|ORIGINAL RESEARCH REPORT
|Year : 2016 | Volume
| Issue : 4 | Page : 163-166
Prevalence of achilles tendinopathy and its association with physical characteristics in recreational sport participants in Lagos, Nigeria
Ayoola Ibifubara Aiyegbusi, Udoka Arinze Okafor, Omotola Patience Leke
Department of Physiotherapy, College of Medicine, University of Lagos, Lagos, Nigeria
|Date of Web Publication||14-Oct-2016|
Ayoola Ibifubara Aiyegbusi
Department of Physiotherapy, College of Medicine, University of Lagos, Lagos
Source of Support: None, Conflict of Interest: None
Background: Achilles tendinopathy (AT) is the most frequently reported injury related to the ankle and foot in different sports activities. Much attention has been paid to elite athletes in competitive sports, but there is paucity of data on its prevalence in recreational sports. Aims: This study investigated the prevalence of AT and its association with selected physical characteristics in a population of recreational sports participants in Lagos, Nigeria. Settings and Design: Cross-sectional analytical study. Materials and Methods: This study involved 302 recreational sports participants in various sports centers in Lagos State. The Royal London test was used to assess for the presence of AT, while the Victorian Institute of Sports Assessment - Achilles questionnaire was used to evaluate the severity of AT among the participants. Statistical Analysis: Data collected were summarized using descriptive statistics and analyzed using Pearson Chi-square. The level of significance was set at P ≤ 0.05. Results: Our findings show that 21% of the participants had AT. Gender, height, and weight showed no significant association with AT; however, the age of the participants showed a significant association with AT. Conclusion: AT is common among recreational sports individuals in Lagos, Nigeria, age being a contributing factor while other physical characteristics had no impact.
Keywords: Achilles tendinopathy, recreational sports, tendinopathy
|How to cite this article:|
Aiyegbusi AI, Okafor UA, Leke OP. Prevalence of achilles tendinopathy and its association with physical characteristics in recreational sport participants in Lagos, Nigeria. J Clin Sci 2016;13:163-6
|How to cite this URL:|
Aiyegbusi AI, Okafor UA, Leke OP. Prevalence of achilles tendinopathy and its association with physical characteristics in recreational sport participants in Lagos, Nigeria. J Clin Sci [serial online] 2016 [cited 2020 Feb 16];13:163-6. Available from: http://www.jcsjournal.org/text.asp?2016/13/4/163/192274
| Introduction|| |
Participation in sport and physical activity is a global priority and encouraged by government agencies worldwide, with immense health and economic benefits.  Unfortunately, sports injuries that can have both long- and short-term adverse effects do occur causing permanent physical damage or disability, affecting quality of life, impacting time at work, and leading to time away from physical activity. , There is recent evidence that the incidence of sports injuries and its associated burdens are increasing. 
Tendinopathy, the most prevalent tendon disorder which is considered as the clinical diagnosis of pain and dysfunction of a tendon is common in sport, and its prevalence is ever-increasing.  Its diagnosis is usually clinical, but ultrasonography and magnetic resonance imaging can refine the diagnosis.  The prognosis is often poor, with a high incidence of chronicity and recurrence. 
Achilles tendinopathy (AT) which is not limited to the athletic populations is the most frequently reported injury related to the ankle and foot in different sports activities.  High incidence rates of 7.8 (per 1000 athlete-week exposure), 83.3 (per 1000 athlete-year exposure), and 107.1 (per 1000 athlete-season exposure) have been reported for AT among runners.  An incidence rate of 2.35/1000 subjects was reported for this injury in the general population (21-60 years) as well.  In 2006, Holmes and Lin  found out that the prevalence of AT is higher with age and in the male gender in contrast to Maffulli et al.  who found that age, gender, weight, and height have no influence on the incidence of AT.
Prior observational studies have shown that competitive athletes have a 24% lifetime incidence of AT, with an even higher incidence of 40-50% in competitive runners.  AT accounts for 6-17% of all running injuries among recreational runners.  One study in the Netherlands estimated the annual incidence of symptoms attributable to AT in the general population at 2.01/1000 people.  Much attention has been paid to elite athletes in the competitive sport while in recreational sport, there are greater numbers of participants, who start younger or continue for longer and for many of them, the equipment are not always adapted to the sports, thereby increasing the risk of tendinopathy.  Acute AT ruptures are frequently seen in young athletes and middle-aged people who are involved in recreational activities most of these injuries occur in soccer, tennis, badminton, and squash players, while 25% of ruptures occur in sedentary patients as well, with the incidence rate ranging from 6 to 18 per 100,000 per year. 
According to Kaux et al.  generalized epidemiologic studies on tendinopathy are difficult because of the varying sporting cultures and sports habits in different countries. A concern from a global perspective, however, is that most population-based sports injury prevalence is based on data reported in developed countries while there is often paucity of data on sport injuries in other parts of the world. There is dearth of data on the prevalence of AT in recreational sports in Nigeria hence the need for this study.
Most of the data on the prevalence and risk factors for sports injuries comes from the population of elite, semi-elite, or professional sports persons. Limited data exist on grassroots sports injuries which arguably involve a higher percentage of the general population.
Both intrinsic and extrinsic risk factors directly influence the occurrence and frequency of sports injury; common among which are age, sex, previous injury, and type of sports.  The aim of this study was to determine the prevalence of AT and its association with selected physical characteristics in recreational sports individuals in Lagos, Nigeria.
| Materials and methods|| |
A total of 302 cases recruited from four sport centers participated in this study. A sample of convenience was used to recruit the selected subjects who were involved in the following sporting events: Basketball, tennis and track and field sports. Subjects who regularly engaged in the recreational sport were recruited while professional sportsmen and women were excluded from this study. Ethical approval was sought and obtained from the Health Research and Ethics Committee of the Lagos University Teaching Hospital, LUTH, Idi-Araba, Lagos, Nigeria.
The purpose of the study was clearly explained to all the participants, and their approval and informed consent was obtained, after which the test was carried out.
Description of instruments
The Royal London test
This was used to check for the presence of AT in the subjects. Subjects were positioned prone on the examination table with their ankles hanging relaxed just over the edge of the table. In this position, the examiner identified the portion of the Achilles tendon which was maximally tender to palpation. The subjects were then asked to actively dorsiflex the ankle. The examiner once again palpated the part of the tendon that was identified as maximally tender, however, this time in maximal dorsiflexion. Subjects with AT often reported a substantial decrease or absence of pain when the palpation technique was repeated in dorsiflexion. With the ankle in maximal active dorsiflexion, the examiner classified the identified area with palpation as "tenderness present" or "tenderness absent." 
Victorian Institute of Sports Assessment - Achilles questionnaire
The Victorian Institute of Sports Assessment - Achilles (VISA-A) questionnaire contains eight questions, covering three necessary domains: Pain, functional status, and activity. Questions 1-3 are related to pain (in this questionnaire, the term pain refers specifically to pain in the Achilles tendon region). Questions 4-6, are related to function while question 7-8 are related to activity. Question 8 actually contains two questions: (a) Pain with activity, and (b) duration of activity. The first seven questions have a score out of 10, and question 8 scores a maximum of 30. The first six questions used a VAS so that the subjects may report the magnitude of continuum of subjective symptoms. The final two questions used a categorical rating scale. Answering question 8 is limited to A, B, or C and relates to the reality of the subject. The subject automatically loses at least 10 of 20 points if he or she has pain during sports activity. The maximum score that can be achieved from the questionnaire is 100, and would be the score of a person who is completely asymptomatic. A lower score indicates more symptoms and greater limitation of physical activity. The VISA-A questionnaire is reliable and valid when used in patients with a range of severity of AT and controls. 
Descriptive statistics of mean, standard deviation, and percentages were calculated for all the variables. An inferential statistics of Chi-square was used to analyze the data atP < 0.05. This was obtained using the Statistical Package for Social Sciences (SPSS Inc., Chicago, Illinois, USA) version 21.0. The result was illustrated with tables and bar chart.
| Results|| |
A total of 345 recreational sports participants were recruited and 302 subjects met the inclusion criteria. A total of 257 (85.09%) male subjects and 45 (14.90%) female subjects participated in the study. [Table 1] shows the age and physical characteristics of the respondents while on [Figure 1], it is seen that most of the respondents were in the age group 21-30 years. [Table 2] shows the association between gender and the severity of AT while on [Table 3]; it was only age that played a role in the prevalence of AT with P = 0.001.
|Table 2: Association between Gender and Severity of Achilles Tendinopathy|
Click here to view
|Table 3: Association between physical characteristics and the presence of Achilles tendinopathy|
Click here to view
| Discussion|| |
This study was carried out to determine the prevalence of AT in recreational sports individuals and its association with some selected physical characteristics. In this cross-sectional survey, the prevalence rate of 21% was observed which suggests that AT is common among the recreational sports individuals surveyed though this is lower than the prevalence in Master Tracks and Field Athletes where a prevalence of 66.9% was reported.  The lower prevalence rate could be because the population sample in this study had most of the participants in the younger age groups [Figure 1].
The data gathered from this study suggested that the male subjects participated more in recreational sport than the females though analysis with Chi-square showed no significant relationship between gender and the development of AT as earlier reported by Maffulli et al.  who concluded that gender has no influence in the development of AT. Gender also had no significant relationship with the severity of AT. These findings are probably because in the population of recreational sports individuals studied, there was a disproportionate male to female ratio with the female participants being just about 14.9% of the total population of sportspersons. Further studies with equal number of males and females would probably give a different picture because as seen in [Table 2], out of the total population of females, 24.4% had AT as opposed to 19.8% in the males. This finding by inference could imply that there is a much higher prevalence of AT in females.
In this study, age had a significant impact on the development of AT (P = 0.001) which supports the finding of Holmes and Lin  that age has been indicated as an important factor that appears to predispose athletes to AT, and the prevalence of Achilles' tendinopathy is higher with age with the peak age being 30-40 years, though the peak age for this study was 21-30 years. This could be because, in Nigeria, more of the younger adults are involved in recreational sports than those in the late adulthood, which makes AT more prevalent among them. The report of this study, however, is in contrast to the finding of Maffulli et al.,  which suggested that age had no influence in the development of AT. These findings may have important clinical consequences because changes in the physiology and function of connective tissues result in a decline in the integrity of these tissues with age resulting in a higher rate of tendon injury. 
Our findings also indicate that the physical characteristics of the participants such as weight, height, and body mass index (BMI) had no significant impact on the development of AT, and this agrees with a prior study by Maffulli et al.,  which reported that weight and height did not have influence in the development of AT. The fact that the subjects were all recreational athletes who had a normal BMI was probably responsible for the nonsignificant impact of physical characteristics on the development of tendinopathy. Some prior studies on the general population reported that subjects with AT were obese compared with age-matched controls. ,
A major strength of this study is that it has provided a preliminary data on the prevalence of AT in recreational sports persons in Lagos Nigeria. Further studies are however necessary with a much larger sample size and investigation of the role of anthropometric variables in the prevalence of this disorder.
One limitation of this study is the fact that imaging studies were not carried out on the subjects to confirm the presence or otherwise of AT.
| Conclusion|| |
AT is common among recreational sports individuals in Lagos, Nigeria, age being the contributing factor whereas other physical characteristics had no impact.
Further studies are necessary to determine other contributing factors as an enhanced understanding of these factors holds the promise of new approaches to the prevention and management of this common condition.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Reiner M, Niermann C, Jekauc D, Woll A. Long-term health benefits of physical activity - A systematic review of longitudinal studies. BMC Public Health 2013;13:813.
Lyons RA, Finch CF, McClure R, van Beeck E, Macey S. The injury list of all deficits (LOAD) framework - Conceptualizing the full range of deficits and adverse outcomes following injury and violence. Int J Inj Contr Saf Promot 2010;17:145-59.
Cook J, Finch C. The long-term impact of overuse injuries on life-long participation in sport and health status. In: Farelli D, editor. Sport Participation: Health Benefits. Injuries and Psychological Effects. Hauppauge, NY: Nova Science Publishers; 2011. p. 85-104.
Finch CF, Wong Shee A, Clapperton A. Time to add a new priority target for child injury prevention? The case for an excess burden associated with sport and exercise injury: Population-based study. BMJ Open 2014;4:e005043.
Ackermann PW, Renström P. Tendinopathy in sport. Sports Health 2012;4:193-201.
Kaux JF, Forthomme B, Goff CL, Crielaard JM, Croisier JL. Current opinions on tendinopathy. J Sports Sci Med 2011;10:238-53.
Fredberg U, Stengaard-Pedersen K. Chronic tendinopathy tissue pathology, pain mechanisms, and etiology with a special focus on inflammation. Scand J Med Sci Sports 2008;18:3-15.
Sobhani S, Dekker R, Postema K, Dijkstra PU. Epidemiology of ankle and foot overuse injuries in sports: A systematic review. Scand J Med Sci Sports 2013;23:669-86.
de Jonge S, van den Berg C, de Vos RJ, van der Heide HJ, Weir A, Verhaar JA, et al.
Incidence of midportion Achilles tendinopathy in the general population. Br J Sports Med 2011;45:1026-8.
Holmes GB, Lin J. Etiologic factors associated with symptomatic Achilles tendinopathy. Foot Ankle Int 2006;27:952-9.
Longo UG, Rittweger J, Garau G, Radonic B, Gutwasser C, Gilliver SF, et al.
No influence of age, gender, weight, height, and impact profile in Achilles tendinopathy in masters track and field athletes. Am J Sports Med 2009;37:1400-5.
Fahlström M, Jonsson P, Lorentzon R, Alfredson H. Chronic Achilles tendon pain treated with eccentric calf-muscle training. Knee Surg Sports Traumatol Arthrosc 2003;11:327-33.
Maffulli N, Wong J, Almekinders LC. Types and epidemiology of tendinopathy. Clin Sports Med 2003;22:675-92.
Longo UG, Petrillo S, Maffulli N, Denaro V. Acute Achilles tendon rupture in athletes. Foot Ankle Clin 2013;18:319-38.
Bahr R, Krosshaug T. Understanding injury mechanisms: A key component of preventing injuries in sport. Br J Sports Med 2005;39:324-9.
Maffulli N, Kenward MG, Testa V, Capasso G, Regine R, King JB. Clinical diagnosis of Achilles tendinopathy with tendinosis. Clin J Sport Med 2003;13:11-5.
Robinson JM, Cook JL, Purdam C, Visentini PJ, Ross J, Maffulli N, et al.
The VISA-A questionnaire: A valid and reliable index of the clinical severity of Achilles tendinopathy. Br J Sports Med 2001;35:335-41.
Warrender WJ, Brown OL, Abboud JA. Outcomes of arthroscopic rotator cuff repairs in obese patients. J Shoulder Elbow Surg 2011;20:961-7.
Klein EE, Weil L Jr., Weil LS Sr., Fleischer AE. Body mass index and Achilles tendonitis: A 10-year retrospective analysis. Foot Ankle Spec 2013;6:276-82.
Scott RT, Hyer CF, Granata A. The correlation of Achilles tendinopathy and body mass index. Foot Ankle Spec 2013;6:283-5.
[Table 1], [Table 2], [Table 3]