support the heel, or zig-zagging up the hill using the sides of the foot, this problem is prevented.

c)      Cricket – very often an Achilles tendon tears when a back foot shot is played to mid-wicket, and a quick single is run. The weight is on the ball of the back foot activating the calf and then the knee straightens for the run, upsetting the calf/quadriceps coordination.

d)     All sports – sudden acceleration from a bent knee position and a plantarflexed foot.

It is tendinopathy, a degenerative lesion, that delays healing, and this damage may cause later rupture. Whether surgery, with longitudinal splitting, encourages invasion of new blood vessels to repair tissue or whether, post surgery, the patient accepts a longer rehabilitation is still debatable. Certainly, an athlete with a tendinopathy can go all the way up the Achilles ladders, play four games and break down again – so it is difficult to project when full recovery has occurred. Ultrasonographic monitoring may help. Vitamin C encourages formation of collagen from fibroblasts in vitro, however, collagen neogenesis is still the problem in vivo, though early stem cell research suggests that nearly normal tendons may be regenerated.

"Concise guide to sports injuries, 2^nd edition",Churchill Livingstone, Malcolm T.F. Read,  foreword by Bryan English