Abstract
The Achilles tendon is formed by the confluence of the gastrocnemius and soleus muscles and inserts on the posterior surface of the calcaneus. Non-insertional Achilles tendinopathy is common. Recently the importance of inflammation has been re-evaluated.
The major symptom in non-insertional Achilles tendinopathy is pain, commonly on first moving after a period of rest. The diagnosis is clinical on the basis of history and presentation, characterised by pain and swelling on the posterior aspect of the tendon insertion.
Furthermore, some clinical tests have been described for non-insertional Achilles tendinopathy diagnosis. They can be divided into palpation tests (tendon thickening, crepitus, pain on palpation, the Royal London Hospital (RLH) test, the painful arc sign) and tendon loading tests (pain on passive dorsiflexion, pain on single heel raise and pain on hopping).
Imaging techniques, including ultrasound (US) and magnetic resonance imaging (MRI) scans, can be useful to identify the nature, location and extent of a lesion. US may be particularly useful with the addition of power Doppler, because the pain seems to be related to areas of neovascularisation.
The first line of management for Achilles tendinopathy is conservative, including nonsteroidal anti-inflammatory drugs, physical therapy, taping, cryotherapy, shock wave therapy, hyperthermia and various peritendinous injections. When conservative treatment fails, between one-quarter and one-third of patients may require surgery.
Keywords
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Carr AJ, Norris SH. The blood supply of the calcaneal tendon. J Bone Joint Surg Br. 1989;71(1):100–1.
Kirkendall DT, Garrett WE. Function and biomechanics of tendons. Scand J Med Sci Sports. 1997;7(2):62–6.
Ackermann PW, Li J, Finn A, Ahmed M, Kreicbergs A. Autonomic innervation of tendons, ligaments and joint capsules. A morphologic and quantitative study in the rat. J Orthop Res. 2001;19(3):372–8.
Ljung BO, Forsgren S, Fridén J. Sympathetic and sensory innervations are heterogeneously distributed in relation to the blood vessels at the extensor carpi radialis brevis muscle origin of man. Cells Tissues Organs. 1999;165(1):45–54.
Kleiner DM. Human tendons: anatomy, physiology and pathology. J Athl Train. 1998;33(2):185–6.
Kvist M. Achilles tendon injuries in athletes. Sports Med. 1994;18(3):173–201.
Leppilahti J, Orava S, Karpakka J, Takala T. Overuse injuries of the Achilles tendon. Ann Chir Gynaecol. 1991;80(2):202–7.
Komi PV, Fukashiro S, Järvinen M. Biomechanical loading of Achilles tendon during normal locomotion. Clin Sports Med. 1992;11(3):521–31.
Fahlström M, Lorentzon R, Alfredson H. Painful conditions in the Achilles tendon region in elite badminton players. Am J Sports Med. 2002;30(1):51–4.
Järvinen TAH, Kannus P, Maffulli N, Khan KM. Achilles tendon disorders: etiology and epidemiology. Foot Ankle Clin. 2005;10(2):255–66.
Puddu G, Ippolito E, Postacchini F. A classification of Achilles tendon disease. Am J Sports Med. 1976;4(4):145–50.
Khan KM, Cook JL, Bonar F, Harcourt P, Astrom M. Histopathology of common tendinopathies. Update and implications for clinical management. Sports Med. 1999;27(6):393–408.
Xu Y, Murrell GAC. The basic science of tendinopathy. Clin Orthop. 2008;466(7):1528–38.
Alfredson H, Ohberg L, Forsgren S. Is vasculo-neural ingrowth the cause of pain in chronic Achilles tendinosis? An investigation using ultrasonography and colour Doppler, immunohistochemistry, and diagnostic injections. Knee Surg Sports Traumatol Arthrosc. 2003;11(5):334–8.
Rolf C, Movin T. Etiology, histopathology, and outcome of surgery in achillodynia. Foot Ankle Int. 1997;18(9):565–9.
Battery L, Maffulli N. Inflammation in overuse tendon injuries. Sports Med Arthrosc Rev. 2011;19(3):213–7.
Abate M, Silbernagel KG, Siljeholm C, Di Iorio A, De Amicis D, Salini V, et al. Pathogenesis of tendinopathies: inflammation or degeneration? Arthritis Res Ther. 2009;11(3):235.
Maffulli N, Khan KM, Puddu G. Overuse tendon conditions: time to change a confusing terminology. Arthroscopy. 1998;14(8):840–3.
Khan KM, Cook JL, Kannus P, Maffulli N, Bonar SF. Time to abandon the “tendinitis” myth. BMJ. 2002;324(7338):626–7.
Longo UG, Ronga M, Maffulli N. Achilles tendinopathy. Sports Med Arthrosc Rev. 2009;17(2):112–26.
Leppilahti J, Puranen J, Orava S. Incidence of Achilles tendon rupture. Acta Orthop Scand. 1996;67(3):277–9.
Levi N. The incidence of Achilles tendon rupture in Copenhagen. Injury. 1997;28(4):311–3.
Nyyssönen T, Lüthje P, Kröger H. The increasing incidence and difference in sex distribution of Achilles tendon rupture in Finland in 1987–1999. Scand J Surg. 2008;97(3):272–5.
Wilder RP, Sethi S. Overuse injuries: tendinopathies, stress fractures, compartment syndrome, and shin splints. Clin Sports Med. 2004;23(1):55–81, vi.
Waldecker U, Hofmann G, Drewitz S. Epidemiologic investigation of 1394 feet: coincidence of hindfoot malalignment and Achilles tendon disorders. Foot Ankle Surg. 2012;18(2):119–23.
Lersch C, Grötsch A, Segesser B, Koebke J, Brüggemann G-P, Potthast W. Influence of calcaneus angle and muscle forces on strain distribution in the human Achilles tendon. Clin Biomech (Bristol, Avon). 2012;27(9):955–61.
Gurdezi S, Kohls-Gatzoulis J, Solan MC. Results of proximal medial gastrocnemius release for Achilles tendinopathy. Foot Ankle Int. 2013;34(10):1364–9.
Rabin A, Kozol Z, Finestone AS. Limited ankle dorsiflexion increases the risk for mid-portion Achilles tendinopathy in infantry recruits: a prospective cohort study. J Foot Ankle Res. 2014;7(1):48.
Fleisch F, Hartmann K, Kuhn M. Fluoroquinolone-induced tendinopathy: also occurring with levofloxacin. Infection. 2000;28(4):256–7.
Corps AN, Harrall RL, Curry VA, Fenwick SA, Hazleman BL, Riley GP. Ciprofloxacin enhances the stimulation of matrix metalloproteinase 3 expression by interleukin-1beta in human tendon-derived cells. A potential mechanism of fluoroquinolone-induced tendinopathy. Arthritis Rheum. 2002;46(11):3034–40.
Aicale R, Tarantino D, Maffulli N. Basic science of tendons. In: Bio-orthopaedics [internet]. Berlin, Heidelberg: Springer; 2017. p. 249–73. https://link.springer.com/chapter/10.1007/978-3-662-54181-4_21.
Singh D. Cholesterol level in non-insertional Achilles tendonopathy. Foot (Edinb). 2015;25(4):228–31.
Holmes GB, Lin J. Etiologic factors associated with symptomatic achilles tendinopathy. Foot Ankle Int. 2006;27(11):952–9.
Järvinen M. Epidemiology of tendon injuries in sports. Clin Sports Med. 1992;11(3):493–504.
Knobloch K, Yoon U, Vogt PM. Acute and overuse injuries correlated to hours of training in master running athletes. Foot Ankle Int. 2008;29(7):671–6.
Kujala UM, Sarna S, Kaprio J. Cumulative incidence of achilles tendon rupture and tendinopathy in male former elite athletes. Clin J Sport Med. 2005;15(3):133–5.
Lysholm J, Wiklander J. Injuries in runners. Am J Sports Med. 1987;15(2):168–71.
Pearce CJ, Carmichael J, Calder JD. Achilles tendinoscopy and plantaris tendon release and division in the treatment of non-insertional Achilles tendinopathy. Foot Ankle Surg. 2012;18(2):124–7.
Tol JL, Spiezia F, Maffulli N. Neovascularization in Achilles tendinopathy: have we been chasing a red herring? Knee Surg Sports Traumatol Arthrosc. 2012;20(10):1891–4.
van Sterkenburg MN, van Dijk CN. Mid-portion Achilles tendinopathy: why painful? An evidence-based philosophy. Knee Surg Sports Traumatol Arthrosc. 2011;19(8):1367–75.
Via AG, Papa G, Oliva F, Maffulli N. Tendinopathy. Curr Phys Med Rehabil Rep. 2016;4(1):50–5.
Knobloch K. The role of tendon microcirculation in Achilles and patellar tendinopathy. J Orthop Surg. 2008;3:18.
Kristoffersen M, Ohberg L, Johnston C, Alfredson H. Neovascularisation in chronic tendon injuries detected with colour Doppler ultrasound in horse and man: implications for research and treatment. Knee Surg Sports Traumatol Arthrosc. 2005;13(6):505–8.
Ohberg L, Lorentzon R, Alfredson H. Neovascularisation in Achilles tendons with painful tendinosis but not in normal tendons: an ultrasonographic investigation. Knee Surg Sports Traumatol Arthrosc. 2001;9(4):233–8.
Williams JG. Achilles tendon lesions in sport. Sports Med. 1993;16(3):216–20.
Hutchison A-M, Evans R, Bodger O, Pallister I, Topliss C, Williams P, et al. What is the best clinical test for Achilles tendinopathy? Foot Ankle Surg. 2013;19(2):112–7.
Maffulli N, Kenward MG, Testa V, Capasso G, Regine R, King JB. Clinical diagnosis of Achilles tendinopathy with tendinosis. Clin J Sport Med. 2003;13(1):11–5.
Reiman M, Burgi C, Strube E, Prue K, Ray K, Elliott A, et al. The utility of clinical measures for the diagnosis of achilles tendon injuries: a systematic review with meta-analysis. J Athl Train. 2014;49(6):820–9.
Wijesekera NT, Calder JD, Lee JC. Imaging in the assessment and management of Achilles tendinopathy and paratendinitis. Semin Musculoskelet Radiol. 2011;15(1):89–100.
Aström M, Gentz CF, Nilsson P, Rausing A, Sjöberg S, Westlin N. Imaging in chronic achilles tendinopathy: a comparison of ultrasonography, magnetic resonance imaging and surgical findings in 27 histologically verified cases. Skelet Radiol. 1996;25(7):615–20.
Andersson G, Danielson P, Alfredson H, Forsgren S. Nerve-related characteristics of ventral paratendinous tissue in chronic Achilles tendinosis. Knee Surg Sports Traumatol Arthrosc. 2007;15(10):1272–9.
Boesen MI, Torp-Pedersen S, Koenig MJ, Christensen R, Langberg H, Hölmich P, et al. Ultrasound guided electrocoagulation in patients with chronic non-insertional Achilles tendinopathy: a pilot study. Br J Sports Med. 2006;40(9):761–6.
Alfredson H, Ohberg L. Sclerosing injections to areas of neo-vascularisation reduce pain in chronic Achilles tendinopathy: a double-blind randomised controlled trial. Knee Surg Sports Traumatol Arthrosc. 2005;13(4):338–44.
Maffulli N, Oliva F, Maffulli GD, Giai Via A, Gougoulias N. Minimally invasive Achilles tendon stripping for the management of tendinopathy of the main body of the Achilles tendon. J Foot Ankle Surg. 2017;56(5):938–42.
Alfredson H, Ohberg L, Zeisig E, Lorentzon R. Treatment of midportion Achilles tendinosis: similar clinical results with US and CD-guided surgery outside the tendon and sclerosing polidocanol injections. Knee Surg Sports Traumatol Arthrosc. 2007;15(12):1504–9.
Ackermann PW, Renström P. Tendinopathy in sport. Sports Health. 2012;4(3):193–201.
Neuhold A, Stiskal M, Kainberger F, Schwaighofer B. Degenerative Achilles tendon disease: assessment by magnetic resonance and ultrasonography. Eur J Radiol. 1992;14(3):213–20.
Movin T, Kristoffersen-Wiberg M, Shalabi A, Gad A, Aspelin P, Rolf C. Intratendinous alterations as imaged by ultrasound and contrast medium-enhanced magnetic resonance in chronic achillodynia. Foot Ankle Int. 1998;19(5):311–7.
Khan KM, Forster BB, Robinson J, Cheong Y, Louis L, Maclean L, et al. Are ultrasound and magnetic resonance imaging of value in assessment of Achilles tendon disorders? A two year prospective study. Br J Sports Med. 2003;37(2):149–53.
Warden SJ, Kiss ZS, Malara FA, Ooi ABT, Cook JL, Crossley KM. Comparative accuracy of magnetic resonance imaging and ultrasonography in confirming clinically diagnosed patellar tendinopathy. Am J Sports Med. 2007;35(3):427–36.
van Schie HTM, de Vos RJ, de Jonge S, Bakker EM, Heijboer MP, Verhaar JAN, et al. Ultrasonographic tissue characterisation of human Achilles tendons: quantification of tendon structure through a novel non-invasive approach. Br J Sports Med. 2010;44(16):1153–9.
Docking SI, Ooi CC, Connell D. Tendinopathy: is imaging telling us the entire story? J Orthop Sports Phys Ther. 2015;45(11):842–52.
Silbernagel KG, Brorsson A, Lundberg M. The majority of patients with Achilles tendinopathy recover fully when treated with exercise alone: a 5-year follow-up. Am J Sports Med. 2011;39(3):607–13.
Weinreb JH, Sheth C, Apostolakos J, McCarthy M-B, Barden B, Cote MP, et al. Tendon structure, disease, and imaging. Muscles Ligaments Tendons J. 2014;4(1):66–73.
Maffulli N, Via AG, Oliva F. Chronic Achilles tendon disorders: tendinopathy and chronic rupture. Clin Sports Med. 2015;34(4):607–24.
Sayana MK, Maffulli N. Eccentric calf muscle training in non-athletic patients with Achilles tendinopathy. J Sci Med Sport. 2007;10(1):52–8.
Alfredson H, Pietilä T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med. 1998;26(3):360–6.
Sussmilch-Leitch SP, Collins NJ, Bialocerkowski AE, Warden SJ, Crossley KM. Physical therapies for Achilles tendinopathy: systematic review and meta-analysis. J Foot Ankle Res. 2012;5(1):15.
Rees JD, Maffulli N, Cook J. Management of tendinopathy. Am J Sports Med. 2009;37(9):1855–67.
Silbernagel KG, Thomeé R, Thomeé P, Karlsson J. Eccentric overload training for patients with chronic Achilles tendon pain-a randomised controlled study with reliability testing of the evaluation methods. Scand J Med Sci Sports. 2001;11(4):197–206.
Roos EM, Engström M, Lagerquist A, Söderberg B. Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathy—a randomized trial with 1-year follow-up. Scand J Med Sci Sports. 2004;14(5):286–95.
Rompe JD, Nafe B, Furia JP, Maffulli N. Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial. Am J Sports Med. 2007;35(3):374–83.
Stanish WD, Rubinovich RM, Curwin S. Eccentric exercise in chronic tendinitis. Clin Orthop. 1986;208:65–8.
Malliaras P, Barton CJ, Reeves ND, Langberg H. Achilles and patellar tendinopathy loading programmes: a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med. 2013;43(4):267–86.
Niesen-Vertommen SL, Taunton JE, Clement DB, Mosher RE. The effect of eccentric versus concentric exercise in the management of Achilles tendonitis. Clin J Sport Med. 1992;2(2):109.
Mafi N, Lorentzon R, Alfredson H. Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis. Knee Surg Sports Traumatol Arthrosc. 2001;9(1):42–7.
Rompe JD, Furia J, Maffulli N. Eccentric loading versus eccentric loading plus shock-wave treatment for midportion achilles tendinopathy: a randomized controlled trial. Am J Sports Med. 2009;37(3):463–70.
Rompe JD, Furia JP, Maffulli N. Mid-portion Achilles tendinopathy--current options for treatment. Disabil Rehabil. 2008;30(20–22):1666–76.
Chen Y-J, Wang C-J, Yang KD, Kuo Y-R, Huang H-C, Huang Y-T, et al. Extracorporeal shock waves promote healing of collagenase-induced Achilles tendinitis and increase TGF-beta1 and IGF-I expression. J Orthop Res. 2004;22(4):854–61.
Rees JD, Wilson AM, Wolman RL. Current concepts in the management of tendon disorders. Rheumatology (Oxford). 2006;45(5):508–21.
Han SH, Lee JW, Guyton GP, Parks BG, Courneya J-P, Schon LCJ. Leonard Goldner award 2008. Effect of extracorporeal shock wave therapy on cultured tenocytes. Foot Ankle Int. 2009;30(2):93–8.
van Sterkenburg MN, van Dijk CN. Injection treatment for chronic midportion Achilles tendinopathy: do we need that many alternatives? Knee Surg Sports Traumatol Arthrosc. 2011;19(4):513–5.
Maffulli N, Papalia R, D’Adamio S, Diaz Balzani L, Denaro V. Pharmacological interventions for the treatment of Achilles tendinopathy: a systematic review of randomized controlled trials. Br Med Bull. 2015;113(1):101–15.
van Sterkenburg MN, de Jonge MC, Sierevelt IN, van Dijk CN. Less promising results with sclerosing ethoxysclerol injections for midportion achilles tendinopathy: a retrospective study. Am J Sports Med. 2010;38(11):2226–32.
de Vos RJ, Weir A, van Schie HTM, Bierma-Zeinstra SMA, Verhaar JAN, Weinans H, et al. Platelet-rich plasma injection for chronic Achilles tendinopathy: a randomized controlled trial. JAMA. 2010;303(2):144–9.
Chan O, O’Dowd D, Padhiar N, Morrissey D, King J, Jalan R, et al. High volume image guided injections in chronic Achilles tendinopathy. Disabil Rehabil. 2008;30(20–22):1697–708.
Humphrey J, Chan O, Crisp T, Padhiar N, Morrissey D, Twycross-Lewis R, et al. The short-term effects of high volume image guided injections in resistant non-insertional Achilles tendinopathy. J Sci Med Sport. 2010;13(3):295–8.
Paavola M, Kannus P, Paakkala T, Pasanen M, Järvinen M. Long-term prognosis of patients with achilles tendinopathy. An observational 8-year follow-up study. Am J Sports Med. 2000;28(5):634–42.
Lohrer H, David S, Nauck T. Surgical treatment for achilles tendinopathy—a systematic review. BMC Musculoskelet Disord. 2016;17:207.
Kvist H, Kvist M. The operative treatment of chronic calcaneal paratenonitis. J Bone Joint Surg Br. 1980;62(3):353–7.
Schepsis AA, Leach RE. Surgical management of Achilles tendinitis. Am J Sports Med. 1987;15(4):308–15.
Snook GA. Achilles tendon tenosynovitis in long-distance runners. Med Sci Sports. 1972;4(3):155–8.
Paavola M, Kannus P, Orava S, Pasanen M, Järvinen M. Surgical treatment for chronic Achilles tendinopathy: a prospective seven month follow up study. Br J Sports Med. 2002;36(3):178–82.
Maffulli N, Binfield PM, Moore D, King JB. Surgical decompression of chronic central core lesions of the Achilles tendon. Am J Sports Med. 1999;27(6):747–52.
Maffulli N, Aicale R, Tarantino D. Autograft reconstruction for chronic Achilles tendon. Tech Foot Ankle Surg. 2017;16(3):117–23.
Paavola M, Orava S, Leppilahti J, Kannus P, Järvinen M. Chronic Achilles tendon overuse injury: complications after surgical treatment. An analysis of 432 consecutive patients. Am J Sports Med. 2000;28(1):77–82.
Longo UG, Ramamurthy C, Denaro V, Maffulli N. Minimally invasive stripping for chronic Achilles tendinopathy. Disabil Rehabil. 2008;30(20–22):1709–13.
Alfredson H. Ultrasound and Doppler-guided mini-surgery to treat midportion Achilles tendinosis: results of a large material and a randomised study comparing two scraping techniques. Br J Sports Med. 2011;45(5):407–10.
Testa V, Capasso G, Benazzo F, Maffulli N. Management of Achilles tendinopathy by ultrasound-guided percutaneous tenotomy. Med Sci Sports Exerc. 2002;34(4):573–80.
Maffulli N, Testa V, Capasso G, Bifulco G, Binfield PM. Results of percutaneous longitudinal tenotomy for Achilles tendinopathy in middle- and long-distance runners. Am J Sports Med. 1997;25(6):835–40.
Alfredson H. Midportion Achilles tendinosis and the plantaris tendon. Br J Sports Med. 2011;45(13):1023–5.
Calder JDF, Freeman R, Pollock N. Plantaris excision in the treatment of non-insertional Achilles tendinopathy in elite athletes. Br J Sports Med. 2015;49(23):1532–4.
Masci L, Spang C, van Schie HTM, Alfredson H. Achilles tendinopathy-do plantaris tendon removal and Achilles tendon scraping improve tendon structure? A prospective study using ultrasound tissue characterisation. BMJ Open Sport Exerc Med. 2015;1(1):e000005.
Van Sterkenburg MN, Kerkhoffs GMMJ, Kleipool RP, Niek van Dijk C. The plantaris tendon and a potential role in mid-portion Achilles tendinopathy: an observational anatomical study. J Anat. 2011;218(3):336–41.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2019 ISAKOS
About this chapter
Cite this chapter
Aicale, R., Tarantino, D., Maffulli, N. (2019). Non-insertional Achilles Tendinopathy: State of the Art. In: Canata, G., d'Hooghe, P., Hunt, K., Kerkhoffs, G., Longo, U. (eds) Sports Injuries of the Foot and Ankle. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-662-58704-1_32
Download citation
DOI: https://doi.org/10.1007/978-3-662-58704-1_32
Published:
Publisher Name: Springer, Berlin, Heidelberg
Print ISBN: 978-3-662-58703-4
Online ISBN: 978-3-662-58704-1
eBook Packages: MedicineMedicine (R0)