Achilles Tendonitis 

  • Author: Laura M Gottschlich, DO; Chief Editor: Sherwin SW Ho, MD   more...
 
Updated: Aug 31, 2011
 

Background

The Achilles tendon, named after the seemingly indestructible mythologic Greek warrior, is the largest and strongest tendon in the human body. Achilles tendinitis was the term originally used to describe the spectrum of tendon injuries ranging from inflammation to tendon rupture. Despite this spectrum, through extensive study of the histopathology of Achilles tendinitis, it has been determined that there is no evidence to support primary prostaglandin-mediated inflammation. There are, however, signs of "neurogenic inflammation with presence of neuropeptides like substance P and calcitonin gene related peptide."

Tendon histopathology has been divided into 4 categories[1, 2, 3, 4] : (1) Cellular activation and increase in cell numbers, (2) increase in ground substance, (3) collagen disarray, and (4) neovascularization. Using this as a guide, a histopathologically determined nomenclature has evolved to classify this range of Achilles tendon pathology into 3 stages: (1) paratenonitis, (2), tendinosis, and (3) paratenonitis with tendinosis.

Partial or full tendon ruptures may result from end-stage paratenonitis. Causes of tendon ruptures are associated with multiple factors including overuse, with both extrinsic and intrinsic factors playing a role in increasing susceptibility.[3, 5, 6, 7, 8, 9, 10, 11] Athletes who are poorly conditioned, overtrained, or insufficiently prepared are at the highest risk for this disease process. Repetitive stresses to the tendon, such as prolonged jumping or running, result in chronic pain and tightness along the tendon.[12]

Tendinitis usually develops insidiously after sudden changes in activity or training level, use of inappropriate footwear, or training on poor running surfaces, especially if high-risk factors are present (eg, age, cavus feet, tibia vara, heel and forefoot varus deformities).

For patient education resources, see the Foot, Ankle, Knee, and Hip Center, as well as Tendinitis, Ruptured Tendon, and Achilles Tendon Rupture.

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Epidemiology

Frequency

United States

The true incidence of Achilles tendinitis is unknown, although there is a reported incidence of 6.5-18% in runners.

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Functional Anatomy

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 tendon's ability to glide is facilitated by the presence of a thin paratenon sheath, which is composed of both a visceral layer and parietal layer, rather than simply a true synovial sheath. The tendon's blood supply arises from the osseous insertion, the musculotendinous junction, and multiple infiltrating mesotenon vessels, which cross the layers of the anterior paratenon.

Various injection and nuclear medicine studies have demonstrated a paucity of mesotenon and intratendinous vessels 2-6 cm proximal to the heel insertion known as the watershed area. Due to the relative lack of blood supply in the watershed area, this region of the tendon is less resilient to repetitive microtrauma and has a higher tendency for irritation, degeneration, and possible rupture than the calcaneal insertion site.[13]

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Sport-Specific Biomechanics

The entire gastrocnemius/soleus 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 body weight have been measured within the tendon.

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Contributor Information and Disclosures
Author

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

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.

Coauthor(s)

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.

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.

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.

Specialty Editor Board

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.

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

Jon B Whitehurst, MD  Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital

Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America

Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD  Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago

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: Breg, Inc. Consulting fee Consulting; Biomet, Inc. Consulting fee Consulting; GMV, Inc. Arthroscopy Simulator Evaluation and teaching; Smith and Nephew Grant/research funds Fellowship funding; DJ Ortho Grant/research funds Course funding; Athletico Physical Therapy Grant/research funds Course, research funding

Acknowledgments

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Henry Marano, MD, to the development and writing of this article.

References

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