Foot / Ankle
Achilles Tendinopathy
아킬레스건 병증
Achilles tendon degeneration from repetitive overload — common in runners and jumping sport athletes
- How common
- Common
- Typical age
- Ages 25–55
What is it?
Repetitive mechanical overload of Achilles tendon → angiofibroblastic degeneration (tendinosis) — degeneration rather than true inflammation
Commonly affected: Achilles tendon (midportion: 2-6cm proximal to calcaneal insertion, or insertional)
How it develops
- Mechanical OverloadRunning and jumping transmit 6-8x body weight to Achilles tendon. Overtraining, sudden intensity increase
- Tendon MicrotraumaRepetitive overload causes collagen fiber microtears within tendon
- Incomplete HealingInefficient healing process → angiofibroblastic degeneration without normal angiogenesis
- NeoinnervationNeovascularization with neoinnervation increases pain sensitivity
Symptoms
- Midportion Achilles PainPain and thickening 2-6cm above calcaneal insertion — most common location
- Warm-up PatternPain at activity start, decreases with warm-up → chronic cases: persists even after warm-up
- Morning StiffnessAchilles tendon stiffness and pain on waking — similar to plantar fasciitis
- Tendon ThickeningFusiform thickening of Achilles tendon midportion — palpable
How it is examined
- Midportion TendernessDirect tenderness at Achilles midportion (2-6cm proximal to insertion) → most important finding
- Royal London Hospital TestMidportion tenderness decreases with dorsiflexion → specific for true midportion tendinopathy
- Thompson's TestRule out complete rupture: absence of plantarflexion with calf squeeze in prone position = complete rupture
- Tendon ThickeningFusiform thickening and tendon nodules palpable — sign of chronic tendinopathy
Imaging
Insertional tendinopathy: assess posterior calcaneal spur and Haglund deformity
- Insertional: posterior calcaneal spur, Haglund deformity (posterior calcaneal prominence)
- Midportion: usually normal
- Intratendinous calcification (rarely)
Confirm tendon degeneration extent and partial/complete tear
- Tendon thickening and T2 hyperintensity (degeneration)
- Partial tear: focal defect and T2 hyperintensity
- Complete tear: loss of tendon continuity, gap visible
Non-surgical care
- Eccentric Exercise (Alfredson Protocol)Eccentric Achilles exercise is most effective treatment — heel drop from step edge slowly
- Activity ModificationReduce training, gradual return. Flat surface running, heel drop footwear
- ESWTESWT when eccentric exercise fails — more effective for midportion than insertional
- PRP InjectionStimulates tendon regeneration via growth factors — promising for midportion tendinopathy
Conservative options are generally tried first. Medications listed here can have side effects — discuss them with your prescriber.
When surgery is considered
Failed conservative treatment >6 months, progressive tendon degeneration
Procedures that may be discussed
- Tendon debridement — removal of degenerate tissue
- Tendon stripping and reconstruction
- Insertional: Haglund resection and tendon reattachment
Outlook
60-80% improvement with 12-week eccentric protocol. Long-term prognosis good but 3-6 months for full recovery