Achilles Tendinitis, defined as an inflammation of the Achilles tendon, can lead to a gradual deterioration of the tendon, with the development of microscopic tears in the tendon fibres. This alters the structure of the tendon causing pain and tenderness in the region.
As one of the primary conditions plaguing the athletic population, Achilles Tendinitis can be caused by overuse or sudden increases in training and training intensity, which repeatedly stresses the tendon in quick successions. This makes it difficult for the body to repair the injured tissue.
In order to provide successful treatment options, it is important to gain a thorough understanding of the associated anatomy of the superficial posterior leg and hindfoot.
The soleus unites with the gastrocnemius, which originates as medial and lateral muscle bellies from their respective femoral condyles. The gastrocnemius transitions to a wide aponeurosis as it courses down the upper half of the leg to form the tendo Achilles with the soleus.
There is a broad insertion located on the middle one-third of the posterior calcaneus, which sends fibres around the undersurface of the calcaneus, uniting with the plantar fascia.
The retrocalcaneal bursa, which is located between the superior surface of the calcaneus and the Achilles, is critical in providing protection and cushioning of the tendon from the adjacent bony surface.
The pre-Achilles bursa, between the tendon and the skin, is far less active than the retrocalcaneal bursa.
The healing process of the tendo Achilles is affected by the lack of a synovial sheath to provide the tendon with nourishing synovial fluid.
The paratenon, which exists in place of the synovial sheath, consists of the epitenon and the overlaying peritenon.
In a study published by Lagergran and Lindholm on the vascular distribution in the Achilles tendon, it was shown that the tendon, 2 cm to 6 cm proximal to its calcaneal insertion, is avascular.
The tendon/bone interface often becomes a site of pathology due to the posteriorly oriented lateral fibres, which causes significant torsional stress in the region.
The absence of a synovial sheath and the relative avascularity alters potential healing in the region.
There are two types of Achilles tendinitis - Insertional and Noninsertional.
The degeneration of the fibres of the Achilles tendon directly at the insertion of the tendon into the heel bone is called Insertional Achilles Tendinitis. This is caused by an inflammation of the retrocalcaneal bursa or tendon sheath.
Noninsertional Achilles Tendinitis occurs proximal to its insertion on the calcaneus, which is an area less resilient to repetitive microtrauma, making it more susceptible to degeneration and rupture.
While considering treatment options for the condition, the degree of damage to the tendon along with the history of the injury need to be considered.
In the early stages of inflammation, the patient is advised to apply a bag of ice wrapped in a thin towel, over the affected area in order to reduce the swelling.
This is followed by the use of a cast to decrease pressure on the injured tendon in order to give it time to heal.
If biomechanical abnormalities such as prolonged pronation or excessive supination are the underlying problems behind the condition, orthotics are recommended as a preventative measure.
A study conducted by Munteanu and Barton was successful in proving that normalising specific rearfoot kinematic variables, ground reaction force, plantar pressure variables, transverse plane tibial moments and function of specific lower limb muscles can reduce the risk of an individual developing Achilles tendinitis.
The addition of heel lifts is sometimes recommended to help reduce the stress off the tendon.
However, it is counterproductive to treat the patient with heel lifts to reduce range of motion at the ankle, while simultaneously making the patient practice calf-strengthening exercises which can increase pressure on the injured tendon.
This is perhaps where the conundrum exists.
The goal is to introduce treatment programs gradually, depending on the progress of the patient and the successful outcomes of each program.
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