Non-insertional achilles tendinopathy: State of the art

Abstract

The Achilles tendon is formed by the confluence of the gastrocnemius and soleus muscles and inserts on the posterior surface of the calcaneus. Non-insertional Achilles tendinopathy is common. Recently the importance of inflammation has been re-evaluated. The major symptom in non-insertional Achilles tendinopathy is pain, commonly on first moving after a period of rest. The diagnosis is clinical on the basis of history and presentation, characterised by pain and swelling on the posterior aspect of the tendon insertion. Furthermore, some clinical tests have been described for non-insertional Achilles tendinopathy diagnosis. They can be divided into palpation tests (tendon thickening, crepitus, pain on palpation, the Royal London Hospital (RLH) test, the painful arc sign) and tendon loading tests (pain on passive dorsiflexion, pain on single heel raise and pain on hopping). Imaging techniques, including ultrasound (US) and magnetic resonance imaging (MRI) scans, can be useful to identify the nature, location and extent of a lesion. US may be particularly useful with the addition of power Doppler, because the pain seems to be related to areas of neovascularisation. The first line of management for Achilles tendinopathy is conservative, including nonsteroidal anti-inflammatory drugs, physical therapy, taping, cryotherapy, shock wave therapy, hyperthermia and various peritendinous injections. When conservative treatment fails, between one-quarter and one-third of patients may require surgery.