Soft tissue disorders are a common complaint in a rheumatologist's office. The term soft tissue disorder encompasses conditions such as tendinopathy, bursitis, fibromyalgia, muscle disorders, and ligament strain.
This article will focus on Achilles tendonopathy, better known as Achilles tendonitis.
The most common cause of pain in the back of the ankle is Achilles tendon dysfunction.
The Achilles tendon consists of the continuation of two calf muscle, the gastrocnemius and the soleus which unite to form a common tendon that inserts into the back of the calcaneus (heel bone).
The blood supply for this tendon comes from arteries of the calcaneus as well as arteries descending down from the two muscles described above.
The major problem is that the blood supply is not complete leaving what is called an "avascular zone" or "watershed zone" where blood supply to the tendon is absent. This avascular zone extends from about two to six centimeters above the Achilles insertion at the calcaneus.
This avascular zone increases the likelihood of injury in this area.
There are two types of Achilles tendonitis. One is insertional where the Achilles tendon attaches at the calcaneus. The other is non-insertional and occurs in the avascular zone.
Insertional Achilles tendonitis occurs at the site of insertion of the Achilles and is associated with obesity, female gender, and age. Tenderness and swelling is noted and bursitis can also be apparent.
Non-insertional Achilles tendonitis is best called Achilles tendinopathy. Why? Sections of an affected tendon seen under a microscope show degeneration of tendon fibers due to repetitive microtrauma. They reveal very little inflammation. The suffix "itis" means inflammation. The suffix "opathy" implies degeneration.
his picture is often seen in male athletes, particularly runners, who report a sudden change in their workout regimen. There can be a small amount of inflammation seen in what is called the peritenon, the surface of the tendon. However, inflammation is minimal compared with tendon fiber degeneration.
The tendon is tender and swollen on examination.
The diagnosis is suspected clinically but can be confirmed by both magnetic resonance imaging as well as diagnostic ultrasound.
Treatment of both types of Achilles tendon problems starts with trying to reduce inflammation and pain.
Therapeutic options include ice, heel lifts, non-steroidal anti-inflammatory drugs, and reduction of activity on a temporary basis. Steroid injections should not be given since these increase the likelihood of tendon rupture. Severe cases can be treated with 4-6 weeks immobilization in a walking Achilles boot.
Physical therapy and eccentric tendon stretching exercises can be quite helpful. One new therapy that has some proponents is low energy shock wave therapy.
Controversy surrounds the use of platelet rich plasma (PRP). Several randomized controlled studies have come up with conflicting results. These results may be explained on the basis of study design as well as technique. For example one study compared tenotomy (peppering the tendon with a needle) versus PRP.
It is accepted that tenotomy works so comparing a treatment that works and then saying PRP doesn't work any better than tenotomy alone is "gaming" the study.
In addition, the platelet concentrate should be high quality. Care should be taken to avoid premature platelet activation.
In our hands using ultrasound needle guidance with tenotomy and PRP, Achilles tendinopathy has responded very well.
Surgery is rarely indicated unless the tendon has ruptures.
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