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TC(1023).(05).Orthopedics Case No 101:- Achilles Tendinitis / Achilles Tendinopathy

Achilles Tendinitis / Achilles Tendinopathy — বাংলা Clinical Note

গুরুত্বপূর্ণ: Achilles tendinitis-এ অনেক সময় “inflammation” কম, বরং tendon degeneration/failed healing বেশি থাকে—তাই chronic case-এ সঠিক term হলো Achilles tendinopathy। Treatment-এর core হলো activity modification + tendon-loading exercise; medicine শুধু pain control/supportive. 2024 JOSPT CPG-তে midportion Achilles tendinopathy-এর জন্য tendon loading exercise first-line বলা হয়েছে।

1. Definition — সংজ্ঞা

Achilles tendinitis/tendinopathy হলো heel-এর পিছনে calf muscle থেকে calcaneus bone-এ লাগা Achilles tendon-এর pain, stiffness, swelling বা degeneration।

দুই ধরন

  1. Mid-portion Achilles tendinopathy
    • Heel bone থেকে প্রায় 2–6 cm উপরে pain/tenderness।
  2. Insertional Achilles tendinopathy
    • Tendon যেখানে calcaneus-এ attach করে, ঠিক সেই জায়গায় pain।
    • Calcaneal spur / Haglund deformity থাকতে পারে।

2. Causes / Etiology & Pathophysiology — কারণ

Common causes — পয়েন্ট আকারে

  1. Overuse / sudden load increase
    • হঠাৎ বেশি হাঁটা, দৌড়ানো, jumping, stair climbing।
    • Gym/football/cricket/running-এ intensity দ্রুত বাড়ানো।
  2. Tight calf muscle
    • Gastrocnemius–soleus tight হলে Achilles tendon-এ traction stress বাড়ে।
  3. Poor footwear
    • Hard sole, worn-out shoe, no heel support।
    • Barefoot hard floor-এ বেশি হাঁটা।
  4. Biomechanical problem
    • Flat foot / overpronation।
    • High arch।
    • limb alignment সমস্যা।
  5. Age-related tendon degeneration
    • বয়স বাড়লে tendon collagen quality কমে।
  6. Obesity / overweight
    • tendon load বেশি পড়ে।
  7. Systemic disease
    • Diabetes mellitus, hypercholesterolaemia, rheumatoid arthritis—tendon quality খারাপ করতে পারে। Achilles tendinopathy-এর risk multifactorial; overweight, diabetes, RA, hypercholesterolaemia, fluoroquinolone use risk factor হিসেবে রিপোর্টেড।
  8. Drug-induced
    • Fluoroquinolone antibiotics: ciprofloxacin, levofloxacin, moxifloxacin।
    • Systemic corticosteroid long-term use।
    • Fluoroquinolone-এর সঙ্গে tendon rupture risk-এর FDA black-box warning আছে; steroid use/age >60 হলে risk বেশি।

3. Symptoms — লক্ষণ

  1. Heel-এর পিছনে pain
    • হাঁটা, দৌড়ানো, stair climbing করলে বাড়ে।
    • Rest নিলে কিছুটা কমে।
  2. Morning stiffness
    • সকালে ঘুম থেকে উঠে heel/ankle শক্ত লাগে।
    • হাঁটাহাঁটি করলে কিছুটা loosen হয়।
  3. Tenderness
    • Achilles tendon চাপ দিলে ব্যথা।
  4. Swelling / thickening
    • tendon মোটা বা ফুলে যেতে পারে।
  5. Activity-related pain
    • শুরুতে exercise-এর শুরুতে pain, warm-up পরে কমে, পরে আবার বাড়ে।
  6. Insertional type
    • জুতার heel counter লাগলে pain বাড়ে।
    • calcaneus-এর পেছনে bony prominence থাকতে পারে।

4. Clinical Diagnosis — কীভাবে clinically diagnosis করবেন

Achilles tendinopathy সাধারণত clinical diagnosis। Imaging সব রোগীর লাগে না।

Specific clinical points

  1. Inspection
    • swelling, redness, tendon thickening, Haglund deformity দেখবেন।
  2. Palpation
    • Midportion: calcaneal insertion থেকে 2–6 cm উপরে tenderness।
    • Insertional: calcaneus insertion site-এ tenderness।
  3. Painful single-leg heel raise
    • রোগী affected leg-এ দাঁড়িয়ে heel raise করলে pain/weakness।
  4. Royal London Hospital Test
    • ankle relaxed অবস্থায় tendon palpation করলে pain থাকে।
    • ankle dorsiflex করলে tenderness কমে যেতে পারে—Achilles tendinopathy suggestive।
  5. Painful Arc Sign
    • tendon-এর nodular swelling ankle movement-এর সঙ্গে move করলে tendinopathy suggestive।
  6. Thompson/Simmonds test — rupture exclude করার জন্য
    • Patient prone, calf squeeze করলে ankle plantarflexion না হলে Achilles rupture suspect।
    • rupture হলে urgent orthopaedic referral।

5. Investigations — specific indication সহ

1) X-ray ankle / calcaneus lateral view

কখন করবেন:

  • Insertional pain
  • bony spur suspect
  • Haglund deformity
  • calcific enthesopathy
  • chronic heel pain

কী দেখা যায়:

  • calcaneal spur
  • Haglund prominence
  • calcification at insertion

2) Ultrasonography — first-line imaging if needed

কখন করবেন:

  • diagnosis unclear
  • tendon thickening/partial tear suspect
  • persistent symptoms
  • dynamic assessment দরকার

কী দেখা যায়:

  • tendon thickening
  • hypoechoic degenerative area
  • neovascularity on Doppler
  • partial tear/fluid

3) MRI ankle

কখন করবেন:

  • partial tear/rupture সন্দেহ
  • surgery planning
  • symptoms >3–6 months despite treatment
  • atypical pain
  • mass/infection/tumour differential

কী দেখা যায়:

  • intratendinous degeneration
  • partial tear
  • retrocalcaneal bursitis
  • marrow oedema
  • insertional pathology

4) Blood tests — selected case only

Routine দরকার নেই।
কিন্তু recurrent/bilateral/atypical হলে:

  • HbA1c — diabetes
  • Lipid profile — hypercholesterolaemia
  • ESR/CRP — inflammatory disease/infection suspect
  • Serum uric acid — gout differential
  • RF/anti-CCP — RA suspect

6. Differential Diagnosis

  1. Achilles tendon rupture
  2. Retrocalcaneal bursitis
  3. Haglund deformity
  4. Calcaneal stress fracture
  5. Plantar fasciitis
  6. Posterior ankle impingement
  7. Sural nerve entrapment
  8. Inflammatory enthesitis — spondyloarthritis
  9. Gout / rheumatoid arthritis
  10. Infection — rare but red flag if fever/redness/severe swelling

7. Complications — বাংলায় সহজভাবে

  1. Chronic pain
    • ঠিকমতো rest + rehab না করলে ব্যথা মাসের পর মাস থাকতে পারে।
  2. Tendon degeneration
    • tendon-এর collagen structure দুর্বল হয়ে যায়।
  3. Partial tear
    • tendon-এর কিছু অংশ ছিঁড়ে যেতে পারে।
  4. Complete Achilles rupture
    • হঠাৎ “pop” শব্দ/অনুভূতি, হাঁটতে কষ্ট, heel raise impossible।
    • জরুরি orthopaedic referral লাগে।
  5. Reduced sports/work capacity
    • দৌড়ানো, jumping, stairs, long standing difficult হয়ে যায়।
  6. Abnormal gait
    • pain avoid করতে গিয়ে হাঁটার pattern বদলে knee/hip/back pain হতে পারে।

8. Treatment / Management — Guideline-based

A. Non-pharmacological treatment — main treatment

Acute painful phase: first 1–2 weeks

  1. Relative rest
    • সম্পূর্ণ bed rest না; painful running/jumping বন্ধ।
    • pain-free walking allowed.
  2. Ice
    • 15–20 মিনিট, দিনে 2–3 বার।
  3. Heel lift
    • shoe-এর ভিতরে heel raise/heel lift দিলে tendon tension কমে।
  4. Footwear modification
    • soft heel counter, cushioned shoe, hard barefoot walking avoid.
  5. Avoid
    • hill running
    • sprinting
    • jumping
    • sudden stair climbing
    • deep calf stretching in acute insertional pain

AAOS Achilles tendinitis management-এ ice, NSAIDs, physical therapy, supportive footwear/orthotics/heel lift ইত্যাদি conservative care উল্লেখ করে।

B. Exercise therapy — core treatment

Midportion tendinopathy

  1. Eccentric heel-drop / progressive calf loading
    • supervised physiotherapy ভালো।
    • সাধারণভাবে 12 weeks programme লাগে।
    • Alfredson eccentric calf training chronic Achilles tendinosis-এ classic evidence-based protocol।
  2. Heavy slow resistance training
    • eccentric training-এর মতোই benefit দিতে পারে; 2015 RCT-তে ECC ও HSR দুইটাই sustained clinical improvement দিয়েছে।

Insertional tendinopathy

  • Deep dorsiflexion heel drop initially avoid।
  • Flat ground heel raise, isometric calf raise, gradual loading।
  • Compression কমানো গুরুত্বপূর্ণ; insertional case-এ compression-reducing programme evidence-supported।

C. Advanced options — specialist/orthopaedic/physiatry

  1. ESWT — Extracorporeal shockwave therapy
    • chronic case, 3 months+ persistent pain।
    • Exercise + ESWT অনেক ক্ষেত্রে better outcome দিতে পারে।
  2. PRP injection
    • evidence mixed; routine first-line নয়।
  3. Corticosteroid injection
    • Achilles tendon-এর ভিতরে steroid injection generally avoid; rupture risk বাড়াতে পারে।
  4. Surgery
    • 6 months+ proper conservative treatment ব্যর্থ হলে।
    • debridement, calcaneal spur/Haglund correction, tendon repair depending pathology।

9. Pharmacological Treatment — Bangladesh prescription pattern

Core rule: Achilles tendinopathy-এর medicine হলো short-term pain control। Antibiotic লাগে না, unless infection. Oral steroid routine নয়. NSAID একসাথে দুইটা দেওয়া যাবে না।

Common prescription approach in Bangladesh

  1. Mild pain: Paracetamol
  2. Local pain/swelling: Topical diclofenac gel
  3. Moderate pain: One oral NSAID — naproxen / aceclofenac / ibuprofen / etoricoxib
  4. Gastric risk থাকলে: PPI — esomeprazole/pantoprazole
  5. Main treatment: physiotherapy + loading exercise

10. Drug List — Generic, Class, Dose, Brand, Side effect, Interaction

1) Paracetamol

বিষয়তথ্য
Generic nameParacetamol
Therapeutic categoryAnalgesic, antipyretic
Pharmacological classPara-aminophenol derivative; central COX inhibition
PurposePain কমাতে; inflammation কমানোর প্রধান drug নয়
Adult dose500–1000 mg PO every 6–8 hours PRN
Max doseসাধারণভাবে 3 g/day নিরাপদ সীমা; physician supervision ছাড়া 4 g/day avoid
Duration3–5 days PRN
Bangladesh brandsNapa 500 mg, Ace 500 mg, Reset 500 mg, Renova 500 mg; Medex-এ these products Paracetamol 500 mg হিসেবে listed।
Side effectsnausea, rash; overdose → severe hepatotoxicity
Interactionalcohol/liver disease → liver injury risk; warfarin long-term high dose → INR effect possible

2) Diclofenac topical gel

বিষয়তথ্য
Generic nameDiclofenac Sodium topical gel
Therapeutic categoryTopical analgesic / anti-inflammatory
Pharmacological classNSAID; COX inhibitor
PurposeLocal pain, swelling, tenderness কমাতে; systemic side effect কম
Dose2–4 g affected area-তে দিনে 3–4 বার apply
Duration7–14 days; broken skin-এ নয়
Bangladesh brandsDiclofen 1% gel, Clofenac 1% gel, DicloGel 1%, Voligel 1%, Voligel Max 2%, Volifen 1%, Voltagel 1%; Medex diclofenac gel brands listed করেছে।
Side effectslocal burning, rash, itching, photosensitivity
Interactionoral NSAID একসাথে নিলে systemic NSAID burden বাড়তে পারে; anticoagulant patient সতর্ক

3) Naproxen / Naproxen Sodium

বিষয়তথ্য
Generic nameNaproxen / Naproxen Sodium
Therapeutic categoryAnalgesic, anti-inflammatory
Pharmacological classNSAID; non-selective COX inhibitor
Purposemoderate pain + inflammatory flare কমাতে
Adult dose250–500 mg PO twice daily after meal
Duration5–7 days; chronic continuous use avoid
Bangladesh brandsNaproxen 500 mg, Naproxin 250/500 mg, Naspro 500 mg, Nax-N 250/500 mg, Naxin 250/500 mg, Naxo 500 mg, Releve 500 mg; Medex Naproxen brands listed করেছে।
Side effectsgastritis, dyspepsia, GI bleeding, renal injury, BP rise
Interactionaspirin/warfarin/clopidogrel/steroid/SSRI → bleeding risk; ACEi/ARB + diuretic → AKI risk; lithium/methotrexate toxicity

Naproxen + Esomeprazole combination

বিষয়তথ্য
GenericNaproxen Sodium + Esomeprazole Magnesium
UseNSAID দরকার কিন্তু gastric protection দরকার হলে
Dose500 mg + 20 mg once/twice daily depending severity; physician-directed
BrandsNaxipraz 500+20 mg, Naxivo 500+20 mg, Naxsil E 375+20 mg; Medex listed।

4) Aceclofenac

বিষয়তথ্য
Generic nameAceclofenac
Therapeutic categoryAnalgesic, anti-inflammatory
Pharmacological classNSAID; COX inhibitor
Purposepain + inflammation control; tendon disease cure করে না
Adult dose100 mg PO twice daily after meal
Duration3–5 days; বেশি হলে reassessment
Bangladesh brandsAvenac 100 mg, Celofen 100 mg, Reservix 100 mg, Vaxtin 100 mg, Aros 100 mg, Preservin SR 200 mg, Ufenac SR 200 mg; Medex aceclofenac brands listed।
Side effectsdyspepsia, gastritis, GI bleeding, renal impairment, edema
Interactionanticoagulant/antiplatelet/steroid/SSRI → GI bleed; ACEi/ARB/diuretic → renal risk; other NSAID avoid

5) Etoricoxib

বিষয়তথ্য
Generic nameEtoricoxib
Therapeutic categoryAnalgesic, anti-inflammatory
Pharmacological classSelective COX-2 inhibitor NSAID
Purposemoderate pain; gastric irritation তুলনামূলক কম, কিন্তু CV/BP risk বেশি হতে পারে
Adult dose60 mg PO once daily; severe acute painে 90 mg short course physician-directed
Duration3–5 days; lowest effective dose
Bangladesh brandsOricox 30/60/90/120 mg, Recox 60/90/120 mg, Ribox 60/90/120 mg, Rito 60/90/120 mg, Etovan 60/90/120 mg, Fabetor 60/90/120 mg; Medex etoricoxib brands listed।
Side effectsBP rise, edema, dyspepsia, renal impairment, CV event risk
Interactionwarfarin → INR/bleeding risk; ACEi/ARB/diuretic → renal risk; uncontrolled HTN/IHD/stroke history হলে avoid/caution

6) Ibuprofen

বিষয়তথ্য
Generic nameIbuprofen
Therapeutic categoryAnalgesic, antipyretic, anti-inflammatory
Pharmacological classNSAID; non-selective COX inhibitor
Purposemild–moderate pain, inflammatory pain
Adult dose400 mg PO 2–3 times daily after meal
Duration3–5 days
Bangladesh brandsFlamex 200/400 mg, Profen 400 mg, Reumafen 200/400 mg, Inflam 400 mg, G-Ibuprofen 400 mg, Iburex 400 mg; Medex ibuprofen brands listed।
Side effectsgastritis, nausea, GI bleed, renal impairment, bronchospasm in NSAID-sensitive asthma
Interactionaspirin-এর antiplatelet effect কমাতে পারে; anticoagulant/steroid/SSRI → bleed; ACEi/ARB/diuretic → AKI

7) Esomeprazole — gastric protection

বিষয়তথ্য
Generic nameEsomeprazole
Therapeutic categoryAnti-ulcerant
Pharmacological classProton pump inhibitor, PPI
PurposeNSAID-induced gastritis/ulcer risk কমাতে; Achilles disease cure করে না
Adult dose20 mg PO once daily, breakfast-এর 30–60 min আগে
DurationNSAID course চলাকালীন 5–14 days; high-risk patientে physician-directed
Bangladesh brandsNexum 20/40 mg, Esotid 20/40 mg, Esoral 20/40 mg, Exor 20/40 mg, Nexe 20 mg, Eprazol 20 mg; Medex esomeprazole brands listed।
Side effectsheadache, nausea, diarrhea/constipation; long-term → hypomagnesemia, B12 deficiency risk
Interactionclopidogrel-এর effect কমতে পারে—especially omeprazole/esomeprazole; warfarin/antiepileptic patient caution

11. কোন drug কবে দেবেন — practical prescription logic

Mild pain

  • Paracetamol 500 mg PRN
  • সঙ্গে ice + heel lift + activity modification

Local tendon pain/swelling

  • Diclofenac gel 1% local apply
  • oral NSAID না দিলেও চলতে পারে

Moderate pain / walking difficulty

  • একটি NSAID বেছে নিন: Naproxen or Aceclofenac or Ibuprofen or Etoricoxib
  • একই সাথে দুই NSAID নয়।

Gastric risk থাকলে

  • NSAID-এর সাথে Esomeprazole 20 mg OD short course

Avoid

  • Routine antibiotic
  • Routine oral steroid
  • Tendon-এর ভিতরে steroid injection
  • Fluoroquinolone antibiotic, especially older age/steroid user/previous tendon problem

12. Red flags — urgent referral

  1. Sudden pop sound + severe pain
  2. Heel raise করতে না পারা
  3. Thompson test positive
  4. Rapid swelling/bruising
  5. Fever/red hot swelling — infection suspect
  6. Pain after fluoroquinolone use
  7. Diabetes/immunosuppression with severe swelling
  8. Symptoms >3 months despite proper rehab

13. Prevention — কীভাবে প্রতিরোধ করবেন

  1. Exercise intensity weekly 10% এর বেশি না বাড়ানো
  2. Running/jumping-এর আগে warm-up
  3. Regular calf strengthening
  4. Tight calf হলে gentle stretching
  5. Proper cushioned footwear
  6. Hard floor barefoot walking avoid
  7. Obesity control
  8. Diabetes/lipid control
  9. Previous tendinopathy থাকলে fluoroquinolone antibiotic avoid if alternative available
  10. Pain শুরু হলে “push through pain” না করে load কমানো

Overview / Summary

Achilles tendinitis/tendinopathy হলো Achilles tendon-এর overuse-related pain, stiffness ও degeneration। Diagnosis বেশিরভাগ ক্ষেত্রে clinical—posterior heel pain, morning stiffness, tenderness, painful heel raise। Investigation দরকার হয় atypical, chronic, rupture/partial tear suspect, insertional calcification বা surgery planning হলে। Treatment-এর মূল হলো relative rest, heel lift, footwear correction, physiotherapy, progressive tendon loading/eccentric exercise। Medicine শুধু short-term pain control—paracetamol, topical diclofenac, short-course NSAID ± PPI।

Actionable Plan / Steps

  1. Pain scale + site identify করুন: midportion নাকি insertional।
  2. Rupture exclude করুন: Thompson test, single-leg heel raise।
  3. First 1–2 weeks: painful activity stop, ice, heel lift, topical NSAID/paracetamol।
  4. Moderate pain: one oral NSAID 3–7 days + PPI if gastric risk।
  5. Start rehab: supervised calf isometric → eccentric/progressive loading for 12 weeks।
  6. No improvement 6–12 weeks: US/MRI + physiatry/orthopaedic referral।
  7. Chronic >3–6 months: ESWT/specialist intervention consider।
  8. Sudden pop/weakness: urgent orthopaedic referral.

Reference List — Textbook + Guideline + DOI

Textbooks

  1. Apley & Solomon’s System of Orthopaedics and Trauma, latest edition — Soft tissue overuse injuries / tendon disorders section.
  2. Maheshwari & Mhaskar, Essential Orthopaedics, latest edition — Foot and ankle disorders / tendon injuries section.
  3. Davidson’s Principles and Practice of Medicine, latest edition — Musculoskeletal pain and rheumatologic differential considerations.
  4. Robbins & Cotran Pathologic Basis of Disease, latest edition — Tissue repair, collagen degeneration, chronic inflammation principles.

Guidelines / Clinical resources

  1. Chimenti RL, Neville C, Houck J, et al. Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision—2024. J Orthop Sports Phys Ther. 2024;54(12):CPG1–CPG32. DOI: 10.2519/jospt.2024.0302.
  2. AAOS OrthoInfo. Achilles Tendinitis — conservative management, ice, NSAIDs, physical therapy, heel lift/orthotics.
  3. MSD Manual Professional. Achilles Tendinopathy — ice, NSAIDs, stretching, heel lift, activity modification.

Peer-reviewed journals with DOI

  1. Alfredson H, Pietilä T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for chronic Achilles tendinosis. Am J Sports Med. 1998;26(3):360–366. DOI: 10.1177/03635465980260030301.
  2. Chimenti RL, Neville C, Houck J, et al. Midportion Achilles Tendinopathy Revision—2024. JOSPT. DOI: 10.2519/jospt.2024.0302.
  3. van der Vlist AC, Winters M, Weir A, et al. Which treatment is most effective for patients with Achilles tendinopathy? Br J Sports Med. 2021;55:249–256. DOI: 10.1136/bjsports-2019-101872.
  4. Beyer R, Kongsgaard M, Hougs Kjær B, et al. Heavy slow resistance versus eccentric training as treatment for Achilles tendinopathy. Am J Sports Med. 2015;43(7):1704–1711. DOI: 10.1177/0363546515584760.
  5. Kim GK. The risk of fluoroquinolone-induced tendinopathy and tendon rupture. J Clin Aesthet Dermatol. 2010;3(4):49–54.

Md.Rafiqul Islam Lipu,Date:-15-06-2026 Monday,Time:-08-37-12 Pm

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