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The Lower Limb Tendinopathies pp 149–164Cite as

Achilles Tendinopathy

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Part of the book series: Sports and Traumatology ((SPORTS))

Abstract

Achilles tendinopathy is a common cause of disability. Despite the economic and social relevance of the problem, the causes and mechanisms of Achilles tendinopathy remain unclear. Tendon vascularity, gastrocnemius-soleus dysfunction, age, sex, body weight and height, pes cavus, and lateral ankle instability are considered common risk factors. Currently, intratendinous degenerative changes are considered responsible for tendinopathy and symptoms. Although Achilles tendinopathy has been extensively studied, there is a clear lack of properly conducted scientific research to clarify the optimal management option. The management of Achilles tendinopathy lacks evidence-based support, and patients are at risk of long-term morbidity with unpredictable clinical outcome. Most patients respond to conservative management. Eccentric exercises and shockwave provide excellent clinical results both in athletic and sedentary patients, with no reported adverse effects. However, in about 20–45 % of cases, patients do not respond well to conservative treatment, and they need surgery. Both minimally invasive and open surgeries have been described with similar results.

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References

  1. Vora AM, Myerson MS, Oliva F, Mafulli N (2005) Tendinopathy of the main body of the Achilles tendon. Foot Ankle Clin 10:293–308

    Article  PubMed  Google Scholar 

  2. Maffulli N, Sharma P, Luscombe KL (2004) Achilles tendinopathy: aetiology and management. J R Soc Med 97:472–476

    Article  PubMed  PubMed Central  Google Scholar 

  3. Rolf CMT (1997) Etiology, histopathology, and outcome of surgery in achillodynia. Foot Ankle Int 18:565–569

    Article  CAS  PubMed  Google Scholar 

  4. Rompe JD, Furia JP, Maffulli N (2008) Mid-portion Achilles tendinopathy: current options for treatment. Disabil Rehabil 30:1666–1676

    Article  PubMed  Google Scholar 

  5. Astrom M (1998) Partial rupture in Achilles tendinopathy. A retrospective analysis of 342 cases. Acta Orthop Scand 69:404–407

    Article  CAS  PubMed  Google Scholar 

  6. Ronga M, Oliva F, Vigneti D et al (2009) Achilles tendinopathy. Physiopathology. In: Maffulli N, Oliva F (eds) Achilles tendon. CIC Edizioni internazionali, Rome, pp 39–45

    Google Scholar 

  7. Nigg B (1994) The role of impact forces and foot pronation: a new paradigm. Clin J Sports Med 11:2–9

    Article  Google Scholar 

  8. Bryant AL, Clark RA, Bartold S et al (2008) Effects of oestrogen on the mechanical behavior of the human Achilles tendon in vivo. J Appl Physiol 105:1035–1043

    Article  PubMed  Google Scholar 

  9. Circi E, Akpinar S, Akgun RC et al (2009) Biomechanical and histological comparison of the influence of oestrogen deficient state on tendon healing potential in rats. Int Orthop 33:1461–1466

    Article  PubMed  PubMed Central  Google Scholar 

  10. Cook JL, Bass SL, Black JE (2007) Hormone therapy is associated with smaller Achilles tendon diameter in active postmenopausal women. Scand J Med Sci Sports 17:128–132

    Article  CAS  PubMed  Google Scholar 

  11. Torricelli P, Veronesi F, Pagani S et al (2013) In vitro tenocyte metabolism in aging and oestrogen deficiency. Age (Dordr) 35:2125–2136

    Article  CAS  Google Scholar 

  12. Ahmed N (2005) Advanced glycation endproducts – role in pathology of diabetic complications. Diabetes Res Clin Pract 67:3–21

    Article  CAS  PubMed  Google Scholar 

  13. Gautieri A, Redaelli A, Buehler MJ et al (2014) Age- and diabetes-related nonenzymatic cross-links in collagen fibrils: candidate amino acids involved in advanced glycation end-products. Matrix Biol 34:89–95

    Article  CAS  PubMed  Google Scholar 

  14. Li Y, Fessel G, Georgiadis M et al (2013) Advanced glycation end-products diminish tendon collagen fiber sliding. Matrix Biol 32:169–177

    Article  CAS  PubMed  Google Scholar 

  15. Duncan WS (1928) The relationship of hyperthysoidism to joint conditions. J Am Med Assoc 91:1779

    Article  Google Scholar 

  16. Oliva F, Berardi AC, Misiti S, Verza Felzacappa C, Iacone A, Maffulli N (2013) Thyroid hormones enhance growth and counteract apoptosis in human tenocytes isolated from rotator cuff tendons. Cell Death Dis 4:e705

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Berardi A, Oliva F, Berardocco M, La Rovere M, Accorsi P, Maffulli N (2014) Thyroid hormones increase collagen I and cartilage matrix protein (COMP) expression in vitro human tenocytes. Muscles Ligaments Tendons J 4:285–291

    PubMed  PubMed Central  Google Scholar 

  18. Warrender WJ, Brown OL, Abboud JA (2011) Outcomes of arthroscopic rotator cuff repairs in obese patients. J Shoulder Elbow Surg 20:961–967

    Article  PubMed  Google Scholar 

  19. Giai Via A, De Cupis M, Spoliti M et al (2013) Clinical and biological aspects of rotator cuff tears. Muscles Ligaments Tendons J 3:70–92

    PubMed Central  Google Scholar 

  20. Gaida JE, Cook JL, Bass SL (2008) Adiposity and tendinopathy. Disabil Rehabil 30:1555–1562

    Article  CAS  PubMed  Google Scholar 

  21. Abate M, Oliva F, Schiavone C et al (2012) Achilles tendinopathy in amateur runners role of adiposity (tendinopathies and obesity). Muscles Ligaments Tendons J 2:44–48

    PubMed  PubMed Central  Google Scholar 

  22. Biancalana A, Veloso LA, Gomes L (2010) Obesity affects collagen fibril diameter and mechanical properties of tendons in Zucker rats. Connect Tissue Res 51:171–178

    Article  CAS  PubMed  Google Scholar 

  23. Hills AP, Hennig EM, Byrne NM et al (2006) The biomechanics of adiposity – structural and functional limitations of obesity and implications for movement. Obes Rev 7:13–24

    Article  PubMed  Google Scholar 

  24. Waggett AD, Ralphs JR, Kwan AP et al (1998) Characterization of collagens and proteoglycans at the insertion of the human Achilles tendon. Matrix Biol 16:457–470

    Article  CAS  PubMed  Google Scholar 

  25. Modesti A, Oliva F (2013) All is around ECM of tendons?! Muscles Ligaments Tendons J 3:1

    PubMed  PubMed Central  Google Scholar 

  26. Dalton S, Cawston TE, Riley GP, Bayley IJ, Hazleman BL (1995) Human shoulder tendon biopsy samples in organ culture produce procollagenase and tissue inhibitor of metalloproteinases. Ann Rheum Dis 54:571–577

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Choi HR, Kondo S, Hirose K et al (2002) Expression and enzymatic activity of MMP-2 during healing process of the acute suprasupinatus tendon tear in rabbits. J Orthop Res 20:927–933

    Article  CAS  PubMed  Google Scholar 

  28. Riley GP, Curry V, DeGroot J et al (2002) Matrix metalloproteinase activities and their relationship with collagen remodelling in tendon pathology. Matrix Biol 21:185–195

    Article  CAS  PubMed  Google Scholar 

  29. Tarantino U, Oliva F, Taurisano G et al (2009) FXIIIA and TGF-beta over-expression produces normal musculoskeletal phenotype in TG2−/−mice. Amino Acids 36:679–684

    Article  CAS  PubMed  Google Scholar 

  30. Oliva F, Zocchi L, Codispoti A et al (2009) Transglutaminases expression in human supraspinatus tendon ruptures and in mouse tendons. Biochem Biophys Res Commun 20:887–891

    Article  Google Scholar 

  31. Dean BJ, Franklin SL, Carr AJ (2013) The peripheral neuronal phenotype is important in the pathogenesis of painful human tendinopathy: a systematic review. Clin Orthop Relat Res 471:3036–3046

    Article  PubMed  PubMed Central  Google Scholar 

  32. Andres KH, von During M, Schmidt RF (1985) Sensory innervation of the Achilles tendon by group III and IV afferent fibers. Anat Embryol (Berl) 172:145–156

    Article  CAS  Google Scholar 

  33. van Sterkenburg M, van Dijk N (2011) Mid-portion Achilles tendinopathy: why painful? An evidence-based philosophy. Knee Surg Sports Traumatol Arthrosc 19:1367–1375

    Article  PubMed  PubMed Central  Google Scholar 

  34. Alfredson H, Ohberg L, Forsgren S (2003) 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 11:334–338

    Article  PubMed  Google Scholar 

  35. Schizas N, Weiss R, Lian O, Frihagen F, Bahr R, Ackermann PW (2012) Glutamate receptors in tendinopathic patients. J Orthop Res 30:1447–1452

    Article  CAS  PubMed  Google Scholar 

  36. Steyaert AE, Burssens PJ, Vercruysse CW, Vanderstraeten GG, Verbeeck RM (2006) The effects of substance P on the biomechanic properties of ruptured rat Achilles’ tendon. Arch Phys Med Rehabil 87:254–258

    Article  PubMed  Google Scholar 

  37. Rogers BS, Leach RE (1996) Achilles tendinitis. Foot Ankle Clin 1:249–259

    Google Scholar 

  38. Binfield PM, Maffulli N (1997) Surgical management of common tendinopathies of the lower limb. Sports Exerc Injury 3:116–122

    Google Scholar 

  39. Maffulli N, Testa V, Capasso G et al (2006) Surgery for chronic Achilles tendinopathy yields worse results in nonathletic patients. Clin J Sport Med 16:123–128

    Article  PubMed  Google Scholar 

  40. Maffulli N, Wong J, Almekinders LC (2003) Types and epidemiology of tendinopathy. Clin Sports Med 22:675–692

    Article  PubMed  Google Scholar 

  41. Rompe JD, Nafe B, Furia JP et al (2007) Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendon Achilles: a randomized controlled trial. Am J Sports Med 35:374–383

    Article  PubMed  Google Scholar 

  42. Petersa JA, Zwervera J, Diercksa RL, Elferink-Gemserb MT, van den Akker-Scheeka I (2016) Preventive interventions for tendinopathy: a systematic review. J Sci Med Sport 19:205–211

    Article  Google Scholar 

  43. Pope R, Herbert R, Kirwan J (1998) Effects of ankle dorsiflexion range and pre-exercise calf muscle stretching on injury risk in Army recruits. Aust J Physiother 44:165–172

    Article  PubMed  Google Scholar 

  44. Amako M, Oda T, Masuoka K et al (2003) Effect of static stretching on prevention of injuries for military recruits. Mil Med 168:442–446

    PubMed  Google Scholar 

  45. Kraemer R, Knobloch K (2009) A soccer-specific balance training program for ham-string muscle and patellar and achilles tendon injuries: an intervention study in premier league female soccer. Am J Sports Med 37:1384–1393.26

    Article  PubMed  Google Scholar 

  46. House C, Reece A, Roiz de Sa D (2013) Shock-absorbing insoles reduce the incidence of lower limb overuse injuries sustained during Royal Marine training. Mil Med 178:683–689

    Article  PubMed  Google Scholar 

  47. Milgrom C, Finestone A, Shlamkovitch N, Wosk J, Laor A, Voloshin A et al (1992) Prevention of overuse injuries of the foot by improved shoe shock attenuation. A randomized prospective study. Clin Orthop Relat Res (281):189–192

    Google Scholar 

  48. Larsen K, Weidich F, Leboeuf-Yde C (2002) Can custom-made biomechanic shoe orthoses prevent problems in the back and lower extremities? A randomized, controlled intervention trial of 146 military conscripts. J Manipulative Physiol Ther 25:326–331

    Article  PubMed  Google Scholar 

  49. Longo UG, Ronga M, Maffulli N (2009) Achilles tendinopathy. Sports Med Arthrosc 17(2):112–126

    Article  PubMed  Google Scholar 

  50. Stanish WD, Rubinovich RM, Curwin S (2008) Eccentric exercise in chronic tendinitis. Clin Orthop Relat Res 1986:65–68

    Google Scholar 

  51. Fahlstrom M, Jonsson P, Lorentzon R et al (2003) Chronic Achilles tendon pain treated with eccentric calf-muscle training. Knee Surg Sports Traumatol Arthrosc 11:327–333

    Article  PubMed  Google Scholar 

  52. Norregaard J, Larsen CC, Bieler T et al (2007) Eccentric exercise in treatment of Achilles tendinopathy. Scand J Med Sci Sports 17:133–138

    CAS  PubMed  Google Scholar 

  53. Alfredson H, Pietila T, Jonsson P et al (1998) Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med 26:360–366

    CAS  PubMed  Google Scholar 

  54. Roos E, Engstrom M, Lagerquist A et al (2004) 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 14:286–295

    Article  PubMed  Google Scholar 

  55. de Vos RJ, Weir A, Visser RJ et al (2007) The additional value of a night splint to eccentric exercises in chronic midportion Achilles tendinopathy: a randomised controlled trial. Br J Sports Med 41:e5

    Article  PubMed  Google Scholar 

  56. Sayana MK, Maffulli N (2007) Eccentric calf muscle training in non-athletic patients with Achilles tendinopathy. J Sci Med Sport 10:52–58

    Article  PubMed  Google Scholar 

  57. Lohrer H, Scholl J, Arentz S (2002) Achilles tendinopathy and patellar tendinopathy. Results of radial shockwave therapy in patients with unsuccessfully treated tendinoses. Sportverletz Sportschaden 16:108–114

    Article  CAS  PubMed  Google Scholar 

  58. Peers K (2003) Extracorporeal shock wave therapy in chronic Achilles and patellar tendinopathy. Leuven University Press, Leuven, pp 61–75

    Google Scholar 

  59. Speed C (2014) A systematic review of shockwave therapies in soft tissue conditions: focusing on the evidence. Br J Sports Med 48:1538–1542

    Article  PubMed  Google Scholar 

  60. Costa ML, Shepstone L, Donell ST et al (2005) Shock wave therapy for chronic Achilles tendon pain: a randomized placebo-controlled trial. Clin Orthop Relat Res 440:199–204

    Article  CAS  PubMed  Google Scholar 

  61. Rasmussen S, Christensen M, Mathiesen I et al (2008) Shockwave therapy for chronic Achilles tendinopathy: a double-blind, randomized clinical trial of efficacy. Acta Orthop 79:249–256

    Article  PubMed  Google Scholar 

  62. Loppini M, Maffulli N (2012) Conservative management of tendinopathy: an evidence-based approach. Muscles Ligaments Tendons J 1:134–137

    PubMed  PubMed Central  Google Scholar 

  63. Chan O, O’Dowd D, Padhiar N et al (2008) High volume image guided injections in chronic Achilles tendinopathy. Disabil Rehabil 30:1697–1708

    Article  PubMed  Google Scholar 

  64. Maffulli N, Spiezia F, Longo UG, Denaro V, Maffulli GD (2013) High volume image guided injections for the management of chronic tendinopathy of the main body of the Achilles tendon. Phys Ther Sport 14:163–167

    Article  PubMed  Google Scholar 

  65. de Vos RJ, Weir A, van Schie HT et al (2010) Platelet-rich plasma injection for chronic Achilles tendinopathy: a randomized controlled trial. JAMA 303:144–149

    Article  PubMed  Google Scholar 

  66. Testa V, Capasso G, Benazzo F, Maffulli N (2002) Management of Achilles tendinopathy by ultrasound-guided percutaneous tenotomy. Med Sci Sports Exerc 34:573–580

    Article  PubMed  Google Scholar 

  67. Maffulli N, Testa V, Capasso G, Bifulco G, Binfield PM (1997) Results of percutaneous longitudinal tenotomy for Achilles tendinopathy in middle- and long-distance runners. Am J Sports Med 25:835–840

    Article  CAS  PubMed  Google Scholar 

  68. Tallon C, Coleman BD, Khan KM, Maffuli N (2001) Outcome of surgery for chronic Achilles tendinopathy: a critical review. Am J Sports Med 29:315–320

    CAS  PubMed  Google Scholar 

  69. Paavola M, Orava S, Leppilahti J, Kannus P, Jarvinen M (2000) Chronic achilles tendon overuse injury: complications after surgical treatment: an analysis of 432 consecutive patients. Am J Sports Med 28:77–82

    CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Musculoskeletal Disorders, School of Medicine and Surgery, University of Salerno, Salerno, Italy

    Nicola Maffulli MD, PhD, FRCP, FRCS

  2. Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mary University of London, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, UK

    Nicola Maffulli MD, PhD, FRCP, FRCS

  3. Department of Orthopaedic and Traumatology, University of Rome “Tor Vergata”, School of Medicine, Viale Oxford 81, 00133, Rome, Italy

    Alessio Giai Via MD & Francesco Oliva MD, PhD

Authors
  1. Nicola Maffulli MD, PhD, FRCP, FRCS
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  2. Alessio Giai Via MD
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  3. Francesco Oliva MD, PhD
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Correspondence to Nicola Maffulli MD, PhD, FRCP, FRCS .

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Editors and Affiliations

  1. Qatar Orthopaedic and Sport Medicine Hospital, Doha , Qatar

    Giannicola Bisciotti

  2. Medical Departement FC. Internazionale, Istituto Clinico Humanitas Milano (Italy), Milano, Italy

    Piero Volpi

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Maffulli, N., Giai Via, A., Oliva, F. (2016). Achilles Tendinopathy. In: Bisciotti, G., Volpi, P. (eds) The Lower Limb Tendinopathies. Sports and Traumatology. Springer, Cham. https://doi.org/10.1007/978-3-319-33234-5_10

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  • DOI: https://doi.org/10.1007/978-3-319-33234-5_10

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