The Achilles tendon ranks as the strongest tendon in the human body. This tendon connects the plantaris, gastrocnemius, and soleus to the calcaneus bone. A sheath-like structure comprised of a single layer of cells surrounds the tendon; this is called the paratenon. The paratenon supplies a significant portion of the blood supply to the tendon. Studies have shown an area of hypovascularity 2 to 6 cm proximal to calcaneal insertion; this is a common area of injury. The Achilles tendon allows the calf muscles to act on the heel, which is necessary for walking or running. The tendon has several causes of injury as well as several locations that are the most commonly injured. In this review, we will discuss insertional tendinitis, mid-body Achilles tendonitis, paratenonitis, and tendon rupture. Please refer to the tendinosis chapter for more information regarding the histological differences between tendinitis and tendinosis.
The causes and mechanisms of Achilles tendinopathy (AT) include the following:
Factors related to a high risk of rupture of the Achilles tendon link to advanced age due to a lack of uniformity of the tendons, slippage of the fascicles, and excessive exercise in athletes, Sports minded individuals tend to have an injury at the Achilles tendon insertion site.
The Achilles tendon has a cumulative lifetime injury incidence of approximately 24% in athletes. Running-related injuries have a prevalence between 11% and 85% or 2.5 to 59 injuries per 1000 hours of running . Results from one study cite the frequency of Achilles tendinopathy to be 1 to 2% in elite adolescent athletes . Another study cited the frequency of injury as 9% in recreational athletes, . The lifetime injury incidence of 2.35 per 1000 is strongly associated with sporting activities. This incidence increases in older men. The overall incidence rate of Achilles tendinopathy ruptures is 2.1 per 100000 person-years, and most AT ruptures occur in males, with a 3.5 to 1 male to female ratio.
The Achilles tendon has two tendinous portions; one proximally and then another merging gradually distally, resulting in a single, homogenous tendon. It comprises three muscular heads; the soleus is monoarticular and the plantaris and gastrocnemius, which are biarticular. There are two sites where the mechanical tension of the tendon occurs, the medial/central portion of the paratenon and the middle part of the tendon which is the most common site of injury.
The Achilles tendon is comprised of type I collagen fibers; these fibers are both very strong and very flexible. The tendon is covered in a thin layer of connective tissue known as paratenon, which is rich in elastin and penetrates into the tendon, keeping the collagen bundles together while allowing movement between them.
The difference between tendinosis and tendinitis is that in the former there are degenerative changes in the tendon's structure and the sheath, making it more vulnerable and prone to breaking. At the cellular level, there is no evidence of an acute or recent inflammatory process. In tendinitis, the opposite happens; there is an acute inflammatory process, resulting from acute trauma, excessive use, or lack of training. Paratenonitis is an inflammation of the outer layers of the tendon and encompasses conditions such as tenosynovitis and tenovaginitis. This pathology generates edema and exudate with inflammatory cells, followed by a fibrinous exudate that causes crepitus and limitation of the tendinous course within the sheath. It can become chronic by developing an immature connective tissue that expands an organized fibrin network known as adhesions.
One study found that the microenvironment of the Achilles tendon in rats induced the stem cells to differentiate into chondrogenic and osteogenic lineages, which predispose to tendon rupture (tendinosis). After this rupture, an inflammatory cascade appears that increases the expression of proinflammatory cytokine mRNA, matrix metalloproteinase-3 (MMP-3), cyclooxygenase-2 (COX-2), interleukin-6 (IL-6) and necrosis factor tumor alpha (TNF-a).
However, the chronic inflammation induces neovascularization that promotes the rupture of the tendon, increasing disability and complexity in management. In a study with rats, researchers observed that denervated tendons express morphological changes such as disorganization of the collagen network, increased production of type III collagen, hypercellularity; disfigured cells, and increased expression of NK-1R, somewhat similar changes to Achilles tendon injury.
The term "Achilles tendinopathy" refers to tendinitis (acute inflammation) and tendinosis (chronic inflammation). It is a condition characterized by pain, inflammation, and stiffness of the Achilles tendon. The inflammation limits lower extremity functionality. Achilles tendinopathy takes a long time to heal; over time there is thickening of the tendon and loss of elasticity. The pain is related to an alteration of the mechanical properties of tension and rigidity of the aponeurosis of the Achilles tendon.
Physical exploration: Clinical signs and symptoms of Achilles tendinopathy include localized pain, focal or diffuse sensitivity, swelling, stiffness/morning pain, perceived rigidity in the Achilles tendon, positive arc sign, Royal London Hospital test, and Thompson test.
Management of Achilles tendinopathy can divide into conservative and surgical. Additionally, one must consider whether it is an acute or chronic condition. Finally, for those with a full rupture, the treatment is usually surgical.
2. Surgical therapy is optional for 10 to 30% of patients who fail conservative therapy after six months. The success rate is higher than 70%, but reports show complication rates of 3 to 40%. The Achilles tendon should undergo reattachment with a tendon rupture of more than 50%.
Posterior heel and ankle pain is a frequent presentation in primary care, and the risk of developing pain is higher with increasing body mass index and age. Primarily, when patients do not improve despite the management established, further investigations are necessary. The most common musculoskeletal disorders of the soft tissues related to ankle pain are:
Erdheim-Chester disease (ECD) is a rare histiocytosis of non-Langerhans cells, reported in a 36-year-old male, with bilateral xanthogranulomas of the Achilles tendon. Although rare, ECD should be a consideration in the differential diagnosis of intratendinous masses. As with all clinical presentations, the potential for non-musculoskeletal, more sinister causes of pain and systemic disease deserve scrutiny.
Achilles tendinopathy has a better prognosis with early and adequate initial management. Surgical intervention for Achilles tendinosis of insertion (TAI) is successful in over 80% of cases. Stenson and his colleagues, discovered that as the number of risk factors increased, the possibility of failure in non-operative treatment also increased. With the usage of the visual analog scale, limited range of motion of the ankle, prior injection of corticosteroids, and the presence of enthesophytes of the Achilles tendon, the probability of failure of the conservative treatment was 55%. Therefore, usage of the risk factors mentioned above can help the surgeon in the decision to perform surgery in the appropriate clinical setting. In a retrospective study of Sanalla and colleagues, they found that strengthening of the Achilles tendon with bone-tendon autograft was an effective procedure with a low risk of complications and reliable results.
In a systematic review, Lohrer and colleagues, concluded that the open and minimally invasive surgical treatment success rates did not differ (83.4%) and that there were no differences in patient satisfaction, but complication rates were lower for the minimally invasive procedures. Baltes and his colleagues classified the complications as follows:
In another review, the surgical results were excellent or good in 89.6% of the cases and fair or poor in 10.4%. The average complication rate was 18.3%, with 15.7% minor complications and 2.6% major complications for surgical treatment of the Achilles tendinopathy insertion.
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