Definition
Achilles tendinopathy is a chronic clinical syndrome.
Clinically characterized by:
pain,
swelling,
functional impairment of the Achilles tendon.
Histopathologically:
acute inflammatory cells (macrophages, neutrophils) are absent.
Represents a degenerative rather than inflammatory condition.
Anatomical Classification
Insertional Achilles Tendinopathy (IAT)
Involves the calcaneal insertion.
First 2 cm of the tendon.
Non-Insertional Achilles Tendinopathy (NIAT)
Involves the mid-portion of the tendon.
Located 2–6 cm proximal to the calcaneal insertion.
Clinical Importance of Anatomical Distinction
Insertional and non-insertional tendinopathies represent:
different clinical entities,
different epidemiology,
different pathophysiology,
different treatment approaches.
Accurate differentiation is essential for:
diagnosis,
treatment planning.
Epidemiology
Based on current concepts review data.
Non-Insertional Tendinopathy
More common in:
younger,
physically active individuals,
athletes (runners, basketball players).
Insertional Tendinopathy
More common in:
middle-aged and older individuals,
less active or sedentary patients,
overweight or former athletes.
Pathophysiology and Risk Factors
Impaired Tendon Healing Capacity
Central mechanism in Achilles tendinopathy.
Results in:
chronic,
progressive,
irreversible structural damage.
Intrinsic Risk Factors
Metabolic disorders:
diabetes mellitus,
hypercholesterolemia,
hyperuricemia.
Inflammatory conditions.
Hypoxic stress.
Genetic predisposition.
Extrinsic Risk Factors
Repetitive overload.
Sudden increase in training intensity.
Abrupt changes in training programs.
Medication use:
corticosteroids,
aromatase inhibitors,
fluoroquinolone antibiotics,
statins.
Structural Tendon Changes
Tendon degeneration.
Neovascularization and neoinnervation.
Increased tenocyte activity.
Increased glycosaminoglycan and water content.
Tendon thickening.
Collagen disorganization:
type I collagen decreases,
type III collagen increases.
Parallel collagen alignment converts to a wavy pattern.
Pain Generation
Neovascularization and neoinnervation contribute to pain.
Degenerative matrix interferes with tendon healing.
Diagnosis – Clinical Evaluation
Symptoms
Classic clinical triad:
pain,
swelling,
functional limitation.
Acute phase:
pain during first steps of the day,
pain at the beginning of exercise,
symptoms may decrease with activity.
Chronic phase:
pain persists during rest.
Inspection
Evaluation of:
foot and ankle alignment,
pes cavus or pes planus deformity.
Palpation
Localized tenderness:
insertional region (IAT),
mid-portion fusiform swelling (NIAT).
Mid-portion swelling is:
tender,
mobile,
fusiform.
Physical Examination – Special Tests
Gastrocnemius Contracture
Frequently associated.
Especially relevant when:
stiffness occurs after prolonged activity.
Influences treatment planning.
Silfverskiöld test used for assessment.
Painful Arc Sign and Royal London Test
Demonstrate:
moderate diagnostic sensitivity,
moderate diagnostic specificity.
Provide supportive clinical information.
Imaging
Plain Radiography
First-line and most commonly used modality.
Findings may include:
soft tissue thickening,
calcifications,
Haglund morphology (in insertional cases).
Ultrasound and MRI
MRI:
most informative imaging modality.
Useful for:
insertional and non-insertional tendinopathy.
Demonstrates:
tendon thickening,
degenerative architecture,
intratendinous signal changes,
retrocalcaneal bursitis,
Haglund morphology.
Is Imaging Always Required?
Imaging is not mandatory when all of the following are present:
localized pain at insertional or mid-portion region,
load-related pain during activity,
localized tendon thickening,
pain with palpation.
In such cases:
diagnosis can be established clinically,
treatment may be initiated without imaging.
Imaging Selection Strategy
Ultrasound:
preferred initial modality.
MRI:
used when ultrasound is unavailable,
required for surgical planning.
X-ray:
useful for evaluating bony morphology,
particularly in insertional tendinopathy.
Treatment Overview
Initial treatment is always non-operative.
Two conceptual approaches:
“wait and see” (acute inflammation model),
“active treatment” (chronic degenerative model).
Achilles tendinopathy corresponds to:
a chronic degenerative condition.
Non-Operative Treatment – Core Approach
Patient education.
Physical therapy.
Activity modification.
Chronic disease course requires:
patience,
long-term adherence.
Activity Modification
Temporary cessation of pain-provoking activity.
Substitution with alternative activities.
Gradual return to sport.
Physical Therapy
Must be included in initial treatment.
Focuses on:
eccentric loading of gastrocnemius–soleus complex.
Goal:
restore tendon load tolerance.
Eccentric Exercise Protocols
Protocol selection depends on:
tendinopathy location.
Commonly used protocols:
Alfredson eccentric protocol,
Silbernagel eccentric–concentric protocol,
Beyer heavy–slow resistance exercises,
Stanish eccentric strengthening.
Alfredson Protocol
Most widely used protocol.
Performed on flat ground.
Knee extended:
3 sets × 15 repetitions.
Knee flexed:
3 sets × 15 repetitions.
Twice daily.
Total:
180 repetitions per day.
Adaptations required for insertional tendinopathy.
NSAIDs
No effect on:
collagen gene expression,
tendon repair.
Provide:
moderate analgesic effect.
Do not enhance physical therapy outcomes.
Associated with:
significant side effects.
Use limited to short-term pain control.
Heel Lifts
Reduce Achilles tendon load.
Improve pain and function.
Should not be used as:
sole treatment modality.
Serve as adjunct to physical therapy.
Stepwise Non-Operative Treatment
First-Line
Patient education.
Eccentric exercises.
NSAIDs.
Heel lifts.
Second-Line
ESWT.
Injection therapies:
PRP,
corticosteroid (with caution),
stromal vascular fraction,
hyaluronic acid,
prolotherapy,
high-volume injection.
Acupuncture.
Extracorporeal Shock Wave Therapy (ESWT)
Proposed mechanisms:
removal of damaged matrix via pro-inflammatory response,
stimulation of anabolic repair processes.
Demonstrated safety in:
insertional and non-insertional tendinopathy.
Represents:
minimally invasive second-line option.
Injection Therapies
PRP:
most extensively studied,
demonstrated safety and efficacy,
preferred second-line injection.
Corticosteroids:
associated with increased rupture risk,
not suitable for routine use.
Indications for Surgery
Reserved for:
persistent cases,
failure of ≥6 months of appropriate conservative treatment.
Approximately 30% of patients may require surgery.
Surgical Treatment Overview
Goal:
pain relief,
functional improvement.
Surgical strategy differs between:
insertional,
non-insertional tendinopathy.
Insertional Achilles Tendinopathy – Surgical Options
Open debridement and decompression.
Endoscopic calcaneoplasty.
Zadek osteotomy.
Osteotomies.
Tendon augmentation procedures.
Open Debridement and Decompression
Reported success rates:
70–90%.
Most extensively studied technique.
Allows:
adequate exposure,
FHL transfer if required.
Low risk of sural nerve injury.
Skin irritation remains a concern.
Surgical Approaches
Midline longitudinal.
Lateral longitudinal.
Cincinnati transverse.
Less invasive approaches:
lower wound complication rates,
limited access for tendon transfer.
Safe Tendon Detachment Limits
<50% detachment:
low rerupture risk,
safe debridement.
· 50% detachment:
reattachment required,
single-row or double-row anchor repair.
Complete detachment:
double-row repair preferred.
Tendon Augmentation
Indicated when:
o 50% tendon resection required.
Common graft choices:
flexor hallucis longus,
flexor digitorum longus,
peroneus brevis,
patellar tendon,
quadriceps tendon,
hamstring autograft.
Endoscopic Calcaneoplasty
Advantages:
minimally invasive,
fewer wound complications.
Limitations:
insufficient evidence as standalone treatment,
technical difficulty in intratendinous calcification removal.
Best suited for:
isolated posterosuperior calcaneal prominence.
Zadek Osteotomy
Dorsal closing-wedge calcaneal osteotomy.
Recently gained popularity.
Performed:
open or percutaneously.
Applicable to:
Haglund deformity,
insertional tendinopathy.
Mechanism of Zadek Osteotomy
Anterior rotation of posterosuperior tuberosity.
Proximal shift of Achilles insertion.
Reduced Achilles tendon tension.
Decreased retrocalcaneal pressure.
Reduced impingement.
Clinical Outcomes of Zadek Osteotomy
Reported outcomes:
significant pain relief,
functional improvement.
Patient satisfaction:
o 90%.
Complication rate:
~10% overall,
~5% with percutaneous technique.
Comparative studies:
similar clinical outcomes to open calcaneoplasty,
lower complication rates.
Non-Insertional Achilles Tendinopathy – Surgical Options
Percutaneous longitudinal tenotomy.
Paratenon stripping.
Open debridement and repair.
Tendon augmentation.
Percutaneous Longitudinal Tenotomy
Indicated for:
mild to moderate focal tendinopathy,
patients at high wound-risk (diabetes, smoking, elderly).
Ultrasound-guided technique.
Reported success rate:
~80%.
Lower complication profile.
Open Debridement and Repair
Indicated for:
advanced,
diffuse tendinopathy.
Tendon augmentation often required.
Common grafts:
FHL,
plantaris tendon.
Take-Home Messages
Tendinopathy is a degenerative condition.
MRI is not mandatory for initial diagnosis.
NSAIDs and heel lifts alone are insufficient.
Eccentric loading is essential.
PRP represents a safer second-line injection.
Surgical treatment must be individualized.
Percutaneous techniques are effective in selected cases.