Achilles Tendon Pain (Achillodynia): Causes

Pathogenesis (development of disease)

The most common cause of Achillodynia is chronic misuse or overuse due primarily to sports activities (running and jumping sports). For example, an athlete’s jumping motion results in intense tensile stress on the Achilles tendon, particularly on one side. The high stress can cause microdamage (microruptures/microtears) to the tendon, which is often localized in its center (two to six centimeters above the calcaneal attachment). Because this area of the Achilles tendon is inherently poorly perfused (“watershed” area), the injuries do not heal well. Thus, local inflammation may occur. If the stress is continued or if the recovery periods are too short, the microdamages can accumulate (build up). In the long term, degenerative changes occur in and around the Achilles tendon (tendinosis), which can also affect the paratenon (loose fibrous connective tissue that coats the collagen fibers of a tendon on the outside; Achilles tendon gliding tissue). As a result, the typical thickening of the Achilles tendon occurs. In addition, neovascularization (new blood vessels forming in the affected tissue) is possible, which is partly responsible for the pain. The resistance of the Achilles tendon to stress depends on several factors: Age of the athlete (collagenous connective tissue weakens with age), training condition, possible previous damage to the Achilles tendon, and the general metabolic situation (hyperuricemia/increased blood uric acid levels, hyperlipoproteinemia/fatty metabolism disorders).

Etiology (causes)

Biographic causes

  • Anatomic variants – leg length discrepancy (mostly due to leg shortening), pes cavovarus (hollow foot).

Behavioral causes

  • Physical activity
    • Chronic misuse/overuse of sports activities:
      • Sports that involve a lot of running and jumping or rapid acceleration and deceleration – track and field athletes are especially affected, but so are athletes in other running and jumping sports (e.g., ballet, tennis, squash, soccer, volleyball, handball, basketball, badminton)
        • With are decisive:
          • Frequency and duration of the load, training intensity, duration of the regeneration phases.
          • Surface – a hard floor is unfavorable.
          • Outdoor temperatures – too cold is unfavorable
          • Footwear – the anatomy of the foot must be taken into account.
        • Especially longer unaccustomed sports activities favor micro-ruptures (micro-tears) at the Achilles tendon
  • Overweight (BMI ≥ 25; obesity).

Disease-related causes

  • Achilles tendon insertion tendinosis* – non-inflammatory tendon insertion disease of the Achilles tendon.
  • Axis deviation (axis deviation) of the lower leg.
  • Apophysitis calcanei* – disease of the growth plate of the calcaneus (calcaneal apophysis); symptomatology: tenderness and swelling in the area of the growth plate of the calcaneus; peak of disease 5-12 years of age; boys are more often affected than girls [heel pain].
  • Arthritides (inflammatory joint diseases) of the ankle joint.
  • Arthritis urica (gout)
  • Osteoarthritis of the ankle joint
  • Diabetes mellitus
  • Bursitis subachillea* (bursitis in the ankle joint; the affected bursa is located between the Achilles tendon and the calcaneus).
  • Bursitis subcutanea calcanea* (bursitis at the Achilles tendon).
  • Heel spur
  • Foot deformities – e.g. high arch, flat foot, flat foot, flat splayfoot.
  • Gout
  • Haglund deformity (Haglund heel) – bony form variant of the calcaneus with accentuated prominence of the proximal tuber calcanei (calcaneal tuberosity); painful swelling [heel pain].
  • Hallux rigidus (synonyms: Osteoarthritis of the metatarsophalangeal joint; metatarsophalangeal joint stiffness; hallux non extensus; hallux flexus; hallux limitus; wear and tear of the metatarsophalangeal joint) – arthritic changes in the metatarsophalangeal joint that has become stiff.
  • Internal rotation defect of the hips
  • Capsular ligament insufficiency of the external ligament of the upper ankle joint (OSG).
  • Bone diseases
  • Cartilage damage to the upper/lower ankle joint (OSG/USG).
  • After a partial rupture (partial tear) of the Achilles tendon.
  • Os trigonum impingement syndrome* (constriction of the tendon structure in the ankle joint due to an additional bone of the ankle bone (Os trigonum)).
  • Osteochondrosis dissecans* – circumscribed aseptic bone necrosis below the articular cartilage, which can end with the rejection of the affected bone area with the overlying cartilage as a free joint body (joint mouse).
  • Paratenonitis crepitans achillea – aseptic inflammation of the tendon gliding tissue of tendons without tendon sheath.
  • Partial Achilles tendon rupture – partial rupture of the Achilles tendon.
  • Metabolic disorders lead to permanent irritation of the tendon tissue due to deposits of fats or crystals:
    • Cerebrotendinous xanthomatosis (CTX)* (HLA-B 277) – genetic disorder with autosomal recessive inheritance; lipid storage disease; first clinical symptom cholestasis and/or chronic diarrhea in infancy; between the ages of 20 and 40, xanthomas may appear on the Achilles tendon, among other sites (due to increased storage of plasma lipoproteins).
    • Hyperlipoproteinemias (lipid metabolism disorders): hypercholesterolemia, hypertriglyceridemia.
    • Hyperuricemia (gout)
  • Stress fracture*
  • Tendopathy of the medial malleolus* (non-inflammatory disease of the tendons due to overuse, misuse or wear).

* pseudo-axillodynia

Laboratory diagnoses – laboratory parameters that are considered independent risk factors.

  • Hypercholesterolemia
  • Hypertriglyceridemia
  • Hyperuricemia

Medication

  • Aromatase inhibitors
  • Cortisone; glucocorticoids
  • Fluoroquinolone antibiotics

Operations

  • After external ligament injury of the upper ankle joint (OSG) with capsular ligament suture.
  • After surgery on the Achilles tendon.