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Achilles tendon pathology, present and future
  1. Professor N Maffulli
  1. Centre for Sport & Exercise Medicine, Queen Mary, University of London


Lecture 18

Introduction The recent progress in molecular biology, could make possible to identify the factors which influence the metabolism of the tenocytes and promote their natural healing process. The role of growth factors in the healing of tendons, for example, is still unclear, although basic fibroblast growth factor can stimulate healing by promoting cell proliferation and synthesis of the matrix. Gene transfer for the targeted delivery of growth factors has been used successfully in animal studies. Excessive repetitive overload of tendons is regarded as the main pathological stimulus which leads to tendinopathy. The aetiology of this pathologic condition remains unclear. Tendinopathies have been linked to overuse, poor vascularity, lack of flexibility, genetic make-up, gender, endocrine or metabolic factors. Excessive loading of the tendon during vigorous physical training is regarded as the main pathological stimulus. The tendon may respond to repetitive overload beyond physiological threshold by either inflammation of its sheath or degeneration of its body, or by a combination of both. Damage to the tendon can occur even if it is stressed within its physiological limits since frequent cumulative microtrauma may not leave enough time for repair. Microtrauma can result from non-uniform stress within tendons producing abnormal concentrations of load within the tendon, frictional forces between the fibrils, and localised damage to fibres. Tendinopathy has been attributed to a variety of intrinsic and extrinsic factors. Vascularity, dysfunction of the gastrocnemius-soleus, age, gender, bodyweight and height, are considered to be common intrinsic factors. Changes in training pattern, poor technique, previous injuries are common extrinsic factors which may predispose the athlete to tendinopathy. The aetiology of pain in tendinopathies is still unclear. Management of tendinopathy can be conservative or surgical, but this is recommended after exhausting periods of conservative management, often lasting for at least 6 months. Conservative management is unsuccessful in 24–45.5% of patients with tendinopathy of Achilles tendon. Failure of conservative management after 6 months is an indication for surgery. Surgery may range from percutaneous longitudinal tenotomy to various open procedures. Long-standing tendinopathy, however is associated with poor results after operation, with a greater rate of reoperation before an acceptable outcome is obtained.

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