ACHILLES TENDONITIS

a.k.a. achilles tendinitis

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What is Achilles tendonitis?
Achilles tendonitis, also known as Achilles tendinitis, is inflammation of the Achilles tendon. The Achilles tendon connects your calf muscles to the back of your heel bone. It allows extension of your foot downward (plantar flexion), away from your body, which lets your heel lift off the ground as you move forward when walking. Every time you take a step you rely on your Achilles tendon.

Achilles tendinopathy is prevalent and potentially incapacitating in athletes involved in running sports. It is a degenerative, not an inflammatory, condition. Most patients respond to conservative measures if the condition is recognised early. Surgery usually involves removal of adhesions and degenerated areas and decompression of the tendon by tenotomy or measures that influence the local circulation.

Hi, I'm the webmaster at Bioenergetic Spectrum. I am using this page for research and notes on what also works for me. About six months ago I began experiencing achilles tendinitis when I woke up. I don't train as hard as most athletes. I figured that it must be atrophy from sitting in front of the computer too long. Although the pain subsides after I do regular calisthenics and taijiquan every morning, the condition continues when I wake up the next morning. I figure there may be some uric acid crystals, calcification or even arthritis involved since I am what most people might call middle aged. I am going to share some proven detox methods as well as warm up exercises for defeating pain and stiffness in this most important of tendons for people who like to walk, run, and jump.

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ANATOMY OF THE ACHILLES TENDON

achilles tendonThe gastrocnemius muscle merges with the soleus to form the Achilles tendon in two different ways. In the more common type 1 junction, the two aponeuroses join 12 cm proximal to their calcaneal insertion. In type 2, the gastrocnemius aponeurosis inserts directly into the aponeurosis of the soleus. The Achilles tendon has a round upper part and is relatively flat in its distal 4 cm.10 The fibres of the Achilles tendon are not vertical, but spiral 90�. This arrangement increases the tendon elongation and helps the release during locomotion of the energy stored within the tendon.1,2

Unlike other tendons around the ankle, which have a synovialsheath, the Achilles tendon is enveloped by a paratenon, a membraneconsisting of two layers: a deeper layer surrounding and indirect contact with the epitenon, and a superficial layer, theperitenon,3,4 which is connected with the underlying layer through the mesotenon. The paratenon originates from the deep fascia of the leg, the fascia cruris, covering the tendon posteriorly. Recently an organised thickening of the paratenon has been described as the "watershed band," consisting of a thickened portion of the paratenon from the deep fascia of the posterior aspect of the leg to envelope the watershed region in the Achilles tendon.5

A microvascular perfusion study in the human Achilles tendonassessed by laser Doppler flowmetry showed that the blood flows considerably lower near the calcaneal insertion but otherwisewas distributed evenly in the tendon.6 Further, blood flow in the symptomatic Achilles tendinopathy was considerably elevated compared with the control tendons.7

Langberg et al8 measured blood flow in the peritendinous space of the human Achilles tendon at rest and after 40 minutes of dynamic contraction of the triceps surae. Blood flow in the peritendinous space 5 cm proximal to its insertion increased fourfold with exercise, while it increased only 2.5-fold when measured 2 cm proximal to the insertion.8 The increase in blood flow during exercise probably results from the considerable rise in the negative tissue pressure in the peritendinous space.9

lower leg including achilles tendon and calf muscles


HISTOLOGY OF NORMAL ACHILLES TENDON
Tenocytes and tenoblasts comprise 90 - 95% of the cellular elements of the tendon. Chondrocytes, vascular cells, synovial cells, and smooth muscle cells form the remaining cellular elements. The extracellular tendon matrix is composed of collagen and elastin fibres, ground substance such as proteoglycans, andorganic components such as calcium.10,11

Collagen fibrils are bundled into fascicles containing blood,lymphatic vessels, and nerves,12 and have been shown to interchange between fascicles.13 The fascicles, which are surrounded by the endotenon, group together to form the gross structure of the tendon. The tendon is enveloped by a well defined layer of connective tissue, the epitenon. This, in its turn, is surrounded by the paratenon, with a thin layer of fluid in between to reduce friction during tendon motion. The innermost layer of the epitenon is in direct contact with the endotenon.


BIOMECHANICS OF THE ACHILLES TENDON
Actin and myosin are present in tenocytes,14 and tendons have almost ideal mechanical properties for the transmission of force from muscle to bone. Tendons are stiff and resilient, with high tensile strength: they can stretch up to 4% before damage.10,15Achilles tendons in men have higher maximum rupture force and stiffness with a larger cross sectional area than in women, while younger tendons have significantly higher tensile rupture stress and lower stiffness.16

The peak Achilles tendon force and the mechanical work by the calf muscles is 2233 Newtons (N) and 34 Joules (J) in the squat jump, 1895 N and 27 J in the counter movement jump, and 3786 N and 51 J when hopping.17 The indirect estimation of peak load on the Achilles tendon, normalised to subject body weight, is 6.1 - 8.2 x body weight during running, with a tensile force of more than 3 kN.18

The loads imposed on the Achilles tendon were measured using a "buckle"-type transducer implanted in the Achilles tendon under local anaesthesia. They reached up to 9 kN during running, corresponding to 12.5 times the body weight, 2.6 kN during slow walking, and less than 1 kN during cycling.2, 19, 22

A tendon loses its wavy configuration when it is stretched more than 2%. As collagen fibres deform, they respond linearly to increasing tendon loads.10,23 The normal wavy appearance of the tendon is regained if the strain placed on it remains at less than 4%. At strain levels greater than 8%, macroscopic rupture will occur.15,24,25

What causes Achilles tendinitis?
Achilles tendinitis can be caused by:

  • overuse of the Achilles tendon;
  • overly tight calf muscles;
  • excessive running up hill or down hill;
  • a sudden increase in the amount of exercise, e.g. running for a longer distance;
  • wearing ill-fitting running shoes, such as those with soles that are too stiff; or
  • wearing high heels often and changing between high heels all day and flat shoes or low running shoes in the evening.

The causes of Achilles tendinopathy remain unclear.2,4 Various theories link tendinopathies to overuse stresses, poor vascularity, lack of flexibility, genetic make up, sex, and endocrine or metabolic factors

Excessive loading of the tendon during vigorous training activitiesis regarded as the main pathological stimulus.2,4,37 The Achilles tendon may respond to repetitive overload beyond physiological threshold by either inflammation of its sheath or degeneration of its body, or by a combination of the two.38 Damage to the tendon can occur even if it is stressed within its physiological limits when the frequent cumulative microtrauma applied do not leave enough time for repair.1 Microtrauma can result from non-uniform stress within the Achilles tendon from different individual force contributions of the gastrocnemius and soleus, producing abnormal load concentrations within the tendon and frictional forces between the fibrils, with localised fibre damage.39

Tendinopathy has been attributed to a variety of intrinsic andextrinsic factors. Tendon vascularity, gastrocnemius-soleusdysfunction, age, sex, body weight and height, pes cavus deformity,and lateral ankle instability are common intrinsic factors.Excessive motion of the hindfoot in the frontal plane, especiallya lateral heel strike with excessive compensatory pronation, is thought to cause a "whipping action" on the Achilles tendon, and predispose it to tendinopathy.40 Also, an appreciable forefoot varus has often been found in patients with Achilles tendon problems.41 Perhaps for these reasons foot orthoses are advocated to control symptoms in chronic Achilles tendinopathy,42 although the scientific evidence from randomised controlled trials for their use is still lacking. Changes in training pattern, poor technique, previous injuries, footwear, and environmental factors such as training on hard, slippery, or slanting surfaces are extrinsic factors that may predispose the athlete to Achilles tendinopathy (table 3Go).4,37,4345 It should be emphasised, however, that these are aetiopathogenetic theories, and a cause-effect relation has not been shown in longitudinal studies based on hypothesis testing.

CLINICAL ASPECTS OF ACHILLES TENDINOPATHY
History and examination play a key role in diagnosis and management of Achilles tendinopathy. The onset of pain, duration, and aggravating factors should be documented. Thorough enquiry should be made into the relation of pain to various activities, intensity of training, and exercise technique. Details of previous treatments are also important.

Achilles tendinopathy typically presents with pain 26 cm proximal to the tendon insertion after exercise. As the pathological process progresses, pain may occur during exercise, and, in severe cases, the pain interferes with activities of daily living.99 There is good correlation between the severity of the disease and the degree of morning stiffness. Runners experience pain at the beginning and end of a training session, with a period of diminished discomfort in between.100

Clinical examination should start by exposing both legs from above the knees, and the patient should be examined standing and prone. The foot and the heel should be inspected for any mal-alignment, deformity, obvious asymmetry in tendon size, localised thickening, Haglund heel, and any previous scars. The Achilles tendon should be palpated to detect tenderness, heat, thickening, nodularity, and crepitation.101 The tendon's excursion is assessed. The "painful arc" sign helps to distinguish between tendon and paratenon lesions. In paratendinopathy, the area of maximum thickening and tenderness remains fixed in relation to the malleoli from full dorsiflexion to plantar flexion, whereas lesions within the tendon move with ankle motion.88 Patients with more chronic tendinopathy may have greater difficulty in performing the test than patients who present more acutely,101 although we have not found this test helpful in clinical practice.

Overuse is common in walkers, runners, dancers and other athletes who do a lot of jumping and sudden starts/stops, which exert a lot of stress on the Achilles tendon.

Continuing to stress an inflamed Achilles tendon can cause rupture of the tendon � it snaps, often with a distinctive popping sound. A ruptured Achilles tendon makes it virtually impossible to walk. An Achilles tendon rupture is usually treated with surgical repair or wearing a cast.

Symptoms of Achilles tendinitis

  • Pain anywhere along the tendon, but most often on or close to the heel.
  • Swelling of the skin over the tendon, associated with warmth, redness and tenderness.
  • Pain on rising up on the toes and pain with pushing off on the toes.
  • A painful heel for the first few minutes of walking after waking up in the morning.
  • Range of motion of the ankle may be limited.

What you can do in the first 48 hours of an Achilles injury

  • Rest the affected foot and avoid weight-bearing activities.
  • Use ice packs to help ease the swelling, pain and redness.
  • Compress the affected foot and ankle with an elastic compression bandage.
  • Elevate the affected foot as much as possible while the inflammation settles.

If you cannot walk properly and think you may have ruptured the tendon, see a doctor straight away. Similarly, if you have a sudden feeling like you have been kicked or shot in the back of the leg, seek medical advice.

HEALING PROCESS
The commonest form of tendon healing is by scarring, which is inferior to healing by regeneration.20,53 A tendon heals in essentially the same way as soft tissue, going through the same inflammatory (17 days of injury), proliferative (721 days), and remodeling (three weeks to one year) phases. Despite collagen maturation and remodeling, tendons are biochemically and metabolically less active than bone and muscle.20,53 Fibroblasts synthesise collagen type III in the proliferative phase. This will be replaced gradually by collagen type I from day 1214 with progressive increase in tensile strength.20

In animals, by 15 days after surgery, the healing tendons regain 48% tensile strength, 30% of energy absorption, 20% tensile stress, and 14% Young's modulus of elasticity of intact tendons. Healing tendons have 80% of the collagen and 60% of the collagen cross links (hydroxypyridinium) of normal tendons. Healing tendons yield more soluble collagen than intact tendons. This has led to the hypothesis that increased collagen synthesis takes place, possibly with enhanced resorption of mature collagen in healing tendons compared with intact tendons. Electron microscopy shows ultrastructural differences between intact and healing tendons.60

Recovery from tendon injury is slow because of many factorsincluding low oxygen consumption, slow synthesis of structural protein, and excessive load. The oxygen consumption of tendons is 7.5 times lower than that of skeletal muscles, and tendons are able to sustain loads of up to 17 times body weight.61 Recent studies have shown that the healing capacity of tendons may have been underestimated.62

Rehabilitation for Achilles tendinitis
See your doctor or sports therapist for further advice. You may be prescribed anti-inflammatory medication and a rehabilitation programme. Sometimes, the ankle may be put in a cast to immobilise the injury.

  • Gentle calf stretching is the first stage of rehabilitation. Don't stretch to the point of pain.
  • Strengthening the Achilles tendon is the second stage. Your doctor or sports therapist will be able to advise you on exercises for this.
  • As symptoms resolve, resume normal weight-bearing activities gradually.
  • Avoid running until all tenderness has gone. Swimming or cycling in low gear are good replacement activities.


Preventing Achilles tendinitis

  • Do strengthening and stretching exercises to keep calf muscles strong and flexible.
  • Keep your hamstring muscles flexible by stretching.
  • Warm up and stretch adequately before participating in any sports.
  • Always increase the intensity and duration of training gradually.
  • Do not continue an exercise if you experience pain in the tendon.
  • Wear properly fitted running and other sports shoes, including properly fitted arch supports if your feet roll inwards excessively (over-pronate).


When to see a doctor
Consult a doctor if you feel pain over your heels that worsens with exercise.

Many clinical and biological aspects of Achilles tendinopathy are still unclear. It is classically considered an overuse injury. Nevertheless, some patients seem to be more prone to it than others despite similar training and competition loads.

CONCLUSIONS
Although Achilles tendinopathy has been extensively studied, there is a clear lack of properly conducted scientific research to clarify its causes, pathology, and optimal management plan.

The outcome of Achilles tendinopathy is more favourable when treated within six months of onset. Most patients respond to conservative measures if the condition is recognised early, whereas continuing the offending activities leads to adhesion and chronic changes which are more resistant to conservative treatment. Teaching patients to control the symptoms may be more beneficial than leading them to believe that Achilles tendinopathy is fully curable. Progressive eccentric training has been reported with encouraging short term results.

Surgery usually involves removal of adhesions and degenerated areas and decompression of the tendon by tenotomy or measures that influence the local circulation.

It is still debatable why tendinopathic tendons respond to surgery.58 For example, we do not know whether surgery induces revascularisation, denervation, or both, resulting in pain reduction. It is also unclear how longitudinal tenotomy improves vascularisation.

As the biology of tendinopathy is being clarified, more effective management regimens may come to light, improving the success rate of both conservative and operative management.

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