Achilles Tendon

The Achilles tendon, also referred to as the calcaneal tendon, is the thickest tendon in the human body and is located in the rear of the lower leg. It connects the plantaris, soleus and gastrocnemius (calf) muscles to the calcaneus (heel) bone. Such muscles produce plantar flexion of the foot at the ankle joint, as well as flexion of the knee (excluding the soleus).

Inflammation (Achilles tendinitis), degeneration, breakage, and getting encrusted with cholesterol deposits are all problems of the Achilles tendon (xanthomas). The Achilles tendon was called after Achilles, the Greek warrior, in 1693.

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Structure

The Achilles tendon, just as other tendons, links muscle to bone and is found at the rear of the lower leg. The gastrocnemius and soleus muscles are connected to the calcaneal tuberosity on the calcaneus through the Achilles tendon (heel bone). The tendon starts at the middle of the calf and collects muscle fibres on its inner surface, especially from the soleus muscle, mostly all the way to the bottom. It goes into the middle section of the rear of the calcaneus bone, progressively thinning downwards. At its lower end, the tendon stretches out a little, with the narrowest section around 4 cm (1.6 in) above the insertion.

The tendon is hidden below the bone and is wrapped by fascia and skin; the gap is filled using adipose and areolar tissue. Between the tendon and the top section of the calcaneus is a bursa. It measures about 15 cm (6 inches) in length. The little saphenous vein runs all along the edge of the muscle and is proximal to it. The sural nerve travels inferolateral to the little saphenous vein as it lowers in the posterior leg, crossing the lateral boundary of the Achilles tendon. The tendon is the human body's thickest tendon. Walking causes load stress of 3.9 times body weight, and running causes load stress of 7.7 times body weight.

The Achilles tendon has a low blood supply, with almost all coming from a recurrent branch of the posterior tibial artery and a few from arterial branches going via surrounding muscles.

Function

The soleus and gastrocnemius muscles act on the Achilles tendon to generate plantar flexion of the foot there at the ankle.  The bottom of the foot is brought closer to the back of the leg by this action. The gastrocnemius is also responsible for knee flexion. 

The tibial nerve supplies innervation to both muscles. Fibres from the gastrocnemius prefer to connect to the outer half of the bone, while fibres from the soleus likely to connect nearer to the midline, due to the tendon's 90-degree spiralling. Without eyesight, tendon vibration seems to have a significant impact on postural orientation. 

In standing subjects, the vibration of the tendo calcaneus tendon generates movement backwards and the perception of the forward body tilt. Since vibrations trigger muscle spindles throughout the calf muscles, this is the case. The central nervous system adjusts by shifting the body backwards once the muscle spindles warn the brain that now the body is going forward.

Clinical Significance

Achilles Tendon Inflammation

In this case, Achilles tendonitis treatment is preferred. Achilles tendinitis is a condition where the inflammation of the Achilles tendon occurs. Achilles tendon inflammation is the pain or stiffness of the tendon, which is exacerbated by exercise and is caused by overuse. Pain and swelling around the damaged tendon are the most prevalent symptoms. The pain is usually stronger at the beginning of an activity session and lessens as time goes on. Ankle stiffness is also a possibility. In most cases, the onset is slow.

Overuse, including running, is a common cause of it. Trauma, a sedentary lifestyle, high-heeled shoes, rheumatoid arthritis, and drugs in the fluoroquinolone or steroid classes are also risk factors. Symptoms and inspection are usually used to make a diagnosis.

Despite stretching and back-strengthening activities frequently suggested for prevention, there is little data to back them up. Ice, rest, nonsteroidal anti-inflammatory drugs (NSAIDs), and physical therapy are common treatments. A heel lift or orthotics could be beneficial as well. Surgery could be recommended if symptoms persist for more than six months despite alternative therapies. Achilles tendonitis treatment can be easily found as it is a common condition.

Degeneration

MRI or ultrasound are commonly used to investigate Achilles tendon deterioration (tendinosis). The tendon is thickened in each of these situations, and the existence of retrocalcaneal, paratenonitis or retro-Achilles bursitis might cause surrounding inflammation. Tendon fibril disorganisation, Elevated blood flow, and partial thickness rips can all be found within the tendon. Tendon torn usually affects the middle of the tendon, but it can also affect the insertion, which is termed enthesopathy. Though enthesopathy is commonly connected with ageing, it is also linked to arthritis, like gout and seronegative spondyloarthritis. Calf muscle tears are believed to be linked to Achilles tendinosis.

Rupture

The rupture of the Achilles tendon occurs when the tendon splits/breaks. The abrupt development of intense pain in the heel is one of the indications. As the tendon fractures and walking gets harder, a snapping sound might be heard.

A rapid twisting up of the foot when the calf muscle is involved, direct trauma, or long-term tendonitis are the most common causes of rupture. Fluoroquinolone use, a considerable alteration in exercise, gout, rheumatoid arthritis, or corticosteroid use are all possible causes. Symptoms and inspection are usually used to make a diagnosis, which is then backed up by medical imaging. Achilles tendon rupture affects roughly one out of every 10,000 persons each year. Men are more likely than females to be afflicted. People in their 30s and 50s are particularly vulnerable.

Stretching before an activity can help prevent injuries. Surgery or a cast with the toes pointed down could be used to treat the condition. Returning to weight-bearing quite quickly (within 4 weeks) looks to be fine. With casting, there is a 25% chance of re-rupture. If proper treatment is not received within four weeks of the injury, the outcome is less favourable.

Xanthomas

Tendon xanthomas are cholesterol aggregates that form in the tendo Achilles rupture of persons who have lipid metabolic problems including familial hypercholesterolemia.

Neurological Exam 

A neurological examination frequently includes an evaluation of the Achilles' tendon. A tendon hammer is used to strike the tendon during this examination. Plantar flexion (downward movement) of the foot is a natural reaction to this examination of the S1 and S2 spinal neurons.

Level or Portion of Tendon Affected

• Insertional - Overuse injury is a common occurrence among running and jumping sportsmen. Patients with insertional Achilles tendinopathy experience discomfort on the back of their heels, and also morning stiffness, edema with activity, and discomfort at the tendon's insertion point.

• Paratendinopathy - A connective tissue sleeve that covers the tendon and defends it from friction, irritation, and recurrent stress is inflamed.

• Mid-Portion: The Achilles tendon insertion into the calcaneus is roughly 2–7 cm away. This level is characterised by a combination of discomfort and edoema. It has been linked to a significant drop in performance.