J Am Board Fam Pract: first published as 10.3122/jabfm.2.3.196 on 1 July 1989. Downloaded from In Athletes Andrew W. Nichols, M.D.

Abstract: Achilles tendinitis is an that com­ normalities that predispose to Achilles tendinitis in­ monly affects athletes in the running and jumping clude gastrocnemius- weakness or in­ sports. It results from repetitive eccentric load-in­ flexibility and hindfoot malalignment with duced microtrauma that stresses the peritendinous hyperpronation. structures causing inflammation. Achilles tendinitis The initial treatment should be conservative with may be classified histologically as peritendinitis, ten­ relative rest, gastrocnemius-soleus rehabilitation. dinosis, or partial rupture. cryotherapy, lifts, nonsteroidal anti-inflamma­ Training errors are frequently responsible for the tory drugs, and correction of biomechanical abnor­ onset of Achilles tendinitis. These include excessive malities. Surgery is recommended only for persons running mileage and training intensity, hill running, with chronic symptoms who wish to continue run­ running on hard or uneven surfaces, and wearing ning and have not benefited from conservative ther­ poorly designed running shoes. Biomechanical ab- apy. (J Am Bd Fam Pract 1989; 2:196-203.)

In Homer's Iliad, the Greek chieftain Achilles was Anatomy mortally wounded by an arrow that pierced his The (calcaneal tendon), which in­ heel, which was his only unprotected area, be­ serts on the . is the common tendon of cause the remainder of his body had been made the gastrocnemius and soleus muscles. The gas­ invulnerable by an Immersion in the River Styx. 1 trocnemius muscle arises from two heads origi­ Today, the Achilles tendon is a common site of nating on the femoral condyles and lies superficial athletic injury because of the demanding training to the soleus. The soleus arises from the posterior regimens of competitive athletes and the rising surfaces of the proximal and and does numbers of recreational athletes. not cross the . This muscle pair primar­ Achilles tendinitis commonly affects athletes in­ ily plantar flexes the foot and secondarily flexes volved in track and field. cross-country running, the leg. 5 The . which completes http://www.jabfm.org/ tennis. basketball. baseball, gymnastics, and bal­ the muscle triad referred to as the "triceps surae," let. James. et a1. found Achilles tendinitis to be the has its own tendon, which contributes no fibers to third most common running injury (11 percent of the Achilles tendon. Two major bursae lie adja­ all such ); only knee pain (29 percent) and cent to the tendon; the subcutaneous bursa is situ­ the posterior tibial syndrome (13 percent) oc­ ated between the skin and the insertion of the curred more frequently. 2 Others have reported Achilles tendon, while the retrocalcaneal bursa to

that Achilles tendinitis accounts for 6.5 and 18 lies deep the tendon, adjacent to the posterior­ on 28 September 2021 by guest. Protected copyright. percent of . 3.4 superior calcaneal border (Figure 1). Achilles tendinitis is believed to result from re­ The tendon is composed of primary bundles of petitive, eccentric musculotendinous loading, dense connective tissue and fibers that which causes microtraumatic structural damage. are packaged into individual tendon functional Middle-aged men are most frequently afflicted. units known as fascicles or secondary bundles. with the average age of onset being 39 years in Groups of fascicles constitute the true tendon, one study.4 Increased susceptibility to injury in which is loosely held together by the surrounding older persons may be due to loss of normal tendon blood vessels, nerves. and lymphatic-carrying en­ elasticity. which predisposes the tendon to eccen­ dotendon. The peri tendon covers the endotendon tric, load-induced microtears. and is composed of a loose, inner connective tis­ sue (epitenon) and an outer tissue (paratenon), which act as an elastic sleeve to allow free tendon From a private practice. Address reprint requests to Andrew W. Nichols. M.D .• Coronado Professional Square, 171 CAve­ movement. The Achilles tendon has no true syno­ nue, Coronado, CA 92118. vial sheath.

196 The Journal of the American Board of Family Practice-Vol. 2 No.3 I July - September 1989

j J Am Board Fam Pract: first published as 10.3122/jabfm.2.3.196 on 1 July 1989. Downloaded from term "tenosy novili " has be 11 us d to drib

Gasl,racn"mIU5 m inflammation of the t ndon and adjacent stru - tur . 17. 11l A more prop'r clas Hi ation of injury types in lucks: (1) peritcndinitis, (2) tcndinosis, (3) pcrilcndiniti with tendino 'is, (4) partial ten­ don ruptllr '. and (5) om pi t tendon rupture. Peritendinitis re~ r to infJammati n f the p ri ­ tendinOll sheath, and tcndino is indi ate tendon mi rostructural di rupti n. Th first four typ' are the ommon, overu c A hilles tendon injuries seen in runn r; omplete tendon rupture i not discussed in this revi w.

Pathomechanics During the push-off phase of running, up to 2000 RelrocolCaneal bursa pounds of force may be transmitted to the A hil ­ les tendon. This tremendous force is absorbed through eccentric tendon loading when the rap­ idly dorsiflexing foot decelerates. 19.20 Repetitive eccentric loading may produce focal or diffuse tendon degeneration and inflammation. As in­ jured tissue heals, granulation tissue develops and frequently forms adhesions between the tendon and para tendon, resulting in recurrent Figure 1. Anatomy of the Achilles tendon and adja­ inflammation. cent structures. Drawing by Gwynne M. Gloege Etiology The etiology of Achilles tendinitis (peritendinHis Three vascular sources supply the Achilles ten­ or tendinosis) is multifactorial. The most impor­ don. These include longitudinal vessels that cross tant factors are poor gastrocnemius and soleus http://www.jabfm.org/ the musculotendinous junction, small vessels that muscle flexibility, hyperpronation of the running anastamose in the periosteum at the tendon-osse­ foot, poor running shoe design, excessive eccen­ ous junction, and most importantly, the vascular tric muscle loading, and overtraining. A tight, branches of the posterior tibial and peroneal arter­ poorly flexible Achilles tendon may be the most ies along the entire length of the tendon.6 A re­ common predisposing factor, aggravated by wear­ gion of reduced vascularity exists in the distal ten­ ing high-heeled shoes and by inadequate stretch­ 7 9 don, 2 to 6 centimeters from its insertion. - ing. The Achilles tendon is long, compared with on 28 September 2021 by guest. Protected copyright. Lindholm and Arner found this to be the site of gastrocnemius and soleus muscle lengths, which tendon rupture in 45 of 46 cases. 10 This region helps absorb large forces. If flexibility is limited, also seems to be the most common site of tendon the tendon loses some of its shock-absorbing ela s­ inflammation. 1 1- 14 The twisting and the lateral ticity, predisposing it to eccentric load-induced rotation of Achilles tendon fibers as they de­ microtears and inflammation. scend produce additional stress and tendon hypo­ The typical sequence of foot biomechanics dur­ vascularity. 15.16 ing running must be reviewed to discuss the effect of hyperpronation. The sequence consists of heel strike, rapid pronation, and supination.21 At heel Classification of Achilles Tendon strike, initial ground contact is made with the lat­ Injuries eral aspect of the heel. Rapid pronation follows as Achilles tendon injury is classified according to the midtarsal joint unlocks, relieving tension on macroscopic and histologic examination. Al­ the plantar and enabling the foot to adjust though no true exists, the to uneven terrain and absorb impact. Supination

Achilles Tendinitis 197 J Am Board Fam Pract: first published as 10.3122/jabfm.2.3.196 on 1 July 1989. Downloaded from then occurs as the midtarsal jOint locks to increase percent, and improper shoes were worn by 10 tension and convert the foot from a percent of the runners. A Canadian survey of track mobile adaptor to a rigid lever in preparation and field athletes with Achilles tendinitis showed for the push-off. Many runners with Achilles ten­ that 74 percent developed symptoms when don problems have a prolonged pronation phase switching to an indoor track with tightly banked (hyperpronation), causing increased medial ten­ turns. 18 don tension and a resultant whipping action or "bowstring" effect on the Achilles tendon. Thirty degrees of change in hindfoot position results in a Iatrogenic Causes 10 percent elongation of the fibers on the stressed. The most common iatrogenic Achilles tendon in­ aspect of the tendon. 16 Poor gastrocnemius-soleus jury is caused by injections. Cortico­ flexibility adds to hyperpronation by forcing a steroids are known to inhibit collagen synthesis, compensatory increase in knee flexion during slow tendon repair, reduce the breakage point of running.22 These conflicting internal and exter­ in animals, and cause fatty degeneration nal rotatory forces imparted to the tibia during and round-cell infiltration of adjacent muscle and 23 27 simultaneous foot pronation and knee exten­ nerve. - Direct injection into the tendon me­ sion may "wring out" tendon vessels to produce chanically separates tendon fibers. 28 The literature avascularity. has numerous reports of injection-induced ten­ Shoe design plays an important role in the de­ don rupture. 10,13,20,28-3 I velopment of Achilles tendon injury. Hyperprona­ tion often results from wearing shoes with soft heel counters, narrow , or poor medial heel History and counter support. Running shoes with high, poorly The athlete with Achilles tendinitis usually com­ padded heel counters place unnecessary pressure plains of gradually progressive pain and stiffness on the tendon. Shoes with inadequate heel eleva­ in the distal 5 centimeters of the tendon, though tion produce increased tendon stretch and, conse­ pain may occur more proximally or dis­ quently, increased loading at heal strike. Rigid, tally. The onset of symptoms frequently coincides inflexible soles add to tendon by lengthen­ with a change in training intensity or quality. Ini­ ing the -to-forefoot lever arm. Poorly cush­ tially, pain occurs only following activity, but with ioned shoes, particularly when worn by persons continued use, the tendon may also become pain­ with rigid, cavus feet, lead to Achilles tendon ful during activity. Symptoms frequently decrease strain through their reduced capacity to absorb or temporarily disappear after a proper muscle http://www.jabfm.org/ impact and eccentric loading. warm-up, probably due to a loosening of inflam­ Training practices that increase eccentric ten­ matory adhesions between the tendon and peri­ don loading, particularly when associated with tendinous sheath. 17 sudden changes in training, often lead to Achilles The physical examination may show tendon tendon injuries. Examples include increases in hill tenderness and thickening, overlying running and sprinting; changes to a harder run­ swelling, and crepitus. Pain is often reproduced ning surface; running on uneven terrain; running by rapidly dorsiflexing the foot, or by asking the on 28 September 2021 by guest. Protected copyright. on a high-traction, all-weather track; sudden patient to hop on one foot. Limited ankle dorsi­ mileage increases; resumption of training after a flexion due to a tight Achilles tendon is com­ break; and changes in running shoes. Overtrain­ mon. Flexibility can be measured by determin­ ing causes damage to immature, healing tendin­ ing the angle between the tibia of the maximally ous granulation tissue and depletes tendinous gly­ dorsiflexed ankle with the knee flexed and a ver­ cogen stores, which may diminish a muscle's tical line extended to the floor. This angle meas­ capacity to generate sufficient protective contrac­ ures 25 to 45 degrees in the normally flexible tile forces.4 person. 17 A palpable tendon defect suggests par­ Clement, et al. reviewed factors associated with tial or total tendon rupture. The Thompson Achilles tendinitis in 109 symptomatic runners.4 squeeze test is useful to help diagnose complete Training errors were apparent in 75 percent, mod­ tendon rupture. In this test, the examiner erate-to-severe hindfoot malalignment with hy­ "squeezes" the muscles and observes for perpronation was present in 56 percent, poor gas­ plantar flexion; an absence of plantar flexion trocnemius-soleus flexibility was noted in 39 indicates complete rupture. Localized tender-

198 The Journal of the American Board of Family Practice-Vol. 2 No. J I July - September 1989 J Am Board Fam Pract: first published as 10.3122/jabfm.2.3.196 on 1 July 1989. Downloaded from ness at the subcutaneous bursa or retrocalcaneal Achilles tendon, anteriorly by the deep flexor ten­ bursa suggests . dons, and inferiorly by the calcaneus, changes rel­ ative to the normal ankle in tendon rupture.20 The Toygar angle refers to an abnormal depression in Associated Conditions the normal, smooth tissue contour overlying the Achilles tendinitis does not exclusively affect ath­ Achilles tendon at the site of the ruptured letes.lts presence, especially in the absence of pre­ tendon. 10 disposing factors, should alert the physician to the Ultrasonography may help define the integrity possibility of other associated medical conditions. of an injured Achilles tendon. Electromyograms A high frequency of Achilles tendinitis has been have been used to detect the presence and loca­ reported among patients with several of the sero­ tion of partial tendon rupture.20 Magnetic reso­ 32 24 negative arthritides. - Fourteen to 31 percent of nance imaging, with its outstanding soft tissue patients with the Reiter syndrome have Achilles resolution, may help diagnose partial and total tendinitis; thus, the combination of Achilles ten­ Achilles tendon ruptures. dinitis and a urethral discharge should suggest the possibility of the Reiter syndrome. Achilles ten­ dinitis is noted in 7.5 to 8.6 percent of patients with , in 17 percent of those Several clinical conditions may mimic Achilles with psoriatic arthritis, and in 9 percent of per­ tendinitis. The following is a differential diagnosis sons with seronegative asymmetric oligoarthritis. of heel and lower leg pain: There is no apparent association between Achilles tendinitis and , osteoarthritis, 1. A calcaneal contusion is due to direct plantar 32 or spondylitis with ulcerative colitis. - 34 Achilles surface trauma, resulting in periosteal in­ tendinitis may also occur in elderly patients with flammation. Clinically, it is characterized by chondrocalcinosis secondary to calcium pyropho­ point tenderness on the plantar surface of the phate dihydrate crystal deposition within the calcaneus. tendon. 35 2. Plantar refers to an inflammation of Recurrent bouts of Achilles tendinitis in chil­ the plantar fascia, with resultant pain and dren may represent an initial manifestation of fa­ tenderness at the calcaneal insertion and milial type 11 hyperlipoproteinemia.36 The inflam­ along the longitudinal arch. mation is a result of xanthomas that form within 3. results from excessive 37

the extensor tendon sheaths. Pain may be so pressure on the bursa from a poorly padded http://www.jabfm.org/ severe during tendinitis attacks that affected chil­ shoe heel counter. The "bursal squeeze test" dren may be unable to walk. is positive if pain is produced when the examiner uses the thumb and finger to exert pressure on the bursa. Diagnosis 4. Subcutaneous bursitis ("pump bump") is also The diagnosis of Achilles tendinitis is usually due to excessive shoe heel counter pressure

made on the basis of the patient's history and the and often occurs in association with a promi­ on 28 September 2021 by guest. Protected copyright. physical examination. Radiographic examina­ nent posterior calcaneal angle. The overlying tions are most useful to rule out other causes of skin may become erythematous, thickened, such pain. The lateral view radiograph should and tender. provide easy visualization of the anterior and pos­ 5. Calcaneal stress fractures result from repetitive terior Achilles tendon margins. 38 Significant ten­ microtrauma, while complete calcaneal frac­ don thickening and calcification may be noted in tures occur only following severe trauma. chronic tendinitis. The lateral view radiograph of The diagnosis of fractures is made with the an acutely ruptured tendon may show retraction use of radiographs, radio nuclide bone scans, and interruption of musculotendinous tracts, soft or computerized tomography. tissue defects, tendon ossification, and fracture of 6. Rupture of the medial head of the gastrocnemius the at the junction of the Achilles ten­ commonly occurs in middle-aged athletes, don and calcaneus.39 The configuration of the presenting as a sudden stabbing pain in the Kager triangle on the lateral radiograph, which is proximal calf. The physical examination bordered posteriorly by the inner contour of the typically shows tenderness near the medial

Achilles Tendinitis 199 J Am Board Fam Pract: first published as 10.3122/jabfm.2.3.196 on 1 July 1989. Downloaded from gastrocnemius origin, a palpable muscle de­ shown the proper method of Achilles tendon fect, and reduced plantar flexion strength , which involves a constant, gentle (with an intact Thompson squeeze test). stretch to the tendon with the ankle in dorsiflex­ 7. Posterior tibial tendinitis () results ion and the knee both fully extended and slightly from inflammation of the posterior tibialis flexed. Complete rest 'of the tendon should be muscle and is characterized by pain and ten­ avoided to prevent further weakening. derness along the medial tibial border. The injured athlete should wann the affected 8. Tibial and fibular stress fractures are usually area before training and should apply ice after­ overuse fractures that exhibit bony point ten­ wards, except in the acute phase of injury when derness. The diagnosis is often continned heat should be avoided. Ultrasonic treatment with radiographs in chronic cases but typi­ often helps to reduce inflammation, but it may cally requires radionuclide bone scans to di­ exacerbate inflammation by disturbing local leu­ agnose acute injuries. kocytes. Nonsteroidal anti-inflammatory drugs 9. A occurs when lower may help reduce inflammation acutely, but they leg intracompartmental pressures increase, are less helpful for chronic injuries. resulting in cramping, pain, swelling, muscle Running shoes should be replaced when they weakness, and sensory loss. show excessive wear. Heel lifts of one-fourth to 10. Nerve entrapment of the medial branch of the three-eighths inch are added to both training and posterior tibial nerve may occur secondary to dress shoes to help reduce tendon stress. Medial shoe pressure. Symptoms include numbness heel wedges with finn heel counters and orthotic and pain in the distribution of the nerve. The devices may help correct hyperpronation in per­ diagnosiS is made with neurologic examina­ sons with hindfoot malalignment. tion or nerve conduction studies. Clement, et a1. treated 109 runners with Achil­ les tendinitis using gastrocnemius-soleus rehabili­ tation, control of pain and inflammation, and cor­ Treatment rection of biomechanical variables with orthotic Conservative devices. After 5 weeks of treatment, excellent re­ The initial management of Achilles tendinitis in­ sults were reported in 73 runners, good results in volves tendon rest. Weekly training mileage, 12, and fair results in only l. The remaining 23 sprint training, and hill training should be reduced athletes did not follow-up.4 to pennit healing of inflamed structures. The rec­ A retrospective study of runners with Achilles ommended amount of rest depends on the sever­ tendinitis showed that 92 percent noted improve­ http://www.jabfm.org/ ity and occurrence of pain experienced by the ment when ice was applied after training, 64 per­ athlete. Type I pain is defined as pain that is expe­ cent reported benefits from ultrasonic treatments, rienced only following activity. These athletes and 10 percent were helped by anti-inflammatory should reduce their training by 25 percent. Type II medications. Fifty-six percent of the runners pain occurs both during and after activity but does could not compete for at least 4 weeks, and 16 not restrict perfonnance. Treatment involves re­ percent noted a pennanent reduction in their competitive perfonnance level. IS ducing training mileage by 50 percent. Type III on 28 September 2021 by guest. Protected copyright. pain refers to pain during and after activity and Heel pads reduce the stretch on the Achilles ten­ does restrict perfonnance. These persons should don, and the use of visco-elastic polymer heel temporarily discontinue running. Type IV pain is wedges has been shown to reduce significantly chronic and unremitting and may require more the magnitude of heel strike force during walking aggressive therapy when conservative measures and running.41 Other studies have conflicting re­ fai1. 4o It is important during the rest phase of treat­ sults on the potential of such heel pads to treat 4 ment that a nonweight-bearing fonn of exercise Achilles tendinitis. 2,43 such as swimming, bicycling, or swimming-pool Rehabilitation of the injured Achilles tendon running be prescribed to help maintain aerobic should focus on stretching to increase the resting conditioning. length of the musculotendinous unit and on In addition to changes in training, the gastroc­ strengthening to increase tendon load-absorbing nemius-soleus musculotendinous unit must be capabilities. As a guideline, the tendon should be stretched to increase flexibility and strengthened exercised to the point of pain or discomfort in only to protect from future injury. Patients should be the last few repetitions of each set. This will insure

200 The Journal of the American Board of Family Practice-Vol. 2 No. 3 / July - September 1989 J Am Board Fam Pract: first published as 10.3122/jabfm.2.3.196 on 1 July 1989. Downloaded from that sufficient tendon loading occurs to produce the pronation phase in persons with excessive strengthening, while protecting the tendon from pronation.4 Running shoes should be replaced further injury. Curwin and Stanish reported im­ regularly before showing signs of excessive wear. provement in all 57 Achilles tendinitis patients Ideally designed running shoes have a wide, who completed an eccentric strengthening and flared heel and a well-cushioned heel counter. A stretching rehabilitation program.44 Fifty-four heel lift of 12 to 15 mm is recommended, and a percent experienced a complete resolution of medial heel wedge may help prevent hyperpro­ symptoms. Unfortunately, no control group nation. The sole should be cushioned to absorb was used. impact and to permit adequate flexibility at the Prolonged casting results in selective atrophy of metatarsophalangeal . Waffled soles may re­ type I muscle fibers, which limits its usefulness in duce the torsional stress transmitted from the treating Achilles tendinitis.45.46 Some authors, ground during the support phase.2 however, advocate its use for short periods when Running training mileage should be increased treating chronic tendinitis that has failed conser­ gradually, particularly after breaks in training. vative therapy.17 Sprint training, hill running, and track running must also be introduced into the runner's training program gradually. The majority of a runner's Surgical training should be done on level asphalt, dirt, Surgery may be appropriate for certain patients or cinder surfaces, because concrete sidewalks, with chronic Achilles tendinitis who wish to con­ banked streets, and tracks with tight turns predis­ tinue running but have not improved with exten­ pose to Achilles tendon injury. When an athlete sive conservative therapy. The most common sur­ begins to experience pain in the Achilles tendon, gical procedure involves exploring the tendon, an early reduction in training intensity is advised. tendon sheath, and mesotendon through a medial longitudinal incision. Inflamed, degenerated tis­ sues and calcifications are resected, adhesions are Partial lysed, and the tendon is inspected for partial rup­ Partial Achilles tendon rupture was thought to be ture. The retrocalcaneal bursa is examined and rare until Ljungqvist described 24 cases in 1968.20 resected if degeneration is noted. If a prominent Unlike total rupture, which tends to occur in mid­ superior calcaneal tubercle is noted to cause dle-aged, deconditioned persons, partial rupture chronic tendon irritation, an oseotomy may be commonly affects young, fully grown, well­ performed. 17.40,47.48 Postoperatively, the lower

trained athletes. Partial rupture usually results http://www.jabfm.org/ extremity is placed in a short leg cast for 3 to 6 from overtraining, but it may occur secondary to weeks, after which ,progressive weight-bearing, direct trauma. Pain is the most prominent symp­ stretching, and strengthening are prescribed. tom, occurring maximally during the push-off Leach and colleagues reported a series of 20 surgi­ phase of running. The onset of symptoms may be cal procedures on athletes with chronic symp­ gradual or sudden. Physical examination may toms. Achilles tenolysis was performed in 11, re­ show tendon tenderness, nodular tendon thicken­

moval of retrocalcaneal superior tuberosities in 6, ing, and a palpable tendon defect. The similarity on 28 September 2021 by guest. Protected copyright. resections of calcium in 3, and a combination of of symptoms with those of tendinitis often makes these procedures in the remaining athletes. All but the distinction difficult to make. Partial tendon one were eventually able to return to their desired rupture can be diagnosed with electromyographic levels of activity. 17 studies or with ultrasonography.20 Lateral ankle radiographs usually show soft tissue swelling. 30 Magnetic resonance imaging may prove to be a Prevention helpful diagnostic aid. Clement postulated that an increased awareness Conservative measures should be used initially of the importance of Achilles tendon stretching in the management of a minimal rupture. Such has reduced the frequency of Achilles tendinitis in treatment includes rest, tendon strapping, cryo­ runners today.4 Regular and proper heel cord therapy, and heel lifts. If conservative therapy fails stretching should be in the training regimen of or if rupture is extensive, surgery may be indi­ every athlete participating in running sports. cated. Denstad and Roaas repaired partially rup­ Orthotic shoe devices may be helpful in limiting tured tendons for 58 patients, 81 percent of whom

Achilles Tendinitis 201 J Am Board Fam Pract: first published as 10.3122/jabfm.2.3.196 on 1 July 1989. Downloaded from were athletes.3o Sixty-seven percent had noted a 5. Crafts RC. A textbook of human anatomy. New gradual onset of pain, 30 percent experienced York: Wiley and Sons, 1979:391-2. 6. Edwards DA. The blood supply and lymphatic sudden increases in pain associated with addi­ drainage of tendons. J Anatomy 1946; 80: 147-52. tional training, and II percent had a history of 7. Inglis AE, Scott WN, Sculco TP, Patterson AH. direct trauma to the tendon. Preoperatively, all Ruptures of the tendo achillis. An objective assess­ patients had localized tendon tenderness, all but 3 ment of surgical and non-surgical treatment. had localized swelling, and only 2 had a palpable J Bone Joint Surg 1976; 58:990-3. 8. Lea RB, Smith 1. Non-surgical treatment of tendo tendon defect. The procedure involved examina­ achiIlis rupture. J Bone Joint Surg 1972; 54: tion with splitting and excision of pathologic tis­ 1398-407. sue and closure of defects side-to-side. Postopera­ 9. Lagergren C, Lindholm A. Vascular distribution in tively, 86 percent of the patients were reportedly the Achilles tendon: an angiographic and mi· pleased with their results, and only 6.5 percent croangiographic study. Acta Chir Scand 1958; 30 116:491-5. were unsatisfied. 10. Amer 0, Lindholm A. Subcutaneous rupture of the Achilles tendon. Acta Chir Scand 1959; 239 (Suppl): 1-51. ., Summary 11. Gillespie HS, George EA. Results of surgical repair Achilles tendinitis is a common injury that af­ of spontaneous rupture of the Achilles tendon. J Trauma 1969; 9:247-9. fects athletes involved in running and jumping 12. Ralston EL, Schmidt ER Jr. Repair of the ruptured sports. The injury results from repetitive micro­ Achilles tendon. J. Trauma 1971; 11: 15-21. trauma caused by eccentric loading, which 13. Shields CL, Kerlan RK, Jobe FW, Carter VS, Lom­ stresses the tendon and peri tendinous struc­ bardo SJ .. The Cybex II evaluation of surgically tures. Histologically, Achilles tendinitis may be repaired Achilles tendon rupture. Am J Sports Med 1978; 6:369-72. due to peritendinitis, tendinosis, peritendinitis 14. Thompson TC, Doherty JH. Spontaneous rupture with tendinosis, or partial tendon rupture. of tendon of Achilles: a new clinical diagnostic Achilles tendinitis most commonly results from test. J Trauma 1962; 2: 126-9. training errors, including excessive running 15. Cummins EJ, Anson BJ, Carr BW, et al. The struc­ mileage, rapid increases in training intensity, ture of the calcaneal tendon (of Achilles) in rela­ tion to orthopaedic surgery. Surg Gynecol Obstet uphill running, sudden changes in running sur­ 1946; 83:107-16. faces, training on indoor tracks, and wearing 16. Barfred T. Experimental rupture of the Achilles poorly designed running shoes. Athletes with tendon. Comparison of various types of experi­ gastrocnemius-soleus inflexibility and weakness mental rupture in rats. Acta Orthop Scand 1971; 42:528-43.

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a medial heel wedge or motion-controlling or­ the Achilles tendon. Acta Orthop Scand 1967; on 28 September 2021 by guest. Protected copyright. thotic may be helpful. Surgery is considered for 113(Suppl):1-86. athletes with partial tendon rupture or chronic 21. Smart GW, Taunton JE, Clement DB. Achilles ten­ tendinitis that is refractory to conservative don disorders in runners-a review. Med Sci Sports Exerc 1980; 12:231-43. therapy. 22. Bates BT, Osternig LR, Mason B, James LS. Foot orthotic devices to modify selected aspects of lower extremity mechanics. Am J Sports Med References . 1979; 7:338-42. 1. Morford M, Lenardon iu. Classical mythology. 23. Wrenn RN, Goldner JL, Markee J1. An experi­ New York: Longman Inc., 1985:3329-35. mental study of the effect of on the heal· 2. James SL, Bates BT, Ostemig LG. Injuries to run­ ing process and tensile strength of tendons. J Bone ners. Am J Sports Med 1978; 6:40-50. Joint Surg 1954; 36A: 588-60 1. 3. Krissoff WB, Ferris WD. Runners' injuries. Physi­ 24. Kennedy JC, Willis RB. The effects of local steroid cian Sports Med 1979; 7:55-64. injections on tendons: a biomechanical and micro­ 4. Clement DB, Taunton JE, Smart GW. Achilles ten­ scopic correlative study. Am J Sports Med 1976; dinitis and peritendinitis: etiology and treatment. 4:11-21. Am J Sports Med 1984; 12: 179-84. 25. Noyes FR, Nussbaum NS, Torvis Pl, Cooper S.

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