Achilles Tendonitis (Achilles Tendinopathy)

**Achilles tendinopathy** is a condition characterized by pain, swelling, and impaired function of the Achilles tendon due to overuse, degeneration, or a combination of both. Modern terminology favors "tendinopathy" over "tendonitis" because the condition is more degenerative than inflammatory. **Two distinct types:** **1. Mid-Portion Achilles Tendinopathy (75-80% of cases):** - Affects the tendon **2-6 cm above its insertion** on the heel bone - This is the "watershed zone" — an area of relatively poor blood supply, making it vulnerable to degeneration - Characterized by a painful, thickened, nodular tendon - Most common in runners and active individuals **2. Insertional Achilles Tendinopathy (20-25% of cases):** - Affects the tendon **at its attachment to the heel bone** (calcaneus) - Often associated with a Haglund's deformity (bony bump on the back of the heel) and retrocalcaneal bursitis - Common in less active individuals and those who wear rigid-heeled shoes - May have calcification within the tendon at the insertion The Achilles tendon withstands enormous forces — **6-8x body weight during running** and **2-4x during walking**. When the tendon's repair capacity is exceeded by the mechanical demands placed on it, tendinopathy develops.

## Root Causes **Training Errors (60-70% of cases):** - Sudden increase in running mileage or intensity (>10% weekly increase) - Adding hill running or speed work too quickly - Returning to high-impact sport after a layoff without gradual progression - Running on hard surfaces (concrete) or cambered roads **Biomechanical Factors:** - Tight calf muscles (gastrocnemius/soleus) — the #1 modifiable risk factor - Overpronation (flat feet) — increases Achilles tendon whipping motion - Leg length discrepancy — overloads the shorter leg's Achilles - Weak calf muscles relative to activity demands **Intrinsic Risk Factors:** - Age 30-50 — tendon degenerative capacity increases with age - Male sex (6x higher risk than women) - Previous Achilles tendon injury — recurrence rate 27-50% - Obesity — increases tendon loading - Diabetes and metabolic syndrome — impaired tendon healing - Fluoroquinolone antibiotics (ciprofloxacin, levofloxacin) — increase tendon rupture risk 2-4x - Systemic corticosteroid use **Footwear:** - Shoes with inadequate heel support or cushioning - Sudden change from high-heeled to flat shoes (increased Achilles stretch) - Worn-out running shoes (replace every 400-500 miles)

## Conservative Treatment (First-Line — 75-80% Success) **1. Eccentric Exercise Program (Gold Standard):** The **Alfredson protocol** is the most evidence-based treatment: - Stand on the edge of a step on the balls of your feet - Rise up on both feet, then SLOWLY lower on the AFFECTED leg only (heel drops below step level) - 3 sets of 15 repetitions, twice daily (90 reps/day) - Do with knee straight AND knee slightly bent (targets both gastrocnemius and soleus) - Continue for **12 weeks** even if pain initially increases — this is expected - Success rate: **60-90%** in clinical trials **2. Load Management:** - Reduce running volume by 50% or more until pain improves - Replace high-impact with low-impact training (cycling, swimming, elliptical) - Pain monitoring: activity is acceptable if pain stays below 5/10 and settles within 24 hours - Gradual return to sport: 10% weekly volume increase once pain-free with eccentric exercises **3. Calf Stretching and Flexibility:** - Wall stretch (straight knee for gastrocnemius, bent knee for soleus) - Hold 30 seconds, 3 reps, 3x daily - Avoid aggressive stretching in the acute phase — can irritate the tendon **4. Additional Measures:** - Heel lifts (1-1.5 cm) in both shoes — reduces tendon strain by 15-20% - Ice after activity — 15-20 minutes to reduce post-exercise swelling - NSAIDs for short-term pain relief during acute flares (avoid long-term — may impair healing) - Shockwave therapy (ESWT) — 60-80% effective for chronic cases (>3 months) **5. Avoid:** - Corticosteroid injection INTO the Achilles tendon — increases rupture risk 3-5x - Complete rest — leads to tendon deconditioning; controlled loading is better than rest - Fluoroquinolone antibiotics if possible — discuss alternatives with your doctor ## Surgical Treatment (20-25% of Chronic Cases) Indicated after 6+ months of failed conservative treatment: - **Debridement**: Removal of degenerative tendon tissue — 75-85% good outcomes - **Haglund's resection**: For insertional tendinopathy with bony prominence - **Tendon repair with augmentation**: For tendons with >50% degenerative involvement - Recovery: 3-6 months; full return to sport 6-12 months post-surgery