Insertional Achilles Tendinopathy

INSERTIONAL ACHILLES TENDINOPATHY

The Achilles tendon is made up of the soleus and gastrocnemius muscles and connects these muscles to the back of the heel. Insertional Achilles tendinopathy (IAT) is a painful acute or chronic condition of the Achilles tendon at its insertion onto the calcaneus.

Pathology

Chronic insertional Achilles tendinopathy is associated with degenerative changes in the tendon.
Man with insertional Achilles tendinopathy

DIAGNOSIS AND TREATMENT

Diagnosis is based on the clinical features along with location of the pain. The spot of maximum pain in IAT is located at the junction of the tendon-bone, in contrast, non-insertional Achilles tendinopathy (MPAT), the spot of maximum pain is 2 to 6 cm proximal to the insertion.

Symptoms can be exacerbated by running on hard surfaces and climbing stairs. Diagnostic imaging such as ultrasound may be considered to rule out other causes of Achilles tendon pain and heel pain or to establish the diagnosis of IAT when in doubt.

The cause of IAT in athletes is likely to be multifactorial and may include (but not limited to) advanced age, obesity, hypertension, diabetes, hyper-pronation and steroid use.

‘Achilles tendon pain occurs more commonly in runners. The annual incidence of insertional Achilles tendinopathy among athletes is approximately 8%. However, individuals of all activity levels and all ages may present with similar complaints’

In athletes the onset of IAT may also be influenced by poor training habits including excessive training, training on hard or sloping surfaces, and abrupt changes in routine.

It has been hypothesised that healing of Achilles tendon overuse injuries involves the penetration of small blood vessels into the tendon in order to increase healing by improving blood flow. However, these small blood vessels are accompanied by small nerve fibres with high concentrations of nociceptive substances including glutamate, substance P, and calcitonin gene-related peptide (CGRP). Those small nerve fibres are considered the cause of pain in chronic insertional Achilles tendinopathy.

Patients not responding to conservative treatment for <6 months may then undergo shock wave therapy.

Insertional Achilles Tendinopathy
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