Achilles tendinosis- Symptoms, Causes, Diagnosis and Treatment

Reviewed by DR. D. DATTA.
Ex. Emergency Medical Officer.

Tendon is a fibrous band of connective tissue that connects muscles with a bone.
In the posterior aspect of the upper part of leg there are two calf muscles (gastrocnemius and soleus), at the lower part of the leg they unite to form a band of fibrous tissue that is called Achilles tendon.
The Achilles tendon is inserted into the heel bone (calcaneus also called calcaneum).
With the help of this tendon
1 The heel is lifted off the ground.
2 This tendon is involved in activities such as walking, climbing stairs, standing on toe tips, running and jumping.
It is the strongest, largest and longest tendon in the body, 6 to 10 inches long.
This tendon is strong enough to bear 4 times of one’s body weight. But this tendon is poorly supplied with blood.
Degenerative changes of the collagen protein of the achilles tendon are called achilles tendinosis.
In tendinosis the tendon fibers become disorganized, thickened and scarred. It is not associated with inflammatory changes.
(Inflammation means swelling, pain, redness or localized rise of temperature in response to some injury). 
It is common in people with ages between 35 to 45 years.  It may also occur in non-athletics.

Achilles tendinosis types

Non insertional achilles tendinosis- Degenerative changes of the tendon above its insertion to the heel bone is called non insertional achilles tendinosis.
Insertional achilles tendinosis-Degenerative changes of tendon at its insertion to the heel bone is called insertional achilles tendinosis. 

Signs and symptoms of achilles tendinosis

1 Pain when touching the affected part.
2 Stiffness when moving the ankle joint.
3 Tender lump in the tendon
4 Pain increases during and even after activity.

Causes of achilles tendinosis

1 Overuse – Repetitive strain to the tendon without adequate time to heal. So this is usually a chronic process. Sometimes achilles tendinitis if not properly treated progresses to achilles tendinosis.
Risk factors-
1 Decreased blood supply
2 Aging
3 Genetic factors
4 Diabetes
5 Hypertension
6 Obesity
7 Hormone replacement therapy
8 Oral contraceptive 

Diagnosis of achilles tendinosis

Due to degenerative changes the tendon becomes weak. There may be partial tearing of the tendon. Microscopically there are very small tears.
Ultrasound – There may be fusiform swelling of the achilles tendon (antero posterior diameter more than 6mm).There may be heterogeneous internal echoes and areas of calcification. On Color Doppler there may be hyperemia due to hypervascularity.
MRI- On MRI the tendon looks thicker.

Treatment of achilles tendinosis

Conservative treatment- 
1 Immobilization will rest the tendon and help healing.
2 Appropriate shoes to decrease stress to the tendon.
3 Physiotherapy- under guidance of a physical therapist.
4 platelet Rich Plasma (PRP)- Patients’ platelet Rich Plasma is injected into the tendon. Growth factor in PRP may cause healing of the tendon.
5 Ultrasound therapy- scarred and damaged tissues within the tendon are destroyed by ultrasound energy. 
6 Shockwave therapy- low energy shock waves to the damaged tissue can cause new blood vessel formation in the area and promote healing.
7 Relef- With radio frequency the tendon is heated. Growth and healing factors come to the area and cause healing.
Surgical treatment of achilles tendinosis- When non-surgical procedures fail, or the tendon is so damaged that it cannot be repaired by non-surgical procedures then surgical approach is adopted.
Degenerative areas of the tendon are removed. If there is significant damage to the tendon, strengthening of the tendon can be done by transferring a nearby tendon to the achilles tendon.

Achilles tendinitis.
Retrocalcaneal bursitis.
Achilles paratenonitis.
Achilles tendon rupture.