eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskeletal Conditions

Achilles Tendon Injuries and Tendonitis

Author: Anthony J Saglimbeni, MD, Staff Physician, Family Practice Residency, President, South Bay Sports and Preventive Medicine Associates; Private Practice; Team Internist, San Francisco Giants; Team Internist, West Valley College; Team Physician, Bellarmine College Prep; Team Physician, Presentation High School
Coauthor(s): Christian J Fulmer, DO, Private Practice in Sports and Family Medicine; Team Physician, Valley Christian High School
Contributor Information and Disclosures

Updated: Oct 14, 2009

Introduction

Background

Achilles tendon rupture is a complete disruption of the Achilles tendon, observed most commonly in patients aged 30-50 years, usually occurring at a point 4-5 cm proximal to the calcaneus. This area above the calcaneus is the zone of poor blood flow in the tendon.

Achilles tendonitis is inflammation of the tendon or paratenon, usually resulting from overuse associated with a change in playing surface, footwear, or intensity of an activity. Terminology used to describe this condition currently is subject to debate. Some evidence suggests that tendinopathy or tendinosis are better terms, as inflammation, suggested by the term tendonitis, may not play a key role in this process.

Pathophysiology

Areas of degeneration may predispose patients to Achilles tendon ruptures (eg, from chronic tendonitis or tendinopathy), or prior cortisone injections may lead to tendon rupture. Common pathophysiology of overuse syndromes applies to Achilles overuse injuries.

Frequency

United States

Exact frequency varies and has been reported at 6 cases per 100,000 persons in Scotland to up to 37 cases per 100,000 persons in Denmark. The condition commonly occurs in the 30- to 44-year-old recreational athletes, and as many as 72-89% of injuries occur during athletic ventures. Some reports show Achilles tendon rupture to be the third most common tendon rupture.

Mortality/Morbidity

Mortality is unreported. Morbidity can include chronic shortening or contracture with Achilles tendon rupture and tendon degeneration with tendonitis.

Sex

Achilles tendon injuries are more prevalent in males at a ratio of 6:1, perhaps due to sports-specific involvement.

Age

This injury usually is observed in recreational athletes aged 30-50 years. As with gastrocnemius tears and strains, this population often is active only intermittently, and they often still challenge their bodies with high-force activities, predisposing them to these kinds of injuries.

Clinical

History

• Achilles tendon rupture is characterized by an acute onset of pain in the distal rear leg. The patient reports feeling like he or she has been shot, kicked, or cut in the back of the leg, resulting in an inability to ambulate further. A very strong athlete, however, usually is able to overcome that gait abnormality by using other plantar flexors to ambulate normally.
• Some patients have a history of chronic recurrent calf or Achilles tendon area pain or prior cortisone injection.
• Achilles tendonitis is seen in jumpers and correlates with the risk factors of increased intensity, participation in a new activity, or new or unsuitable footwear. Injury is observed more commonly in runners, gymnasts, cyclists, and volleyball players; hyperpronation may contribute. In cyclists, a causative factor may be low saddle height, resulting in extra dorsiflexion of the ankle with pedaling.

Physical

• Achilles tendon rupture is indicated by obvious leg swelling with a palpable defect in the Achilles tendon. Active plantar flexion is weak or absent. Some strong athletes still may be able to perform toe raises by overcoming the defect with strong peroneals, toe flexors, and posterior tibialis.
• The Thompson test generally is positive. This test is performed by having the patient lie prone with his knee passively flexed. Squeeze the calf, looking for normal foot plantar flexion. Absence of plantar flexion is considered a positive test. Comparison easily can be made to the uninjured side.
• In Achilles tendonitis, the area is tender to palpation from 2-5 cm proximal to the calcaneus. Nodules also may be palpable, as well as a "wet leather" sign of crepitation with ankle plantar flexion and dorsiflexion. This is demonstrated by gently squeezing or palpating the Achilles tendon while the athlete or patient actively plantar flexes and dorsiflexes the foot and ankle. The examiner's fingers feel the crepitus as an area of sponginess, as one would expect with "wet leather." Passive ankle dorsiflexion and active resisted plantar flexion may cause increased pain.

Causes

• Achilles tendon rupture usually comes after a forced dorsiflexion during active plantar flexion, as with gastrocnemius tears. This is commonly seen in basketball, diving, tennis, and other sports that require forceful push off from the foot. Other predisposing factors include chronic recurrent Achilles tendonitis and prior history of cortisone injections to the Achilles tendon.
• 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.
• Higher-than-average rates of Achilles rupture have been noted in patients with blood type O, gout, systemic lupus erythematosus, and rheumatoid arthritis.
• Achilles tendon rupture is seen in patients who are using steroid medication and fluoroquinolone-type antibiotics.

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