Introduction
Cause
Symptoms
Diagnosis
Non-surgical treatment
Surgical treatment
Rehabilitation
Prevention
Achilles tendinosis can either be acute or chronic. It is common among runners and athletes involved in impact-loading sports.
Achilles tendinosis usually occurs 3 to 5 cm above the insertion of the Achilles tendon to the heel bone in the form of a painful, bulbous mass. It is described as a non-inflammatory condition, which is the result of repeated minor tear of the tendon fibres. Microscopic analysis of the collagen and related fibers that make up the Achilles tendon reveal that the cells are disorganized, degenerated and scarred. The condition is often classified as non-insertional tendinopathy, in which it is distinguished from insertional tendionpathy, where the pathology lies at the tendon bone junctional region, and is usually inflammatory in origin. Both intrinsic and extrinsic factors contribute to the pathophysiology of the disease. Intrinsic causes include flat feet and heel cord tightness. Extrinsically, any sudden alternation in the routine pattern or the intensity level of training may also provoke similar tendinopathy.
Achilles tendinosis is more common among young to middle-aged athletes. Pain usually arises close to the insertion of the Achilles tendon to the heel bone, with or without swelling in that area. The pain may come on gradually or only occur when you walk or run. However, the pain may become recurrent and episodic. You may also experience less strength and range of motion of the ankle.
The Achilles tendon is usually tender at a site 3 to 5cm above the insertion of the tendon to the heel bone. At a later stage, the tendon may be visibly swollen or thickened on palpation. The calf muscle may also be tight.
X-rays are usually negative but is important to exclude other insertional tendinopathy, for example, Haglund’s lesion (“pump bump”), in which a prominent posterior superior calcaneous deformity may co-exist with the Achilles tendinosis. MRI will demonstrate the swollen, thickened and lack of healthy tendon tissue of the Achilles tendon, and is useful in excluding other pathology as well as to determine the severity of the tendinosis.
Conservative management should always be the first step to the treatment of Achilles tendinosis. These include R.I.C.E. (Rest, Ice, Compression and Elevation) in the acute stage. In chronic cases, physiotherapy may be useful. Eccentric calf muscle training, ultrasound or shockwave therapies and pulsed electromagnetic field are some of non-exhaustive ways to manage Achilles tendinosis. Orthosis is prescribed to correct any intrinsic foot problems to improve the efficiency of treatment. Tendinosis may not be responsive to anti-inflammatory medication, except for pain relief. Treatment, of course, is customized for each patient. Among athletic or active people, it is important to have a specific and organised rehabilitation programme and at the same time encourage alternative physical activities (e.g. swimming) that will not have further impact on the heel cord while the athlete slowly recovers with conservative treatment.
It may take up to 12 weeks or even more for the patient to have the pain resolved. However, the hallmark fusiform swelling may persist despite the resolution of the symptoms.
Surgical intervention is recommended only in some recalcitrant cases in which conservative treatments have failed. This may include an excision of the diseased or degenerated part of the Achilles tendon with or without tendon transfer or augmentation, depending on the condition of the remaining tendon. Additional procedures with an excision of osteophyte or Haglund’s deformity may be required if present.
Post-operatively the ankle may need to be splinted for a few weeks followed by progressive range-of-motion, weight-bearing and strengthening exercises. Physical therapy modalities mentioned above are certainly useful during the rehabilitation. Running may begin at around 6-8 weeks after the surgery. However, participation in competitive sports may be delayed for 3-6 months depending on the recovery progress. The athlete may need to return to sports with a heel lift initially and wean out of it when conditions become more tolerable. Stretching and correcting any biomechanical problems or faulty sports techniques are equally important during the later phase of rehabilitation.
A sudden increase in training intensity especially in impact-loading sports should be avoided since it will introduce a lot of stress to the Achilles tendon. Flexibility training is always important. As mentioned above, eccentric calf muscle training is the hallmark in strengthening of the Achilles tendon. Correction of the underlying foot deformity by means of an orthosis can also help prevent the development of Achilles tendinosis.
Dr. CHAN, Wai-lam