Achilles tendonopathy

• introduction
• anatomy/biomechanics
• pathology
• epidemiology/natural history
• clinical
  • history
  • examination
• investigation
• management
  • non-surgical
  • surgery
    • insertional
    • non-insertional
    • reconstruction
• references (this page)

Last evidence check January 2012.

Principal authors: Jim Barrie and Marie Wilson

• Alfredson, H and Lorentzon, R (2003). Intratendinous glutamate levels and eccentric training in chronic Achilles tendinosis: a prospective study using microdialysis technique. Knee Surg Sports Traumatol Arthrosc 11(3): 196-9.
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• Alfredson, H and Ohberg, L (2005). Sclerosing injections to areas of neo-vascularisation reduce pain in chronic Achilles tendinopathy: a double-blind randomised controlled trial. Knee Surg Sports Traumatol Arthrosc 13(4): 338-44.
• Alfredson, H (2005). The chronic painful Achilles and patellar tendon: research on basic biology and treatment. Scand J Med Sci Sports 15(4): 252-9.
• Alfredson H (2011). Midportion Achilles tendinosis and the plantaris tendon. Br J Sports Med 2011;45:1023–5
• Brown, R, Orchard, J, et al. (2006). Aprotinin in the management of Achilles tendinopathy: a randomised controlled trial. Br J Sports Med 40(3): 275-9.
• Brunner, J, Anderson, J, et al. (2005). Physician and patient based outcomes following surgical resection of Haglund's deformity. Acta Orthop Belg 71(6): 718-23.
• Calder, JD and Saxby, TS (2003). Surgical treatment of insertional Achilles tendinosis. Foot Ankle Int 24(2): 119-21.
• Calder, JD and Saxby, TS (2006). Independent evaluation of a recently described Achilles tendon repair technique. Foot Ankle Int 27(2): 93-6.
• Coombes BK et al. (2010) Effi cacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet 376:1751-67
• Corps, AN, Robinson, AH, et al. (2006). Increased expression of aggrecan and biglycan mRNA in Achilles tendinopathy. Rheumatology (Oxford) 45(3): 291-4.
• Corrao, G, Zambon, A, et al. (2006). Evidence of tendinitis provoked by fluoroquinolone treatment: a case-control study. Drug Saf 29(10): 889-96.
• Costa, ML, Shepstone, L, et al. (2005). Shock wave therapy for chronic Achilles tendon pain: a randomized placebo-controlled trial. Clin Orthop Relat Res 440: 199-204.
• Costa, ML, Donell, ST, et al. (2006). The long-term outcome of tendon lengthening for chronic Achilles tendon pain. Foot Ankle Int 27(9): 672-6.
• de Jonge S et al (2011). Incidence of midportion Achilles tendonopathy in the general population. Br J Sports Med 45:1026-8
• de Jonge S et al (2011) One-year follow-up of platelet-rich plasma treatment in chronic Achilles tendonopathy: a double-blind randomised placebo-controlled trial. Am J Sports Med 39:1623-9
• Den Hartog, BD (2003). Flexor hallucis longus transfer for chronic Achilles tendonosis. Foot Ankle Int 24(3): 233-7.
• Furia, JP (2006). High-energy extracorporeal shock wave therapy as a treatment for insertional Achilles tendinopathy. Am J Sports Med 34(5): 733-40.
• Gardin, A, Bruno, J, et al. (2006). Magnetic resonance signal, rather than tendon volume, correlates to pain and functional impairment in chronic Achilles tendinopathy. Acta Radiol 47(7): 718-24.
• Haims, AH, Schweitzer, ME, et al. (2000). MR imaging of the Achilles tendon: overlap of findings in symptomatic and asymptomatic individuals. Skeletal Radiol 29(11): 640-5.
• Holmes, GB and Lin, J (2006). Etiologic factors associated with symptomatic achilles tendinopathy. Foot Ankle Int 27(11): 952-9.
• Johnson, KW, Zalavras, C, et al. (2006). Surgical management of insertional calcific achilles tendinosis with a central tendon splitting approach. Foot Ankle Int 27(4): 245-50.
• Jones, GC, Corps, AN, et al. (2006). Expression profiling of metalloproteinases and tissue inhibitors of metalloproteinases in normal and degenerate human achilles tendon. Arthritis Rheum 54(3): 832-42.
• Khan, KM, Forster, BB, et al. (2003). Are ultrasound and magnetic resonance imaging of value in assessment of Achilles tendon disorders? A two year prospective study. Br J Sports Med 37(2): 149-53.
• Khan, RJ, Fick, D, et al. (2005). Treatment of acute achilles tendon ruptures. A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am 87(10): 2202-10.
• Knobloch, K, Kraemer, R, et al. (2006). Achilles tendon and paratendon microcirculation in midportion and insertional tendinopathy in athletes. Am J Sports Med 34(1): 92-7.
• Knobloch, K, Kraemer, R, et al. (2007). Eccentric training decreases paratendon capillary blood flow and preserves paratendon oxygen saturation in chronic achilles tendinopathy. J Orthop Sports Phys Ther 37(5): 269-76.
• Knobloch K et al. Gender and eccentric training in achilles mid-portion tendinopathy. Knee Surg Sports Traumatol Arthrosc (2009).
  
• Kumai, T and Benjamin, M (2002). Heel spur formation and the subcalcaneal enthesis of the plantar fascia. J Rheumatol 29(9): 1957-64.
• Kuskucu, M, Mahirogullari, M, et al. (2005). Treatment of rupture of the Achilles tendon with fibrin sealant. Foot Ankle Int 26(10): 826-31.
• Labib, S, Hage, WD, et al. (2007). The effect of ankle position on the static tension in the Achilles tendon before and after operative repair: a biomechanical cadaver study. Foot Ankle Int 28(4): 478-81.
• Leitze, Z, Sella, EJ, et al. (2003). Endoscopic decompression of the retrocalcaneal space. J Bone Joint Surg Am 85-A(8): 1488-96.
• Lintz F et al (2010). The role of plantaris longus in Achilles tendonopathy: a biomechanical study. Foot and Ankle Surgery 17; 252–5
• Lohrer, H, Nauck, T, et al. (2006). Comparison of endoscopic and open resection for Haglund tuberosity in a cadaver study. Foot Ankle Int 27(6): 445-50.
• Lu, CC, Cheng, YM, et al. (2007). Angle analysis of Haglund syndrome and its relationship with osseous variations and Achilles tendon calcification. Foot Ankle Int 28(2): 181-5.
• Maffulli, N, Testa, V, et al. (2006). Surgery for chronic Achilles tendinopathy yields worse results in nonathletic patients. Clin J Sport Med 16(2): 123-8.
• Mafi, N, Lorentzon, R, et al. (2001). Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis. Knee Surg Sports Traumatol Arthrosc 9(1): 42-7.
• Mahieu, NN, Witvrouw, E, et al. (2006). Intrinsic risk factors for the development of achilles tendon overuse injury: a prospective study. Am J Sports Med 34(2): 226-35.
• Mathieu N et al. Effect of eccentric training on the plantar flexor muscle-tendon tissue properties. Med Sci Sports Exerc. 2008;40(1):117-23
• Martin, RL, Manning, CM, et al. (2005). An outcome study of chronic Achilles tendinosis after excision of the Achilles tendon and flexor hallucis longus tendon transfer. Foot Ankle Int 26(9): 691-7.
• Mitchell AW et al. The use of ultrasound in the assessment and treatment of achilles tendinosis. J Bone Joint Surg Br (2009).91(11):1405-9.
  
• Nicholson, CW, Berlet, GC, et al. (2007). Prediction of the success of nonoperative treatment of insertional Achilles tendinosis based on MRI. Foot Ankle Int 28(4): 472-7.
• Norregaard, J, Larsen, CC, et al. (2007). Eccentric exercise in treatment of Achilles tendinopathy. Scand J Med Sci Sports 17(2): 133-8.
• Ohberg, L, Lorentzon, R, et al. (2001). Good clinical results but persisting side-to-side differences in calf muscle strength after surgical treatment of chronic Achilles tendinosis: a 5-year follow-up. Scand J Med Sci Sports 11(4): 207-12.
• Ortmann, FW and McBryde, AM (2007). Endoscopic bony and soft-tissue decompression of the retrocalcaneal space for the treatment of Haglund deformity and retrocalcaneal bursitis. Foot Ankle Int 28(2): 149-53
• Paavola, M, Kannus, P, et al. (2000). Long-term prognosis of patients with achilles tendinopathy. An observational 8-year follow-up study. Am J Sports Med 28(5): 634-42.
• Pearce CJ et al. Is apoptosis the cause of noninsertional achilles tendinopathy? Am J Sports Med (2009).37(12):2440-4.
• Pearce CJ et al (2011). Achilles tendinoscopy and plantaris tendon release and division in the treatment of non-insertional Achilles tendinopathy. Foot Ankle Surg (e-pub)
• Pearson J et al. (2011) Autologous blood injection for treatment of Achilles tendonopathy? A randomised controlled trial. J Sport Rehab (e-pub)
• Raleigh SM et al (2009). Variants within the MMP3 gene are associated withAchilles tendinopathy: Possible interaction with the COL5A1 gene. Br J Sports Med 43:514-20
  
• Rettig, AC, Liotta, FJ, et al. (2005). Potential risk of rerupture in primary achilles tendon repair in athletes younger than 30 years of age. Am J Sports Med 33(1): 119-23.
• Robinson, JM, Cook, JL, et al. (2001). The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy. Br J Sports Med 35(5): 335-41.
• Rompe, JD, Nafe, B, et al. (2007). Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial. Am J Sports Med 35(3): 374-83
• Roos, EM, Engstrom, M, 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(5): 286-95.
• Rufai A et al. Structure and histopathology of the insertional region of the human Achilles tendon. J Orthop Res 1995; 13:585-93
• Sayana, MK and Maffulli, N (2007). Eccentric calf muscle training in non-athletic patients with Achilles tendinopathy. J Sci Med Sport 10(1): 52-8
• Schubert, TE, Weidler, C, et al. (2005). Achilles tendinosis is associated with sprouting of substance P positive nerve fibres. Ann Rheum Dis 64(7): 1083-6.
• September AV et al. (2009) Variants within the COL5A1 gene are associated with Achilles tendinopathy in two populations. Br J Sports Med 43:357-65
• Silbernagel, KG, Thomee, R, et al. (2007). Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. Am J Sports Med 35(6): 897-906
• Silbernagel KG et al (2011). The majority of patients with Achilles tendonopathy recover fully when treated with exercise aone: a 5-year follow-up. Am J SPorts Med 39:607-13
• Sode, J, Obel, N, et al. (2007). Use of fluroquinolone and risk of Achilles tendon rupture: a population-based cohort study. Eur J Clin Pharmacol 63(5): 499-503
• Tashjian, RZ, Hur, J, et al. (2003). Flexor hallucis longus transfer for repair of chronic achilles tendinopathy. Foot Ankle Int 24(9): 673-6.
• Testa, V, Capasso, G, et al. (2002). Management of Achilles tendinopathy by ultrasound-guided percutaneous tenotomy. Med Sci Sports Exerc 34(4): 573-80.
• van der Plas A et al. (2011) A 5-year follow-up study of Alfredson's heel-drop exercise programme in chronic midportion Achilles tendinopathy. Br J Sports Med, epub.
• van Dijk, CN, van Dyk, GE, et al. (2001). Endoscopic calcaneoplasty. Am J Sports Med 29(2): 185-9.
• van Sterkenberg MN et al. (2011) The plantaris tendon and a potential role in mid-portion Achilles tendinopathy: an observational anatomical study. J Anat 218:336-41
• van Sterkenberg MN et al. (2011) Good outcome after stripping the plantaris tendon in patients with chronic mid-portion Achilles tendinopathy. Knee Surg Sports Traumatol Arthrosc 19:1362–6
• Wagner, E, Gould, JS, et al. (2006). Technique and results of Achilles tendon detachment and reconstruction for insertional Achilles tendinosis. Foot Ankle Int 27(9): 677-84.
• Yodlowski, ML, Scheller, AD, Jr., et al. (2002). Surgical treatment of Achilles tendinitis by decompression of the retrocalcaneal bursa and the superior calcaneal tuberosity. Am J Sports Med 30(3): 318-21.
• Zantop, T, Tillmann, B, et al. (2003). Quantitative assessment of blood vessels of the human Achilles tendon: an immunohistochemical cadaver study. Arch Orthop Trauma Surg 123(9): 501-4.