The Achilles tendon, the longest tendon in the body, runs down the back of the lower leg and connects the calf muscle to the heel bone. Also called the “heel cord,” the Achilles tendon facilitates walking by helping to raise the heel off the ground and is used in activities that involve walking, running and jumping.
Achilles tendonitis is an inflammation of the Achilles tendon. Inflammation is a natural response to injury or disease, and often causes swelling, pain and irritation in the area that is affected. There are two types of Achilles tendinitis named for where the tendon is affected.
NON-INSERTIONAL ACHILLES TENDINITIS
Non-insertional Achilles tendonitis affects the middle portion of the tendon, usually half way between the heel bone and the muscular portion of the calf. When this occurs, fibers in the middle portion of the tendon have begun to break down with tiny tears, and this results in swelling and thickening of the tendon.
Tendinitis of the middle portion of the tendon more commonly affects younger, active people.
INSERTIONAL ACHILLES TENDINITIS
Insertional Achilles tendinitis involves the portion of the heel where the tendon attaches (inserts) to the heel bone. In this type of tendonitis, the fibers that attach the tendon to the bone are inflamed and irritated. This can result in swelling and pain while walking. Bone spurs (extra bone growth) often form with insertional Achilles tendinitis. A surgical procedure is often necessary for removal.
Tendinitis that affects the insertion of the tendon can occur at any time, even in patients who are not active.
Achilles tendinitis is typically not related to a specific injury. The problem results from repetitive stress to the tendon. This often happens when we push our bodies to do too much, too soon. Other factors can make it more likely to develop tendinitis, including:
SUDDEN INCREASE IN THE AMOUNT OR INTENSITY OF EXERCISE ACTIVITY
For example, increasing the distance you run every day by a few miles without giving your body a chance to adjust to the new distance can result in micro-injury of the tendon fibers. Due to ongoing stress on the tendon, the body is unable to repair the injured tissue. The structure of the tendon is then altered, resulting in continued pain.
TIGHT CALF MUSCLES
Having tight calf muscles, also known as an equinus, and suddenly starting an aggressive exercise program without an adequate stretching program can put extra stress on the Achilles tendon.
Extra bone growth where the Achilles tendon attaches to the heel bone can rub against the tendon and cause pain
EXCESSIVE PRONATION (FLATTENING OF THE ARCH)
People with excessive pronation (flattening of the arch) have a tendency to develop Achilles tendonitis and tendonosis due to the greater demands placed on the tendon when walking. If these individuals wear shoes without adequate stability, their over-pronation could further aggravate the Achilles tendon.
Athletes are at high risk for developing disorders of the Achilles tendon, particularly if their training regimens do not provide for adequate stretching regimens.
Weekend warriors are less conditioned individuals who participate in athletics only on weekends or infrequently. These individuals are at a higher risk of injury due to placing increased demands on a tendon without proper conditioning.
The symptoms associated with Achilles tendonitis;
PAIN, ACHING, STIFFNESS SORENESS OR TENDERNESS WITHIN THE TENDON
This may occur anywhere along the tendon’s path, beginning with the narrow area directly above the heel upward to the region just below the calf muscle. Often pain appears upon arising in the morning or after periods of rest, then improves somewhat with motion but later worsens with increased activity.
TENDERNESS OR INTENSE PAIN
This occurs when the sides of the tendon are squeezed. There is less tenderness, however, when pressing directly on the back of the tendon.
NODULES IN THE TENDON
When the disorder progresses to degeneration, the tendon may become enlarged and may develop nodules in the area where the tissue is damaged.
If you have experienced a sudden ‘pop’ in the back of your calf or heel, you may have ruptured (torn) your Achilles tendon. See your Podiatric physician immediately for examination and treatment.
After you describe your symptoms and discuss your concerns, the doctor will examine your foot and ankle. The doctor will look for these signs:
- Swelling along the Achilles tendon or at the back of your heel
- Thickening or enlargement of the Achilles tendon
- Bony spurs at the lower part of the tendon at the back of your heel (insertional tendinitis)
- The point of maximum tenderness
- Pain in the middle of the tendon, (non-insertional tendinitis)
- Pain at the back of your heel at the lower part of the tendon (insertional tendinitis)
- Limited range of motion in your ankle—specifically, a decreased ability to flex your foot (bring your toes towards your nose)
Depending on your exact symptoms, your Podiatric physician may order additional testing such as x-rays, MRI or ultrasound.
X-ray tests provide clear images of bones. X-rays can show whether the lower part of the Achilles tendon has calcified or become hardened. This calcification indicates insertional Achilles tendinitis. In cases of severe non-insertional Achilles tendinitis, there can be calcification in the middle portion of the tendon.
MAGNETIC RESONANCE IMAGING (MRI)
Although magnetic resonance imaging (MRI) is not necessary to diagnose Achilles tendinitis, it can be helpful in diagnosis and to measure the extent of injury. An MRI scan can show how severe the damage is in the tendon. If surgery is needed, your Podiatric physician will select the best procedure for you based on the amount of tendon damage present and your athletic and activity needs.
Although ultrasound is not necessary to diagnose Achilles tendonitis or Achilles tendinosis, an ultrasound is a quick, non-invasive test to assess for calcification and/or degeneration in the tendon, as well as for longitudinal tendon tears.
Treatment approaches for Achilles tendonitis are selected on the basis of how long the injury has been present the degree of damage to the tendon. At Feldman Foot And Ankle we design the treatment based on both the injury and the needs of the patient.
In most cases, nonsurgical treatment options will provide pain relief, although it may take a few months for symptoms to completely subside. Here at Feldman Foot And Ankle Specialists we have designed a protocol for Achilles tendonitis:
- Rest: The first step in reducing pain is to decrease or even stop the activities that make the pain worse. If you regularly do high-impact exercises (such as running), switching to low-impact activities will put less stress on the Achilles tendon. Cross-training activities such as biking, elliptical exercise, and swimming are low-impact options to help you stay active.
- Ice: Placing ice on the most painful area of the Achilles tendon is helpful and can be done daily. The best way to ice this area is to fill a bucket or large bowl with ice cubes and cold water. Submerge the painful portion of your heel for 10 minutes.
- Non-Steroidal Anti-Inflammatory Medications and Gels: Drugs such as ibuprofen and naproxen, or ketorolac gel helps to reduce pain and swelling. They do not, however, reduce the thickening of the degenerated tendon. stomach protection should be used if using drugs for long periods of time.
- Calf Stretch: Lean forward against a wall with one knee straight and the heel on the ground. Place the other leg in front, with the knee bent. To stretch the calf muscles and the heel cord, push your hips toward the wall in a controlled fashion. Hold the position for 10 seconds and relax. Repeat this exercise 5 times for each foot. A strong pull in the calf should be felt during the stretch.
- Physical Therapy: Physical therapy is very helpful in treating Achilles tendinitis. Massage of the tendon using anti-inflammatory gels works well and is encouraged. Laser therapy (LLLT) has been found to reduce swelling dramatically and allow the body to self heal. As few as two sessions has been seen to decrease over 50% of the symptoms. We use the ARC 980nm Q4 laser and sessions last 15-30 min each.
- Cortisone Injections: Cortisone, a type of steroid, is a powerful anti-inflammatory medication. Not recommended for this type of problem as the cortisone weakens the tendon.
- Supportive Shoes, heel lifts, and Orthotics: Pain from insertional Achilles tendinitis is often helped by certain shoes, as well as orthotic devices. For example, shoes that are softer at the back of the heel can reduce irritation of the tendon. In addition, heel lifts can take some strain off the tendon.
Heel lifts are also very helpful for patients with insertional tendinitis because they can move the heel away from the back of the shoe, where rubbing can occur. They also take some strain off the tendon. Like a heel lift, a silicone Achilles sleeve can reduce irritation from the back of a shoe.
Orthotics are highly recommened for this problem. Orthotics will help reduce the inflammation by lifting the foot and keeping the foot in an inverted position decreasing the likelihood that the problem will recur in the future.
Surgery should be considered to relieve Achilles tendinitis only if the pain does not improve after conservative treatment has been exhausted. The specific type of surgery required depends on the location of the tendinitis and the amount of damage to the tendon. All options will be discussed with you by our team at Feldman Foot and Ankle Specialist.
- Débridement and Repair (tendon is less than 50% damaged): The goal of this operation is to remove the damaged part of the Achilles tendon leaving as much healthy tendon as possible. Once the unhealthy portion of the tendon has been removed, the remaining tendon is repaired with sutures (stitches).
If there is a bone spur present, it may also be removed. Repair of the tendon in these instances may require the use of metal or plastic anchors to help hold the Achilles tendon to the heel bone.
After débridement and repair, most patients are allowed to walk in a removable boot or cast within 2 weeks. However, this can vary from patient to patient and is heavily dependent on the amount of damage present in the tendon.
- Recovery: Most patients have good results from surgery. The main factor in surgical recovery is the amount of damage to the tendon. The greater the amount of tendon involved, the longer the recovery period.
Physical therapy is an important part of recovery. Many patients require as many as 6 months of rehabilitation before they are pain-free. Laser (LLLT) therapy has been found to greatly reduce recovery time by decreasing inflammation.
As a general rule, Achilles Tendon procedures are performed on an out-patient basis in an AHS approved Surgical Center or in a Hospital. Surgical procedural costs are covered by AHS or the patient may opt for private surgery to avoid a waiting time. A visit to Feldman Foot And Ankle Specialists will CLEARLY define all available patient options.