yogabook / pathologie / achillodynia

Achilles tendon injuries / achillodynia / tendinitis, tendinosis or tendinopathie of the Archilles tendon

Definition

Irritation, injury, tearing, rupture of the tendon of the triceps surae that attaches to the heel bone. Mainly a „weekend warrior“ injury, i.e. people who exercise mainly at the weekend and then tend to overexert themselves. Top male, active in sports, 30-50 years old. Competitive athletes are often affected from the age of 24, recreational athletes usually from the age of 40. The disorder also affects regular athletes quite often: approx. 50% of middle and long-distance runners are affected during their career, 10% of all joggers, and the disorder is bilateral in almost half of the cases. Athletes with flat feet are one and a half times more likely to be affected, and those with high-arched feet almost twice as often. Non-athletes are still 10% affected, especially people who have to stand a lot. In runners, between 2.5 and 12.5 times their body weight acts on the Achilles tendon; in a marathon with around 30,000 steps, this adds up to 30,000 tons. A rupture of the Achilles tendon, which is on average 20-25 cm long, usually occurs 2-7 cm above the calcaneus, as this is where the arterial supply (from above and below) is poorest. Basically, the tendon is too poorly vascularized in relation to its load. The microlesions that develop also impair the vascular supply, which promotes degeneration. It is not uncommon to find hypervascularization, presumably caused by hypoxia.
Intraoperatively, a destroyed fiber structure is usually seen, followed microscopically by an abnormal structure of the collagen, which heals poorly. Signs of inflammation are rare. The paratendinous tissue is normal or edematous and often shows scarring.
Irritations of the Achilles tendon are usually classified as insertional tendinopathy, but can also (and additionally) be insertional tendinopathies and are quite regularly an overuse syndrome. It usually takes 10 years, on average 12 years, for symptomatic Achillodynia to develop as a result of performance-oriented training. It then usually takes another 2 years before a diagnosis is made. If left untreated, the disease progresses and ends in a rupture. While the pain initially only occurs after prolonged exertion, it later occurs during or after moderate exertion and can lead to pain at rest. Conservative therapy is successful in 70-80% of cases and usually lasts 3-6 months. Spontaneous healing is also possible without treatment, but is unlikely without rest. Overall, non-conservative treatment is rarely necessary. Achillodynia can occur together with retrocalcaneal bursitis, which then also causes painful soft tissue swelling. Superficial bursitis, on the other hand, is often the result of a shoe cap that presses too hard. Achillodynia usually shows a thickened tendon with reduced resilience. Intensive long-term sporting activity, especially if it is one-sided, has clear preconditions if it is to be free of side effects. Even slight deviations from physiological processes or physiological kinetics can lead to symptomatic disorders in their cumulative effect after they may have been asymptomatic for a long time but could have been detected using appropriate methods. In principle, the incidence correlates with the years of running and the amount of training. In the case of tears, movement habits, needs and necessities as well as psychological factors play a major role in the choice of therapy.

A distinction must be made between the very common midsection achillodynia, which is located 2-7 cm above the insertion at the calcaneus and shows a clear risk of tears, but is not classified as insertional tendopathy and the insertional tendopathy at the attachment to the calcaneus. The latter often occurs together with dorsal heel spurs and calcifications of the tendon. In addition to pain, stiffness and often a permanent feeling of swelling are reported. Degenerative changes in the tendon can often be detected here, including dorsal bone spurs (heel spurs). Additional retrocalcaneal bursitis also localises medially and laterally to the achilles tendon. In contrast, subcutaneous bursitis would often be induced by footwear.

ICD M76.6

Cause

1. Eccentric stretching with high force requirements, acute trauma, extreme strain, overuse; often with existing previous damage or malpositioning
2. dorsal heel spur
3. Previous fractures in the OSG or tibia area

Predisposing

– Musculoskeletal system

1. short heel bone
2. hyperextensible knee joints (reduce the flexibility requirement of the triceps surae when walking/running)
3. Instability of the longitudinal arch of the foot: flat foot, fallen arches
4. Insufficient flexibility of the triceps surae and Achilles tendon
5. Limited hip extension, limited endorotation in the hip joint
6. Unstable ankle (ligament injuries, e.g. after supination trauma)
7. Altered leg statics, especially knock-knees
8. Leg length differences
9. Previous Achilles tendinopathy (occurrence as recurrence)
10. Knee or hip joint problems
11. Misalignments or axis deviations
12. Hyperpronation
13. Foot deformities such as hollow foot, flat foot, fallen arches, flat foot, fallen arches, kinked foot
14. In children and adolescents: Apophysitis calcanei
15. Arthritis of the ankle joint
16. pre-existing subachilles bursitis or subcutaneous calcaneal bursitis
17. Plantar fasciitis or heel spur
18. Haglund deformity (Haglund heel)
19. Hallux rigidus, hallux limitus
20. Insufficiency of the outer capsular ligament of the OSG
21. Bone diseases
22. Osteochondrosis dissecans
23. Existing stress fracture
24. Tendopathies of the medial malleolus

– Exercise behavior/sport

1. Activities/sports with jerky load requirements: Running, athletics, dancing, ball sports, racket sports, jumping sports. The practice of sports indoors, on asphalt or other hard surfaces is also beneficial
2. Exercising in an insufficiently warmed-up state or in cold or wet conditions
3. inadequate footwear
4. Lack of training
5. Poor running style
6. Uphill run
7. Resumption of training after a long break
8. Unfavorable running conditions: e.g. wet, slippery leaves
9. Overexertion, „too much, too soon“
10. unfamiliar surface (too hard for trained people, too soft for untrained people)
11. Predominantly sedentary lifestyle and activities
12. Mismatch between the frequency and duration of exercise and training intensity and, on the other hand, the duration of the regeneration phases
13. Running on sand and other loose surfaces
14. Low drop of the running shoe
15. Pressure of the running shoe on the Achilles tendon

– Health risk factors

1. Metabolic diseases: Hyperuricemia(gout), hypertriglyceridemia, hyperlipoproteinemia and diabetes mellitus interfere with the healing of microlesions
2. rheumatoid diseases
3. older age
4. Overweight
5. Previous local glucocorticoid injections, oral glucocorticoids or antibiotics taken for a longer period of time
6. Taking fluoroquinolones (gyrase inhibitors, special antibiotics)
7. Familial hypercholesterolemia
8. Smoking
9. Corticoids, statins, quinolones can cause and delay healing

Diagnosis

1. Achilles tendon tenderness (pincer grip)
2. palpable dent during attachment and detachment
3. Sonography shows cross-sectional proliferation and texture change. Doppler shows vascularization
4. MRI shows ruptures/partial ruptures
5. X-ray in 2 planes
6. Tests and signs: Thompson test, needle test according to O’Brien, ball of foot test

Symptoms

1. creeping pain on movement (diffuse, dull or even sharp stabbing pain, often above the insertion at the base of the heel bone in the area with the poorest supply), especially when rolling the foot and plantar flexion, more pronounced in the morning and after rest. The pain during the rolling movement is strongest under eccentric load, when the body overtakes the standing foot. The pain is usually clear and radiates longitudinally, rarely diffuse.
   Over the course of the run, the pain can decrease, usually without completely subsiding.
2. Pronounced pain on stretching
3. In the case of initial irritation, initial pain on exertion and morning pain; if it persists for a longer period of time, the pain increases over the duration of the exertion and can even be sharp; sporting activity must be discontinued or is not even possible. The pain on exertion may persist for some time(post-exertion pain) and may turn into pain at rest
4. Pressure soreness
5. Significant thickening of the Achilles tendon
6. the flexibility of the Achilles tendon in the surrounding tissue may be restricted or eliminated,
7. Changing the gait pattern to avoid pain
8. signs of inflammation, if applicable: Tumor, Calor, Rubor
9. If necessary, adaptation of a pointed foot to relieve the Achilles tendon
10. possibly peritendinitis with thickening of the peritendinum and reduced displacement of the Achilles tendon in the surrounding tissue as well as auscultatory or papillary crepitations
11. In case of avulsion: no orderly gait possible, loss of active plantar flexion, i.e. also of the toe position
12. on demolition: whipcrack-like noise
13. on demolition: Hematoma
14. Possibly altered gait pattern on the affected side: limited dorsiflexion of the ankle, premature lifting of the heel, reduced hip extension, increased pelvic rotation
15. Abnormalities when descending stairs backwards: avoidance behavior can be observed due to the pain during the eccentric contraction of the triceps surae for dorsiflexion in the ankle joint

Complications

1. Complication of Achillodynia: rupture of the Achilles tendon

Therapy

1. Conservative in 80%; depending on severity: Immobilization/rest/load reduction, analgesics, anti-inflammatory drugs. Achilles tendon discomfort indicates rest or a break from exertion and sufficient regeneration
2. Local anti-inflammatory drugs as an ointment
3. If necessary, technique training, optimization of sports footwear
4. Suitable running shoes with sufficient cushioning in the heel area, taking into account the service life of the shoes: approx. 500 to 1000 training kilometers
5. Adapted footwear/insoles for malpositioned feet
6. For functional disorders of the ankle joints or anterior foot joints: PT
7. Detection and elimination of functional deficits in the hip joint (especially extension, endorotation)
8. If necessary: weight reduction, from BMI 25: medically supervised weight loss program
9. No training under pain medication!
10. If necessary, temporarily switch to gentler sports such as cycling
11. If necessary, nutritional therapy with sufficient omega-3 supply
12. Shock wave therapy
13. Keep the Achilles tendon warm before starting sport, then cool it down
14. Autologous blood with hyaluronic acid infiltration
15. Strength training and later endurance training
16. Functional leg axis training
17. PT
18. Gold standard: stretching(gastrocnemius and soleus and the antagonistic foot lifts) with your own body weight, mobilization, strengthening, adequate warm-up during exercise. No lasting therapeutic success without this
19. Stretching the plantar fascia and toe flexors
20. Temporary orthopaedic elevation of the heel if necessary, be careful when removing it!
21. In the event of an attachment/tear: tendon incision, removal of degenerated parts or tendon suture
22. In case of avulsion: if the tendon stumps communicate at 20° dorsiflexion, conservatively with plaster, especially in older patients
23. In case of rupture: surgery, has lower risk of rerupture (only 2.3% instead of 3.9%) but slightly higher complication rate (4.9% vs. 1.6%)
24. When resuming training: suitable footwear, familiarization with the surface, sufficient warm-up, correction/compensation of misalignments, regular stretching of the triceps surae The following applies to the extent and intensity of training after resuming: pain RNS (Numerical Rating Scale) 1-2 is harmless, 35 points can be tolerated for the time being, but must be observed. Severe pain is contraindicated.
25. NO local administration of corticosteroids! Corticosteroids worsen the prognosis. Better: Nitrospray
26. Surgery without tear: at the earliest after 6 months of insufficiently successful conservative therapy, preferably microinvasive due to lower complication rate

Asana practice and movement therapy

If there is no tear, it is important on the one hand to ensure that the triceps surae is well stretched, but on the other hand also to carry out sustained strengthening that leads to increased metabolism in the Achilles tendon and trains it. Shock loads, as in many sports, are not suitable for this, but rather detrimental – especially when excessive. In the area of stretching, both the monoarticular soleus and, above all, the biarticular gastrocnemius should be stretched, the tone of which is likely to be more relevant for everyday movements and most sports. Exercises with pronounced dorsiflexion of the ankle joint with and without an extended knee joint are therefore required

Furthermore, a stable ankle should be ensured, which affects both the performance of the muscles – speed is particularly important in athletic movements – and proprioception, for which balance postures or postures with a balancing character are very suitable. In order to improve the performance of a muscle, it is generally possible to train high-speed strength or heavy strength. If the tendon is already damaged, you must never go into the area of high-speed strength, because if the muscle performance capacity is exceeded during training – even for just milliseconds – the elasticity of the tendons is acquired. This must be avoided at all costs if the tendon is already damaged.

All muscular imbalances must be addressed and the best possible symmetry established with the help of stretching and strengthening postures.

The supinators of the ankle rarely exhibit a lack of extensibility, but nevertheless often show excessive tone due to strain, leading to irritations such as tibial plateau syndrome. Although the range of motion of the ankle is very large in this direction, as part of the natural rolling of the foot, which usually begins with a slight supination, the gravity-induced reactive pronation must be absorbed by the supinators. The pronators, on the other hand, are often tense in runners and athletes whose discipline includes significant running components. The more supinated the foot is placed, the more pronounced this is likely to be.

As the rolling motion of the foot also depends on the tension of the plantar fasciac and the toe flexors as a whole, attention should also be paid to these. Excessive tension in the plantar fascia tends to overload the Achilles tendon. The small fascia roll does a good job here.

Last but not least, don’t forget the group of antagonists of the triceps surae, which are transferred via the Achilles tendon: the foot lifts should be checked for tension. virasana and baddha padasana as well as hip opener 5 offer good opportunities for this.

Among all the tasks mentioned, it should not be overlooked that training the flexibility and strength of the triceps surae itself (as the muscle whose strength the Achilles tendon transmits) remains the most important.

Asanas

1. Asanas in 851: Stretching the foot extensors / plantar flexors / calf muscles
2. Asanas in 852: Strengthening the foot extensors / plantar flexors / calf muscles
3. Asanas in 861: Stretching the supinators
4. Asanas in 862: Strengthening the supinators
5. Asanas in 871: Stretching the pronators
6. Asanas in 872: Strengthening the pronators
7. Asanas in 971: Stretching the toe flexors
8. virasana and baddha padasana for relaxed antagonists.