Medscape is available in 5 Language Editions – Choose your Edition here.


Achilles Tendon Injuries

  • Author: Anthony J Saglimbeni, MD; Chief Editor: Consuelo T Lorenzo, MD  more...
Updated: Jun 03, 2014

Practice Essentials

Achilles tendon pathologies include rupture and tendonitis. Many experts now believe, however, that tendonitis is a misleading term that should no longer be used, because signs of true inflammation are almost never present on histologic examination. Instead, the following histopathologically determined nomenclature has evolved:

  • Paratenonitis: Characterized by paratenon inflammation and thickening, as well as fibrin adhesions [1]
  • Tendinosis: Characterized by intrasubstance disarray and degeneration of the tendon [2, 1]

Signs and symptoms

Tendon rupture

Patients with an Achilles tendon rupture frequently present with complaints of a sudden snap in the lower calf associated with acute, severe pain. The patient reports feeling like he or she has been shot, kicked, or cut in the back of the leg, which may result in an inability to ambulate further. A patient with Achilles tendon rupture will be unable to stand on his or her toes on the affected side.


Tendinosis is often pain free. Typically, the only sign of the condition may be a palpable intratendinous nodule that accompanies the tendon as the ankle is placed through its range of motion (ROM).


Patients with paratenonitis typically present with warmth, swelling, and diffuse tenderness localized 2-6 cm proximal to the tendon's insertion.

Paratenonitis with tendinosis

This is diagnosed in patients with activity-related pain, as well as swelling of the tendon sheath and tendon nodularity.

See Clinical Presentation for more detail.


Laboratory studies

Laboratory studies usually are not necessary in evaluating and diagnosing an Achilles tendon rupture or injury, although evaluation may help to rule out some of the other possibilities in the differential diagnosis.

Imaging studies

  • Plain radiography: Radiographs are more useful for ruling out other injuries than for ruling in Achilles tendon ruptures
  • Ultrasonography: Ultrasonography of the leg and thigh can help to evaluate the possibility of deep venous thrombosis and also can be used to rule out a Baker cyst; in experienced hands, ultrasonography can identify a ruptured Achilles tendon or the signs of tendinosis
  • Magnetic resonance imaging (MRI): MRI can facilitate definitive diagnosis of a disrupted tendon and can be used to distinguish between paratenonitis, tendinosis, and bursitis

See Workup for more detail.


Achilles tendon rupture

Medical therapy for a patient with an Achilles tendon rupture consists of rest, pain control, serial casting, and rehabilitation to maximize function. Ongoing debate surrounds the issue of whether medical or surgical therapy is more appropriate for this injury.[3, 4]

Surgical techniques for rupture repair are varied but usually involve reapproximation of the torn ends of the Achilles tendon, sometimes reinforced by the gastrocsoleus aponeurosis or plantaris tendon. Open reconstruction is undertaken using a medial longitudinal approach.

Studies indicate that patients who undergo percutaneous, rather than an open, Achilles tendon rupture repair have a minimal rate of infection but a high rate of sural nerve entrapment (16.7% of treated cases).[5]

Achilles tendinosis and paratenonitis

Conservative management of Achilles tendinosis and paratenonitis includes the following:

  • Physical therapy: Eccentric exercises are the cornerstone of strengthening treatment, with most patients achieving 60-90% pain relief [6, 7, 8]
  • Orthotics: Orthotic therapy in Achilles tendinosis consists of the use of heel lifts
  • Nonsteroidal anti-inflammatory drugs (NSAIDs): Tendinosis tends to be less responsive than paratenonitis to NSAIDs
  • Steroid injections: Although these provide short-term relief of painful symptoms, there is concern that they can weaken the tendon, leading to rupture
  • Vessel sclerosis
  • Platelet-rich plasma injections
  • Nitric oxide
  • Shock-wave therapy

Surgery may also be used in the treatment of Achilles tendinosis and paratenonitis. In paratenonitis, fibrotic adhesions and nodules are excised, freeing up the tendon. Longitudinal tenotomies may be performed to decompress the tendon. Satisfactory results have been obtained in 75-100% of cases.

In tendinosis, in addition to the above procedures, the degenerated portions of the tendon and any osteophytes are excised. Haglund’s deformity, if present, is removed. If the remaining tendon is too thin and weak, the plantaris or flexor hallucis longus tendon can be weaved through the Achilles tendon to provide more strength. The outcome is generally less favorable than it is in paratenonitis surgery.

See Treatment and Medication for more detail.



Achilles tendon pathologies include rupture and tendonitis. Achilles tendon rupture, a complete disruption of the tendon, is observed most commonly in patients aged 30-50 years who have had no previous injury or problem in the affected leg and are typically "weekend warriors" who are active intermittently. (See Etiology and Epidemiology.)

Achilles tendonitis refers to inflammation of the tendon or paratenon, usually resulting from overuse associated with a change in playing surface, footwear, or intensity of an activity. Many experts now believe, however, that tendonitis is a misleading term that should no longer be used, because signs of true inflammation are almost never present on histologic examination. Instead, the following histopathologically determined nomenclature has evolved (See Pathophysiology and Etiology):

  • Paratenonitis: Characterized by paratenon inflammation and thickening, as well as fibrin adhesions [1] ; localized thickening of the paratenon, tenderness, crepitus, and pain with active movement also may be present [2]
  • Tendinosis: Characterized by intrasubstance disarray and degeneration of the tendon [2, 1]
  • Paratenonitis with tendinosis

Patient education

Educating the patient throughout the physical therapy treatment program and at subsequent follow-up visits is very important. Include information on adequate stretching prior to physical activity, as well as on appropriate technique and appropriate and properly fitting footwear. (See Treatment and Medication.)

For patient education information, see Ruptured Tendon and Achilles Tendon Rupture.



The Achilles tendon (tendo calcaneus) is formed from the tendinous contributions of the gastrocnemius and soleus muscles, coalescing approximately 15 cm proximal to its insertion. Along its course in the posterior aspect of the leg, the tendon spirals 30-150° until it inserts into the calcaneal tuberosity.

The spiraling of the tendon as it reaches the calcaneus allows for elongation and elastic recoil within the tendon, facilitating storage and release of energy during locomotion. This phenomenon also allows higher shortening velocities and greater instantaneous muscle power than could be generated by the gastrocsoleus complex alone.

Because actin and myosin are present in tenocytes, tendons have almost ideal mechanical properties for the transmission of force from muscle to bone. Tendons are stiff but resilient, possess a high tensile strength, and have the ability to stretch up to 4% before damage occurs.[9] With stretch greater than 8%, macroscopic rupture occurs.

The tendon's ability to glide is facilitated by the presence of a thin paratenon sheath, which is composed of a visceral layer and a parietal layer, rather than simply a true synovial sheath.

The paratenon can become inflamed and enlarged, this being a form of peritenonitis known specifically as paratenonitis. This condition is often found in runners, with acute crepitus felt over the fusiform swelling (which can originate from the paratenon or from the tendon itself).

Just anterior to the Achilles tendon lies the retrocalcaneal bursa. This can become inflamed, leading to pain anterior to the tendon, especially on dorsiflexion of the foot. It is important to differentiate this type of pain from paratenon inflammation or tendinosis. An enlarged bony prominence at the posterosuperolateral aspect of the calcaneus, called the Haglund process, may be associated with retrocalcaneal bursitis but also with insertional tendonitis as well. This is a reason why plain radiography still has value in diagnosis and management.

On average, Achilles tendons in women have a smaller cross-sectional area than in men. This possibly suggests that less force is generated in a woman’s Achilles tendon, which may account for the lower rate of rupture in women.[10]

Blood supply

The blood supply to the Achilles tendon is derived mainly from vessels traversing the mesotendon. The main blood supply is derived from the vincula, both long and short, via the paratenon and especially from the ventral mesotendon. Small longitudinal supplies from the muscle bellies and the distal insertion are also present. However, blood supply is also derived directly from the muscle bellies themselves and distally from bone where the tendon inserts into the calcaneus.

Microvascular Doppler flow studies have shown that flow is distributed evenly throughout the tendon, but it is less at the insertion.[11] Studies have also demonstrated higher resting blood flow rates in individuals with tendinosis than in healthy control subjects.[12]

Cadaveric studies have shown a relative decrease in the frequency and the total area of vessels in the midportion of the Achilles tendon.[13] Dynamic studies have refuted the once-popular historical theory that the pathology is related mainly to a hypovascular zone at the midtendon. However, the relative lack of blood vessels in the area that usually ruptures has led to the term watershed area, which is still used today. Although the blood supply is a factor in Achilles tendinosis, whether it is causative or reactive is still under debate.



Achilles tendonitis was the term originally used to describe the spectrum of tendon injuries ranging from inflammation to tendon rupture, but it now is seen as more of a garbage term. Current literature has delineated the terminology further to pinpoint the area of injury in hopes of guiding practitioners to more effective treatment of the patient.

Furthermore, through extensive histopathologic study, it has been determined that there is no evidence to support the presence of primary prostaglandin-mediated inflammation in Achilles tendonitis. There are, however, signs of neurogenic inflammation, with neuropeptides such as substance P and calcitonin gene–related peptide present.[14]

Tendon histopathology has been divided into the following 4 categories[15, 16, 17] :

  • Cellular activation and increase in cell numbers
  • Increase in ground substance
  • Collagen disarray
  • Neovascularization: However, some more recent studies comparing the degree of neovascularization and the severity of Achilles tendinosis have failed to link a direct relationship [18]

Using this as a guide, a histopathologically determined nomenclature has evolved as follows, to classify Achilles complex pathology:

  • Paratenonitis: Characterized by paratenon inflammation and thickening, as well as fibrin adhesions [1] ; localized thickening of the paratenon, tenderness, crepitus, and pain with active movement also may be present [2]
  • Tendinosis: Characterized by intrasubstance disarray and degeneration of the tendon [2, 1]
  • Paratenonitis with tendinosis

Partial or full tendon ruptures may result from end-stage paratenonitis. Causes of tendon pathologies, including ruptures, are associated with multiple intrinsic and extrinsic factors (see Etiology).[19, 1, 17]

Extracellular and intracellular matrices

Histologic changes in the Achilles tendon include changes to the extracellular and intracellular matrices. These include collagen degeneration, fiber disorientation, and increased mucoid ground substance; however, no increase in inflammatory cells occurs. Focal hypercellularity and vascular proliferation are usually present. The number and morphologic variations of tenocytes increases.[20] Also increased is the number of apoptotic (dead) cells in the degenerate and in the ruptured tendon.[21] The proportion of type III collagen is also increased in the degenerate tendon.

Pathologically, Achilles degeneration has been described as lipoid or mucoid.[22] In mucoid degeneration, the tendon becomes more brown or gray, with mucoid patches and vacuoles. Lipoid degeneration involves increased lipid content in the tendon tissue.[23] Other studies have shown an increase of type I and type III collagen messenger ribonucleic acid (mRNA). Glutamate concentrations also increase in the painful degenerate tendon.[10]


Neovascularization is often a feature of the degenerate tendon. It is associated with painful tendinosis.[24] Eccentric training leading to good clinical results is associated with a reduction and/or absence of neovascularization, and conversely, poor results are associated with continuing neovascularization.[25, 26] Tendon rupture is almost always the terminal event in the ongoing degenerative process of the tendon, as confirmed in histologic studies of ruptured tendons.[27]


Adult tendons are composed of large-diameter type I collagen fibrils. These are 150 nm in diameter, tightly packed with type III collagen, and dispersed in an aqueous gel containing proteoglycan and elastic fibers.[28] The actin and myosin bundles are arranged helically. In healthy tendons, 95% of the collagen is type I.[29] Degenerate tendons have less type I collagen and significantly more type III collagen. The same changes are also seen during the natural aging process, although to a lesser extent. This may be why the tendon is less elastic in older individuals and more prone to rupture.

Type III collagen seems to be the major collagen synthesized in the healing tendon after injury. This observation suggests that the tendon degeneration in tendinosis is an incomplete repair process.

Animal testing has shown that tendons can stretch by 4% of their original length before damage occurs. If they are stretched more than 8%, rupture is likely.[30]

Sport-specific biomechanics

The entire gastrocsoleus musculotendinous unit spans the knee joint, tibiotalar (ankle) joint, and talocalcaneal (subtalar) joint. Contracture of this complex flexes the knee, plantar flexes the ankle, and supinates the subtalar joint. During running, forces equaling 10 times the runner’s body weight have been measured within the tendon.

When there is dysfunction in the gait cycle secondary to Achilles tightness, excessive pronation, or other factors, compensatory posturing up and down the kinetic chain (eg, hip external rotation), functional genu recurvatum, and midtarsal rotation may occur and add not only to Achilles tendinosis but also, in some cases, to a "whipping effect” of the Achilles tendon.[1]



A number of intrinsic and extrinsic factors, including excessive, repetitive strain, appear to be linked to the degeneration and rupture of the Achilles tendon.[31] The exact etiology of such injuries, however, seems to be multifactorial, complicated, and incompletely understood.

Achilles tendinosis is noted more commonly in runners, gymnasts, cyclists, and volleyball players. Hyperpronation may contribute in these cases; moreover, the tendon can be subjected to 8-10 times a person's body weight during strenuous exercise, with Komi having recorded forces of up to 4000 N passing through the Achilles tendon when a person is running on his or her toes.[32, 33]

In cyclists, low saddle height, resulting in extra dorsiflexion of the ankle with pedaling, may be a causative factor in tendinosis.

Intrinsic factors

Systemic diseases that affect the Achilles tendon include the following:

Other intrinsic factors in Achilles tendon injuries include the following[1] :

  • Varus alignment with functional hyperpronation
  • Tibia vara ( Blount disease)
  • Insufficient gastrocsoleus strength and flexibility
  • Limited ankle dorsiflexion

As previously mentioned, age is another factor associated with Achilles tendinosis. Increased incidence of Achilles rupture and Achilles tendinosis has also been associated with having blood group O.[36, 37]

Family history is also a possible risk factor for Achilles tendon disorders. According to a study by Kraemer et al, individuals with a positive family history of Achilles tendinosis have a 5-fold greater risk for such injuries.[38]

Extrinsic factors

Drugs that can play a role in Achilles tendon pathology include the following:

  • Steroids: Whether taken systemically or injected around the tendon, steroids appear to increase the rate of acute rupture [39, 40]
  • Quinolones: Numerous case reports appear to link the administration of quinolone antibiotics to tendon rupture; these drugs may have a toxic effect on the tenocytes, leading to tendon degeneration [41, 42]

Extrinsic causes of Achilles tendinosis also include the following[2, 1, 43, 15, 44] :

  • Overuse
  • Activities with jumping and running
  • Participation in a new activity
  • Increased intensity of activity
  • Increased duration of training
  • Stairs
  • Hill climbing
  • Poor conditioning
  • Improper shoes
  • Improper training surfaces
  • Improper stretching exercises

Tendon rupture

Most Achilles tendon tears occur in the left leg in the substance of the tendo-Achilles, approximately 2-6 cm above the calcaneal insertion of the tendon. That the left Achilles tendon is torn more frequently may be related to handedness; right-handed individuals "push off" more frequently with the left foot.

The most common mechanisms of injury include sudden, forced plantar flexion of the foot; unexpected dorsiflexion of the foot; and violent dorsiflexion of a plantar-flexed foot. Other mechanisms include direct trauma and, less frequently, attrition of the tendon as a result of longstanding paratenonitis, with or without tendinosis.[5, 19, 15]

Achilles tendon rupture resulting from forced dorsiflexion during active plantar flexion is commonly seen in basketball, diving, tennis, and other sports that require forceful push off from the foot.

Other risk factors for Achilles tendon rupture, aside from those previously noted (ie, age, systemic illnesses, medications, blood type), include the following[45] :

  • Poor conditioning
  • Fluoroquinolone antibiotic use
  • Corticosteroid use
  • Overexertion

Although a link between smoking and biceps tendon rupture has been proven, no association between smoking and Achilles tendinosis or rupture is reported in the literature.

Persons who have had an Achilles rupture are more likely than others to have tendinosis and repeat rupture on the contralateral side.[46]


Traditionally, tendinosis is thought to occur with overuse, causing microtrauma to a degree and at a frequency at which the tendon can no longer heal itself. This situation leads to mechanical breakdown of the tendon.[47]

Several authors have studied factors that may influence the development of tendinosis, such as training mileage, rest periods for military recruits between runs, anatomic alignments of the lower limb, and mechanical factors related to shoes and inserts. As yet, no clear-cut evidence has been found linking these to tendinosis. Further confusion arises because tendinosis also can occur in relatively inactive individuals.[48, 49]



The true incidence of Achilles tendinosis is unknown, although reported incidence rates are 6.5-18% in runners, 9% in dancers, 5% in gymnasts, 2% in tennis players, and less than 1% in American football players. It is estimated that Achilles disorders affect approximately 1 million athletes per year.[1]

Occurrence in the United States

The incidence of Achilles tendinosis is believed to be rising, in terms of tendinosis and acute ruptures. An estimated 10% of Americans are involved in some form of recreational running or in other jumping or pivoting activities, and often for longer periods than in previous generations. No data describe the incidence or prevalence of Achilles tendinosis, but it is known to affect 7-18% of club runners.

International occurrence

The exact frequency of tendon rupture varies, having been reported at 6 cases per 100,000 persons in Scotland and 37 cases per 100,000 persons in Denmark.[50]

Sex- and age-related demographics

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

These injuries usually are observed in recreational athletes aged 30-50 years. Many persons in this age group are active only intermittently but still challenge their bodies with high-force activities, predisposing them to Achilles tendinosis.



Achilles tendon injury has an excellent prognosis, allowing for some degree of morbidity through reduced range of motion (ROM).

With proper treatment (conservative or surgical) and rehabilitation, most athletes with Achilles tendon rupture are able to return to their previous activity levels. However, individuals who undergo surgical treatment have a rerupture rate of just 0-5%, compared with nearly 40% for patients who opt for conservative treatment.[51]

Surgical repair results following tendon rerupture are poorer than those following the initial operative treatment of an acute tendon rupture.



Achilles tendon contracture and/or scarring may result from excessive immobilization. In addition, permanent weakness has been known to occur with as little as 4 weeks of immobilization.

Operative treatments have several potential complications, including wound complications (eg, infection, skin slough, sinus formation), adhesions, and sural nerve injury (especially if surgery is conducted through a lateral longitudinal approach).

Contributor Information and Disclosures

Anthony J Saglimbeni, MD 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; Team Physician, Santa Clara University; Consultant, University of San Francisco, Academy of Art University, Skyline College, Foothill College, De Anza College

Anthony J Saglimbeni, MD is a member of the following medical societies: California Medical Association, Santa Clara County Medical Association, Monterey County Medical Society

Disclosure: Received ownership interest from South Bay Sports and Preventive Medicine Associates, Inc for board membership.


Christian J Fulmer, DO Private Practice in Sports and Family Medicine; Team Physician, Valley Christian High School

Christian J Fulmer, DO is a member of the following medical societies: American Academy of Family Physicians, American Academy of Osteopathy, American Medical Society for Sports Medicine, American Osteopathic Association

Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD Medical Director, Senior Products, Central North Region, Humana, Inc

Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.


Michael T Andary, MD, MS Professor, Residency Program Director, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine

Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Association of Academic Physiatrists

Disclosure: Allergan Honoraria Speaking and teaching

Edward Behn, MBBS, MRCS

Disclosure: Nothing to disclose.

David T Bernhardt, MD Director of Adolescent and Sports Medicine Fellowship, Associate Professor, Department of Pediatrics/Ortho and Rehab, Division of Sports Medicine, University of Wisconsin School of Medicine and Public Health

David T Bernhardt, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Sports Medicine, and American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Jason H Calhoun, MD, FACS Department Chief, Musculoskeletal Sciences, Spectrum Health Medical Group

Jason H Calhoun, MD, FACS, is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Diabetes Association, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Missouri State Medical Association, Musculoskeletal Infection Society, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, and Texas Orthopaedic Association

Disclosure: Biocomposite Grant/research funds Other

James K DeOrio, MD Associate Professor of Orthopedic Surgery, Duke University School of Medicine

James K DeOrio, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Foot and Ankle Society

Disclosure: Merete Royalty Other; SBi Royalty Other; BioPro Royalty Other; Acumed, LLC Honoraria Speaking and teaching; Wright Medical Technology, Inc Honoraria Speaking and teaching; SBI Honoraria Speaking and teaching; Integra Speaking and teaching; Datatrace Publishing Honoraria Speaking and teaching; Exactech, Inc Honoraria Speaking and teaching; Tornier Honoraria Speaking and teaching

Kevin J Eerkes, MD Clinical Assistant Professor, Department of Medicine, New York University School of Medicine; Medical Team Physician, New York University Athletics

Disclosure: Nothing to disclose.

Laura M Gottschlich, DO Assistant Professor of Family and Community Medicine, Medical College of Wisconsin; Consulting Staff, Family Medicine Residency Program, St Joseph Hospital, Wheaton Franciscan Healthcare

Laura M Gottschlich, DO is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Association, American Medical Society for Sports Medicine, and American Osteopathic Association

Disclosure: Nothing to disclose.

Richard Hargrove, MBBS, FRCS(Ire), FRCS Consulting Staff, Hip and Hip Revision Arthroplasty, Frimley Park Hospital

Richard Hargrove, MBBS, FRCS(Ire), FRCS is a member of the following medical societies: Royal College of Surgeons of England and Royal Society of Medicine

Disclosure: Nothing to disclose.

Sherwin SW Ho, MD Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, and Herodicus Society

Disclosure: Biomet, Inc. Consulting fee Consulting; Smith and Nephew Grant/research funds Fellowship funding; DJ Ortho Grant/research funds Course funding; Athletico Physical Therapy Grant/research funds Course, research funding

Shepard R Hurwitz, MD Executive Director, American Board of Orthopaedic Surgery

Shepard R Hurwitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for the Advancement of Science, American College of Rheumatology, American College of Sports Medicine, American College of Surgeons, American Diabetes Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Association for the Advancement of Automotive Medicine, Eastern Orthopaedic Association, Orthopaedic Research Society, Orthopaedic Trauma Association, and Southern Orthopaedic Association

Disclosure: Nothing to disclose.

Brian A Jacobs, MD, FACSM Consulting Staff, Private Practice, Family Medicine of South Bend; Team Physician, Marian High School

Brian A Jacobs, MD, FACSM is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, and American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

David Y Lin, MD Fellow, Department of Orthopedic Surgery, Section of Pediatrics, University of Tennessee Campbell Clinic

David Y Lin, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Henry Marano, MD Director, Department of Orthopedic Surgery, Associate Professor, St Joseph's Hospital, Albert Einstein College of Medicine

Henry Marano is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, and Medical Society of the State of New York

Disclosure: Nothing to disclose.

Chris McLean, MBBS, MRCS(Glasg), AFRCS(Ire) Specialist Registrar, Departments of Orthopedic and Trauma Surgery, Frimley Park Hospital, UK

Chris McLean, MBBS, MRCS(Glasg), AFRCS(Ire) is a member of the following medical societies: British Medical Association

Disclosure: Nothing to disclose.

Evan Schwartz, MD Director of Orthopedic Surgery, New York Medical College; Assistant Professor, St John's Queens Hospital, Department of Surgery, Albert Einstein School of Medicine

Evan Schwartz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Society for Sports Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM President and Director, Georgia Pain Physicians, PC; Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, Emory University School of Medicine

Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, American Medical Association, International Association for the Study of Pain, and Texas Medical Association

Disclosure: Nothing to disclose.

  1. Albers D, Hoke B. Techniques in Achilles tendon rehabilitation. Tech Foot Ankle Surg. 2003. 2(3):208-19.

  2. Asplund CA, Best TM. Achilles tendon disorders. BMJ. 2013 Mar 12. 346:f1262. [Medline].

  3. Chan AP, Chan YY, Fong DT, Wong PY, Lam HY, Lo CK, et al. Clinical and biomechanical outcome of minimal invasive and open repair of the Achilles tendon. Sports Med Arthrosc Rehabil Ther Technol. 2011 Dec 20. 3(1):32. [Medline].

  4. Nilsson-Helander K, Silbernagel KG, Thomeé R, Faxén E, Olsson N, Eriksson BI, et al. Acute achilles tendon rupture: a randomized, controlled study comparing surgical and nonsurgical treatments using validated outcome measures. Am J Sports Med. 2010 Nov. 38(11):2186-93. [Medline].

  5. Khan RJ, Fick D, Keogh A, Crawford J, Brammar T, Parker M. Treatment of acute achilles tendon ruptures. A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am. 2005 Oct. 87(10):2202-10. [Medline].

  6. Childress MA, Beutler A. Management of chronic tendon injuries. Am Fam Physician. 2013 Apr 1. 87(7):486-90. [Medline].

  7. Wiegerinck JI, Kerkhoffs GM, van Sterkenburg MN, Sierevelt IN, van Dijk CN. Treatment for insertional Achilles tendinopathy: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2013 Jun. 21(6):1345-55. [Medline].

  8. Stevens M, Tan CW. Effectiveness of the Alfredson protocol compared with a lower repetition-volume protocol for midportion Achilles tendinopathy: a randomized controlled trial. J Orthop Sports Phys Ther. 2014 Feb. 44(2):59-67. [Medline].

  9. Moore KL. Clinically Oriented Anatomy. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1999.

  10. Kader D, Saxena A, Movin T, Maffulli N. Achilles tendinopathy: some aspects of basic science and clinical management. Br J Sports Med. 2002 Aug. 36(4):239-49. [Medline]. [Full Text].

  11. Aström M, Westlin N. Blood flow in chronic Achilles tendinopathy. Clin Orthop Relat Res. 1994 Nov. 166-72. [Medline].

  12. Aström M, Westlin N. Blood flow in the human Achilles tendon assessed by laser Doppler flowmetry. J Orthop Res. 1994 Mar. 12(2):246-52. [Medline].

  13. Carr AJ, Norris SH. The blood supply of the calcaneal tendon. J Bone Joint Surg Br. 1989 Jan. 71(1):100-1. [Medline].

  14. Gaida J, Alfredson H, Forsgren S, Cook J. Decreased tumour necrosis factor alpha (tnf-a) in serum of patients with achilles tendinopathy: further evidence against the role of inflammation in the chronic stage. Br J Sports Med. 2014 Apr. 48(7):597. [Medline].

  15. Keene JS. Tendon injuries of the foot and ankle. DeLee JC, Drez D, eds. Orthopaedic Sports Medicine. Philadelphia, Pa: WB Saunders; 1994. 1788-94.

  16. Saltzman C, Bonar S. Tendon problems of the foot and ankle. Lutter LD, Mizel MS, Pfeffer GB, eds. Orthopaedic Knowledge Update: Foot and Ankle. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1994. 236-73.

  17. Wheaton MT, Molnar TJ. Overuse injuries of the lower extremities. Griffin, LY, ed. Orthopaedic Knowledge Update: Sports Medicine. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1994. 225-7.

  18. De Jonge S, Warnaars JL, De Vos RJ, Weir A, van Schie HT, Bierma-Zeinstra SM, et al. Relationship between neovascularization and clinical severity in Achilles tendinopathy in 556 paired measurements. Scand J Med Sci Sports. 2013 Apr 22. [Medline].

  19. Schepsis AA, Jones H, Haas AL. Achilles tendon disorders in athletes. Am J Sports Med. 2002 Mar-Apr. 30(2):287-305. [Medline].

  20. Kannus P, Józsa L. Histopathological changes preceding spontaneous rupture of a tendon. A controlled study of 891 patients. J Bone Joint Surg Am. 1991 Dec. 73(10):1507-25. [Medline].

  21. Yuan J, Wang MX, Murrell GA. Cell death and tendinopathy. Clin Sports Med. 2003 Oct. 22(4):693-701. [Medline].

  22. Józsa L, Kannus P. Histopathological findings in spontaneous tendon ruptures. Scand J Med Sci Sports. 1997 Apr. 7(2):113-8. [Medline].

  23. Maffulli N, Barrass V, Ewen SW. Light microscopic histology of achilles tendon ruptures. A comparison with unruptured tendons. Am J Sports Med. 2000 Nov-Dec. 28(6):857-63. [Medline].

  24. Zanetti M, Metzdorf A, Kundert HP, Zollinger H, Vienne P, Seifert B, et al. Achilles tendons: clinical relevance of neovascularization diagnosed with power Doppler US. Radiology. 2003 May. 227(2):556-60. [Medline].

  25. Ohberg L, Alfredson H. Effects on neovascularisation behind the good results with eccentric training in chronic mid-portion Achilles tendinosis?. Knee Surg Sports Traumatol Arthrosc. 2004 Sep. 12(5):465-70. [Medline].

  26. Alfredson H, Ohberg L, Forsgren S. Is vasculo-neural ingrowth the cause of pain in chronic Achilles tendinosis? An investigation using ultrasonography and colour Doppler, immunohistochemistry, and diagnostic injections. Knee Surg Sports Traumatol Arthrosc. 2003 Sep. 11(5):334-8. [Medline].

  27. Cetti R, Junge J, Vyberg M. Spontaneous rupture of the Achilles tendon is preceded by widespread and bilateral tendon damage and ipsilateral inflammation: a clinical and histopathologic study of 60 patients. Acta Orthop Scand. 2003 Feb. 74(1):78-84. [Medline].

  28. Harries M. Oxford textbook of Sports Medicine. 2nd ed. New York, NY: Oxford University Press; Chapt 4.4.3.

  29. Maffulli N, Ewen SW, Waterston SW, Reaper J, Barrass V. Tenocytes from ruptured and tendinopathic achilles tendons produce greater quantities of type III collagen than tenocytes from normal achilles tendons. An in vitro model of human tendon healing. Am J Sports Med. 2000 Jul-Aug. 28(4):499-505. [Medline].

  30. Whittaker P, Canham PB. Demonstration of quantitative fabric analysis of tendon collagen using two-dimensional polarized light microscopy. Matrix. 1991 Feb. 11(1):56-62. [Medline].

  31. Kvist M. Achilles tendon injuries in athletes. Sports Med. 1994 Sep. 18(3):173-201. [Medline].

  32. Scott RT, Hyer CF, Granata A. The correlation of Achilles tendinopathy and body mass index. Foot Ankle Spec. 2013 Aug. 6(4):283-5. [Medline].

  33. Van Ginckel A, Thijs Y, Hesar NG, Mahieu N, De Clercq D, Roosen P, et al. Intrinsic gait-related risk factors for Achilles tendinopathy in novice runners: a prospective study. Gait Posture. 2009 Apr. 29(3):387-91. [Medline].

  34. Hofmann GO, Weber T, Lob G. [Tendon rupture in chronic kidney insufficiency--"uremic tendonopathy"? A literature-supported documentation of 3 cases]. Chirurg. 1990 Jun. 61(6):434-7. [Medline].

  35. Spencer JD. Spontaneous rupture of tendons in dialysis and renal transplant patients. Injury. 1988 Mar. 19(2):86-8. [Medline].

  36. Jozsa L, Balint JB, Kannus P, Reffy A, Barzo M. Distribution of blood groups in patients with tendon rupture. An analysis of 832 cases. J Bone Joint Surg Br. 1989 Mar. 71(2):272-4. [Medline].

  37. Kujala UM, Järvinen M, Natri A, Lehto M, Nelimarkka O, Hurme M, et al. ABO blood groups and musculoskeletal injuries. Injury. 1992. 23(2):131-3. [Medline].

  38. Kraemer R, Wuerfel W, Lorenzen J, Busche M, Vogt PM, Knobloch K. Analysis of hereditary and medical risk factors in Achilles tendinopathy and Achilles tendon ruptures: a matched pair analysis. Arch Orthop Trauma Surg. 2012 Jun. 132(6):847-53. [Medline].

  39. Shrier I, Matheson GO, Kohl HW 3rd. Achilles tendonitis: are corticosteroid injections useful or harmful?. Clin J Sport Med. 1996 Oct. 6(4):245-50. [Medline].

  40. Newnham DM, Douglas JG, Legge JS, Friend JA. Achilles tendon rupture: an underrated complication of corticosteroid treatment. Thorax. 1991 Nov. 46(11):853-4. [Medline]. [Full Text].

  41. Malaguti M, Triolo L, Biagini M. Ciprofloxacin-associated Achilles tendon rupture in a hemodialysis patient. J Nephrol. 2001 Sep-Oct. 14(5):431-2. [Medline].

  42. Harrell RM. Fluoroquinolone-induced tendinopathy: what do we know?. South Med J. 1999 Jun. 92(6):622-5. [Medline].

  43. Diehl J. Platelet-rich plasma therapy in chronic Achilles tendinopathy. Tech Foot Ankle Surg. March 2011. 10(1):2-6.

  44. Malliou P, Rokka S, Beneka A, Gioftsidou A, Mavromoustakos S, Godolias G. Analysis of the chronic lower limb injuries occurrence in step aerobic instructors in relation to their working step class profile - A three year longitudinal prospective study. J Back Musculoskelet Rehabil. 2014 Feb 20. [Medline].

  45. Maffulli N, Longo UG, Maffulli GD, Khanna A, Denaro V. Achilles tendon ruptures in elite athletes. Foot Ankle Int. 2011 Jan. 32(1):9-15. [Medline].

  46. Arøen A, Helgø D, Granlund OG, Bahr R. Contralateral tendon rupture risk is increased in individuals with a previous Achilles tendon rupture. Scand J Med Sci Sports. 2004 Feb. 14(1):30-3. [Medline].

  47. Almekinders LC, Weinhold PS, Maffulli N. Compression etiology in tendinopathy. Clin Sports Med. 2003 Oct. 22(4):703-10. [Medline].

  48. Aström M. Partial rupture in chronic achilles tendinopathy. A retrospective analysis of 342 cases. Acta Orthop Scand. 1998 Aug. 69(4):404-7. [Medline].

  49. Hutchison AM, Evans R, Bodger O, Pallister I, Topliss C, Williams P, et al. What is the best clinical test for Achilles tendinopathy?. Foot Ankle Surg. 2013 Jun. 19(2):112-7. [Medline].

  50. de Jonge S, van den Berg C, de Vos RJ, van der Heide HJ, Weir A, Verhaar JA, et al. Incidence of midportion Achilles tendinopathy in the general population. Br J Sports Med. 2011 Oct. 45(13):1026-8. [Medline].

  51. Saxena A, Ewen B, Maffulli N. Rehabilitation of the operated achilles tendon: parameters for predicting return to activity. J Foot Ankle Surg. 2011 Jan-Feb. 50(1):37-40. [Medline].

  52. Tonarelli JM, Mabry LM, Ross MD. Diagnostic imaging of an Achilles tendon rupture. J Orthop Sports Phys Ther. 2011 Nov. 41(11):904. [Medline].

  53. De Zordo T, Chhem R, Smekal V, Feuchtner G, Reindl M, Fink C, et al. Real-time sonoelastography: findings in patients with symptomatic achilles tendons and comparison to healthy volunteers. Ultraschall Med. 2010 Aug. 31(4):394-400. [Medline].

  54. Juras V, Zbyn S, Pressl C, Domayer SE, Hofstaetter JG, Mayerhoefer ME, et al. Sodium MR Imaging of Achilles Tendinopathy at 7 T: Preliminary Results. Radiology. 2012 Jan. 262(1):199-205. [Medline].

  55. Grigg NL, Stevenson NJ, Wearing SC, et al. Incidental walking activity is sufficient to induce time-dependent conditioning of the Achilles tendon. Gait Posture. 2009 Oct 5. [Medline].

  56. Henriksen M, Aaboe J, Bliddal H, et al. Biomechanical characteristics of the eccentric Achilles tendon exercise. J Biomech. 2009 Sep 21. [Medline].

  57. Gardin A, Movin T, Svensson L, et al. The long-term clinical and MRI results following eccentric calf muscle training in chronic Achilles tendinosis. Skeletal Radiol. 2009 Sep 23. [Medline].

  58. Hawkins D, Lum C, Gaydos D, et al. Dynamic creep and pre-conditioning of the Achilles tendon in-vivo. J Biomech. 2009 Sep 15. [Medline].

  59. Cohen RS, Balcom TA. Current treatment options for ankle injuries: lateral ankle sprain, Achilles tendonitis, and Achilles rupture. Curr Sports Med Rep. 2003 Oct. 2(5):251-4. [Medline].

  60. Alfredson H, Pietilä T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med. 1998 May-Jun. 26(3):360-6. [Medline].

  61. Rees JD, Lichtwark GA, Wolman RL, Wilson AM. The mechanism for efficacy of eccentric loading in Achilles tendon injury; an in vivo study in humans. Rheumatology (Oxford). 2008 Oct. 47(10):1493-7. [Medline].

  62. Reese RC Jr, Burruss TP, Patten J. Athletic training techniques and protective equipment. Nicholas JA, Hershman EB, eds. The Lower Extremity & Spine in Sports Medicine. 2nd ed. St Louis, Mo: Mosby; 1995. 267-75.

  63. Marsolais D, Côté CH, Frenette J. Nonsteroidal anti-inflammatory drug reduces neutrophil and macrophage accumulation but does not improve tendon regeneration. Lab Invest. 2003 Jul. 83(7):991-9. [Medline].

  64. Ohberg L, Alfredson H. Ultrasound guided sclerosis of neovessels in painful chronic Achilles tendinosis: pilot study of a new treatment. Br J Sports Med. 2002 Jun. 36(3):173-5; discussion 176-7. [Medline]. [Full Text].

  65. Clementson M, Lorén I, Dahlberg L, Aström M. Sclerosing injections in midportion Achilles tendinopathy: a retrospective study of 25 patients. Knee Surg Sports Traumatol Arthrosc. 2008 Sep. 16(9):887-90. [Medline].

  66. de Jonge S, de Vos RJ, Weir A, van Schie HT, Bierma-Zeinstra SM, Verhaar JA, et al. One-year follow-up of platelet-rich plasma treatment in chronic Achilles tendinopathy: a double-blind randomized placebo-controlled trial. Am J Sports Med. 2011 Aug. 39(8):1623-9. [Medline].

  67. Mautner K, Colberg RE, Malanga G, Borg-Stein JP, Harmon KG, Dharamsi AS, et al. Outcomes after ultrasound-guided platelet-rich plasma injections for chronic tendinopathy: a multicenter, retrospective review. PM R. 2013 Mar. 5(3):169-75. [Medline].

  68. Paoloni JA, Appleyard RC, Nelson J, Murrell GA. Topical glyceryl trinitrate treatment of chronic noninsertional achilles tendinopathy. A randomized, double-blind, placebo-controlled trial. J Bone Joint Surg Am. 2004 May. 86-A(5):916-22. [Medline].

  69. Fox A, Murrell G. Nitric oxide and tendon healing. Tech Orthoped. 2007. 22(1):14-9.

  70. Al-Abbad H, Simon JV. The effectiveness of extracorporeal shock wave therapy on chronic achilles tendinopathy: a systematic review. Foot Ankle Int. 2013 Jan. 34(1):33-41. [Medline].

  71. Rompe JD, Furia J, Maffulli N. Eccentric loading versus eccentric loading plus shock-wave treatment for midportion achilles tendinopathy: a randomized controlled trial. Am J Sports Med. 2009 Mar. 37(3):463-70. [Medline].

  72. McLaughian GJ, Handol HG. Interventions for treating acute and chronic Achilles tendinitis. (Cochrane review). The Cochrane Library,. Chichester, UK: John Wiley and Sons; Issue 1:

  73. Brosseau L, Casimiro L, Milne S, Robinson V, Shea B, Tugwell P, et al. Deep transverse friction massage for treating tendinitis. Cochrane Database Syst Rev. 2002. CD003528. [Medline].

  74. Zhang BM, Zhong LW, Xu SW, Jiang HR, Shen J. Acupuncture for chronic Achilles tendnopathy: a randomized controlled study. Chin J Integr Med. 2013 Dec. 19(12):900-4. [Medline].

  75. Wegrzyn J, Luciani JF, Philippot R, et al. Chronic Achilles tendon rupture reconstruction using a modified flexor hallucis longus transfer. Int Orthop. 2009 Aug 21. [Medline].

  76. Metz R, Verleisdonk EJ, van der Heijden GJ, Clevers GJ, Hammacher ER, Verhofstad MH, et al. Acute Achilles tendon rupture: minimally invasive surgery versus nonoperative treatment with immediate full weightbearing--a randomized controlled trial. Am J Sports Med. 2008 Sep. 36(9):1688-94. [Medline].

  77. Twaddle BC, Poon P. Early motion for Achilles tendon ruptures: is surgery important? A randomized, prospective study. Am J Sports Med. 2007 Dec. 35(12):2033-8. [Medline].

  78. Keller A, Ortiz C, Wagner E, Wagner P, Mococain P. Mini-Open Tenorrhaphy of Acute Achilles Tendon Ruptures: Medium-Term Follow-up of 100 Cases. Am J Sports Med. 2014 Mar. 42(3):731-6. [Medline].

  79. Wilkins R, Bisson LJ. Operative versus nonoperative management of acute Achilles tendon ruptures: a quantitative systematic review of randomized controlled trials. Am J Sports Med. 2012 Sep. 40(9):2154-60. [Medline].

  80. Amendola A. Outcomes of open surgery versus nonoperative management of acute achilles tendon rupture. Clin J Sport Med. 2014 Jan. 24(1):90-1. [Medline].

  81. DeLee JC, Drez D Jr, Miller MD, eds. Orthopaedic Sports Medicine. 2nd ed. Philadelphia, Pa: WB Saunders; 2003.

  82. Pajala A, Kangas J, Siira P, Ohtonen P, Leppilahti J. Augmented compared with nonaugmented surgical repair of a fresh total Achilles tendon rupture. A prospective randomized study. J Bone Joint Surg Am. 2009 May. 91(5):1092-100. [Medline].

  83. Rahm S, Spross C, Gerber F, Farshad M, Buck FM, Espinosa N. Operative treatment of chronic irreparable Achilles tendon ruptures with large flexor hallucis longus tendon transfers. Foot Ankle Int. 2013 Aug. 34(8):1100-10. [Medline].

  84. Silbernagel KG, Nilsson-Helander K, Thomee R, et al. A new measurement of heel-rise endurance with the ability to detect functional deficits in patients with Achilles tendon rupture. Knee Surg Sports Traumatol Arthrosc. 2009 Aug 19. [Medline].

  85. Maquirriain J, Kokalj A. Acute Achilles tendinopathy: effect of pain control on leg stiffness. J Musculoskelet Neuronal Interact. 2014 Mar. 14(1):131-6. [Medline].

  86. Miners AL, Bougie TL. Chronic Achilles tendinopathy: a case study of treatment incorporating active and passive tissue warm-up, Graston Technique, ART, eccentric exercise, and cryotherapy. J Can Chiropr Assoc. 2011 Dec. 55(4):269-79. [Medline]. [Full Text].

All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.