Achilles tendinitis is an inflammatory process in the tendon area of the calf and flounder muscles. It proceeds acutely or chronically. It is provoked by chronic overloads or a single excessive load on the tendons. It is manifested by pain, swelling and a slight restriction of the back flexion of the foot. The diagnosis is made on the basis of symptoms, MRI and radiography data. Treatment is usually conservative: physical therapy, physiotherapy procedures. Immobilization is rarely required. In some cases, with a persistent course, an operation is indicated.
M76.6 Tendinitis of the calcaneal [Achilles] tendon
Achilles tendinitis causes
Achilles tendinitis is more often detected in athletes, is a consequence of overload, incorrect technique or violation of the training regime. It can be diagnosed in people 40-60 years old after a single intensive load of the Achilles tendon (for example, when trying to run), the high probability of tendinitis in such cases is due to the rigidity of the Achilles tendon increasing with age and some decrease in the volume of movements in the ankle joint.
In clinical traumatology and orthopedics, there are three forms of tendinitis. Peritendinitis is called inflammation of the tissues surrounding the Achilles tendon. Tendinitis is an inflammation of the tendon itself, leading to its degeneration. Enthesopathy is an inflammatory process localized in the area of attachment of the Achilles tendon to the heel bone, may be accompanied by the formation of a heel spur and calcification foci in the tendon tissue. All three forms of the disease can occur in isolation, be observed simultaneously or pass into one another.
Achilles tendinitis symptoms
The disease develops gradually, at first the patient feels pain in the ankle (in the Achilles tendon area) only in the first minutes of exercise or training. After warming up, the pain decreases, and finally disappears at rest. When palpating the lesion area, there is some discomfort, but pain, as a rule, is absent. In the absence of treatment, the disease eventually turns into a chronic form. Within a few weeks or months, the pain syndrome increases. Unlike the initial stage, after the warm-up, the pain does not decrease, but increases. Even prolonged rest does not bring relief, some patients are disturbed by pain after a night’s sleep.
Many patients report pain when descending or climbing stairs or an inclined surface. Examination reveals tension of the calf muscle, thickening of the Achilles tendon, local hyperemia and a local increase in skin temperature in the affected area. The amount of movement in the ankle joint is somewhat limited. With peritendinitis, pain is usually localized throughout the tendon, with tendinitis – 2-6 cm above the heel, with enthesopathy – in the area of attachment of the tendon or slightly above it.
The diagnosis is made during the consultation of the orthopedist on the basis of complaints and external examination data. Of the additional research methods, radiography of the lower leg and ankle joint, magnetic resonance imaging and ultrasound of the ankle joint are used. On radiographs, in some cases, foci of calcification are determined. With tendinitis, they are “scattered” throughout the tendon, with enthesopathy they are localized mainly in its lower part. The absence of calcifications is not a basis for confirming or refuting the diagnosis of tendinitis.
Ultrasound and MRI are more accurate techniques that allow to examine soft tissues in detail, to determine the foci of inflammation and areas of degenerative changes. In addition, MRI of the ankle joint makes it possible to identify the acute stage of inflammation – at this stage, a large amount of fluid accumulates in the tendon tissue, but the external edema is not pronounced or absent, which complicates clinical diagnosis.
Achilles tendinitis treatment
Treatment is mainly conservative, carried out on an outpatient basis in a trauma center. In the acute phase, rest is shown, the elevated position of the limb and tight bandaging during walking. In the first days of the disease, cold should be applied to the affected area. To eliminate pain, eliminate the inflammatory process and restore the function of the tendon, the patient is prescribed NSAIDs for a period of no more than 7-10 days.
After the elimination or significant reduction of the pain syndrome, therapeutic gymnastics classes begin. The exercise therapy program for tendinitis includes light strengthening and stretching exercises that help to restore the tendon and strengthen the calf muscle. Subsequently, resistance exercises are gradually introduced. Along with physical therapy, physiotherapy procedures are used to restore the tendon: electrical stimulation, electrophoresis and ultrasound therapy.
Massage is used to improve blood circulation, strengthen and stretch the tendon. In case of hallux valgus or varus deformity of the foot, the patient is recommended to wear special fixators for the ankle joint. Fixation using a plaster cast is used very rarely – only with severe constant pain in the tendon area. With a particularly persistent pain syndrome, therapeutic blockades with glucocorticoid drugs are sometimes performed. Glucocorticoids are injected only into the surrounding tissues, injections into the tendon itself or the place of its attachment are strictly prohibited, since these drugs can stimulate degenerative processes and provoke tendon rupture.
Surgical intervention is indicated when conservative therapy is ineffective for six months or more. The operation is carried out as planned in the conditions of a traumatology or orthopedic department. A median incision is performed, a skin incision is made along the posterior surface of the lower leg, the Achilles tendon is isolated, examined and degeneratively altered tissues are excised. If 50% or more of the Achilles tendon tissue had to be excised during the intervention, the removed areas are replaced with a plantar muscle tendon. In the postoperative period, immobilization is carried out for 4-6 weeks using an orthosis or a plaster cast. Stepping on the foot is allowed after 2-4 weeks, rehabilitation measures are carried out within 6 weeks.
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