Achilles tendinitis
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Achilles tendinitis, also known as Achilles tendinopathy, is soreness of the Achilles tendon. It is accompanied by alterations in the tendon's structure and mechanical properties.<ref name="OI2010">Template:Cite journal</ref> The most common symptoms are pain and swelling around the back of the ankle.<ref name=Hub2018/> The pain is typically worse at the start of exercise and decreases thereafter.<ref name=Mer2018/> Stiffness of the ankle may also be present.<ref name=OI2010/> Onset is generally gradual.<ref name=Hub2018/>
Achilles tendinopathy is idiopathic, meaning the cause is not well understood. Theories of causation include overuse such as running,<ref name=OI2010/><ref name=Mer2018>Template:Cite web</ref> a lifestyle that includes little exercise, high-heel shoes, rheumatoid arthritis, and medications of the fluoroquinolone or steroid class.<ref name=Hub2018>Template:Cite journal</ref> Diagnosis is generally based on symptoms and examination.<ref name=Mer2018/>
Proposed interventions to treat tendinopathy have limited or no scientific evidence to support them, such as pre-exercise stretching, strengthening calf muscles, avoiding over-training, adjustment of running mechanics, and selection of footwear.<ref name=Park2006>Template:Cite journal</ref><ref name=Pet2016>Template:Cite journal</ref><ref>Template:Cite web</ref> Treatment is symptomatic and non-specific such as ice, non-steroidal antiinflammatory agents (NSAIDs), and physical therapy.<ref name=Hub2018/><ref name=OI2010/> People who are not satisfied with symptomatic treatment may be offered surgery.<ref name=OI2010/> Achilles tendinitis is relatively common.<ref name=OI2010/>
Signs and symptoms
Symptoms can vary from an ache or pain and swelling in the local area of one or both ankles, or a burning that surrounds the whole joint. With this condition, the pain is usually worse during and after activity, and the tendon and joint area can become stiff the following day, as swelling impinges on the movement of the tendon.
Achilles tendon injuries can be separated into insertional tendinopathy (20%–25% of the injuries), midportion tendinopathy (55%–65%), and proximal musculotendinous junction (9%–25%) injuries, according to the location of pain.<ref>Template:Cite journal</ref>
Cause
Achilles tendinitis is a common injury, particularly in sports that involve lunging and jumping, occurs both laterally and bilaterally, and is often induced in a single ankle by trauma. It is also a known side effect of fluoroquinolone antibiotics such as ciprofloxacin, as are other types of tendinitis.<ref>Template:Cite news</ref>
Achilles tendinitis is thought to have physiological, mechanical, or extrinsic (i.e. footwear or training) causes. The Achilles tendon has a generally poor blood supply throughout its length, as measured by the number of vessels per cross-sectional area. Blood is supplied via the synovial sheaths that surround it.<ref>Template:Cite journal</ref> This lack of blood supply can lead to the degradation of collagen fibers and inflammation.<ref>Template:Cite journal</ref> Tightness in the calf muscles has also been known to be involved in the onset of Achilles tendinitis.<ref name = "maffuli" >Template:Cite journal</ref>
During the loading phase of the running and walking cycle, the ankle and foot naturally pronate and supinate by approximately 5 degrees.<ref name = "one">Template:Cite journal</ref> Excessive pronation of the foot (over 5 degrees) in the subtalar joint is a type of mechanical mechanism that can lead to tendinitis.<ref name = "maffuli"/><ref name = "one"/>
An overuse injury refers to repeated stress and strain, which is likely the case in endurance runners.<ref>Template:Cite journal</ref><ref name="McCrory">Template:Cite journal</ref> Overuse can simply mean an increase in running, jumping or plyometric exercise intensity too soon. Another consideration would be the use of improper or worn-down footwear, which lack the necessary support to maintain the foot in the natural/normal pronation.<ref name="McCrory"/>
Pathophysiology
Because the Achilles tendon does not have good blood supply, injuries can be slow to heal. The tendon receives nutrients from the tendon sheath or paratendon. When an injury occurs to the tendon, cells from surrounding structures migrate into the tendon to assist in repair. Some of these cells come from blood vessels that enter the tendon to provide direct blood flow to increase healing. With the blood vessels come nerve fibers. Researchers including Alfredson and his team in Sweden believe these nerve fibers to be the cause of the pain - they injected local anaesthetic around the vessels and this decreased significantly the pain in the Achilles tendon.<ref name="Alfredson-2003">Template:Cite journal</ref>
Diagnosis
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Achilles tendinitis is usually diagnosed from a medical history, and physical examination of the tendon. Projectional radiography shows calcification deposits within the tendon at its calcaneal insertion in approximately 60 percent of cases.<ref name=aofas/> Magnetic resonance imaging (MRI) can determine the extent of tendon degeneration, and may show differential diagnoses such as bursitis.<ref name=aofas>Template:Cite web</ref>
Prevention
Performing consistent physical activity will improve the elasticity and strength of the tendon, which will assist in resisting the forces that are applied.<ref name = "source1">Template:Cite journal</ref>
Stretching before beginning an exercise session is often recommended, however evidence to support this practice is limited.<ref name=Park2006/><ref name=Pet2016/> Prevention of recurrence includes following appropriate exercise habits and wearing low-heeled shoes. In the case of incorrect foot alignment, orthotics can be used to properly position the feet.<ref name = "source1"/> Footwear that is specialized to provide shock-absorption can be utilized to defend the longevity of the tendon.<ref name="source2">Template:Cite journal</ref> Achilles tendon injuries can be the result of exceeding the tendon's capabilities for loading, therefore it is important to gradually adapt to exercise if someone is inexperienced, sedentary, or is an athlete who is not progressing at a steady rate.<ref name = "source2"/>
Eccentric strengthening exercises of the gastrocnemius and soleus muscles are utilized to improve the tensile strength of the tendon and lengthen the musculotendinous junction, decreasing the amount of strain experienced with ankle joint movements.<ref>G T Allison, C Purdam. Eccentric loading for Achilles tendinopathy — strengthening or stretching? Br J Sports Med 2009;43:276-279</ref> This eccentric training method is especially important for individuals with chronic Achilles tendinosis which is classified as the degeneration of collagen fibers.<ref name = "source2"/>
Treatment
Treatment typically involves rest, ice, non-steroidal antiinflammatory agents (NSAIDs), and physical therapy.<ref name=Hub2018/><ref name=OI2010/> A heel lift<ref>Template:Cite web</ref> or orthotics <ref>Template:Cite journal</ref> may also be helpful,<ref name=Mer2018/><ref name=OI2010/> but evidence for either is limited. Foam rolling may increase range of motion, but there is only weak evidence for the direct treatment of stiffness.<ref>Template:Cite journal</ref> Other treatments include:
- An eccentric exercise routine designed to strengthen the tendon.
- Application of a boot or cast.
Injections
The evidence to support injection therapies is poor.<ref name=Kea2015>Template:Cite journal</ref>
- This includes corticosteroid injections.<ref name=Hub2018/> These can also increase the risk of tendon rupture.<ref name=Kea2015/>
- Autologous blood injections - results have not been highly encouraging and there is little evidence for their use.<ref>Template:Cite web</ref><ref>Template:Cite web</ref><ref name=Hub2018/>
- Stem-cell injection might be beneficial for achilles tendon pathologies that enhance healing.<ref>Template:Cite journal</ref>
Procedures
Tentative evidence supports the use of extracorporeal shockwave therapy.<ref>Template:Cite journal</ref>
Epidemiology
The prevalence of Achilles tendinitis varies among different ages and groups of people. Achilles tendinitis is most commonly found in individuals aged 30–40.<ref name = "Leach">Template:Cite journal</ref> Runners are susceptible,<ref name = "Leach"/> as well as anyone participating in sports, and men aged 30–39.<ref>Template:Cite journal</ref>
Risk factors include participating in a sport or activity that involves running, jumping, bounding, and change of speed. Although Achilles tendinitis is mostly likely to occur in runners, it also is more likely in participants in basketball, volleyball, dancing, gymnastics and other athletic activities.<ref name = "Leach"/> Other risk factors include gender, age, improper stretching, and overuse.<ref name="Kainberger">Template:Cite journal</ref> Another risk factor is any congenital condition in which an individual's legs rotate abnormally, which in turn causes the lower extremities to overstretch and contract; this puts stress on the Achilles tendon and will eventually cause Achilles tendinitis.<ref name="Kainberger"/>