Concerning Achilles Tendonitis

Overview

Achilles TendonAchilles tendonitis, also sometimes called Achilles tendinitis, is a painful and often debilitating inflammation of the Achilles tendon (heel cord). The Achilles tendon is the largest and strongest tendon in the body. It is located in the back of the lower leg, attaches to the heel bone (calcaneus), and connects the leg muscles to the foot. The Achilles tendon gives us the ability to rise up on our toes, facilitating the act of walking, and Achilles tendonitis can make walking almost impossible. There are three stages of tendon inflammation, Peritenonitis, Tendinosis, Peritenonitis with tendinosis. Peritenonitis is characterized by localized pain during or following activity. As this condition progresses, pain often develops earlier on during activity, with decreased activity, or while at rest. Tendinosis is a degenerative condition that usually does not produce symptoms (i.e., is asymptomatic). It may cause swelling or a hard knot of tissue (nodule) on the back of the leg. Peritenonitis with tendinosis results in pain and swelling with activity. As this condition progresses, partial or complete tendon rupture may occur. The overall incidence of Achilles tendonitis is unknown. The condition occurs in approximately 6-18% of runners, and also is more common in athletes, especially in sports that involve jumping (e.g., basketball), and in people who do a lot of walking. Achilles tendonitis that occurs as a result of arthritis in the heel is more common in people who are middle aged and older.

Causes

Although a specific incident of overstretching can cause an Achilles tendon disorder, these injuries typically result from a gradually progressive overload of the Achilles tendon or its attachment to bone. The cause of this chronic overload is usually a combination of factors that can put excess stress on the tendon: being overweight, having a tight calf muscle, standing or walking for a long period of time, wearing excessively stiff or flat footwear, or engaging in significant sports activity.

Symptoms

Symptoms of Achilles tendonitis include, pain in the back of the heel, difficulty walking, sometimes the pain makes walking impossible, swelling, tenderness and warmth of the Achilles tendon. Achilles tendonitis is graded according to how severe it is, mild – pain in the Achilles tendon during a particular activity (such as running) or shortly after. Moderate – the Achilles tendon may swell. In some cases, a hard lump (nodule) may form in the tendon. Severe – any type of activity that involves weight bearing causes pain of the Achilles tendon. Very occasionally, the Achilles tendon may rupture (tear). When an Achilles tendon ruptures, it is said to feel like a hard whack on the heel.

Diagnosis

The diagnosis is made via discussion with your doctor and physical examination. Typically, imaging studies are not needed to make the diagnosis. However, in some cases, an ultrasound is useful in looking for evidence of degenerative changes in the tendon and to rule out tendon rupture. An MRI can be used for similar purposes, as well. Your physician will determine whether or not further studies are necessary.

Nonsurgical Treatment

The main treatments for Achilles tendinitis do not involve surgery. It is important to remember that it may take at least 2 to 3 months for the pain to go away. Try putting ice over the Achilles tendon for 15 to 20 minutes, two to three times per day. Remove the ice if the area gets numb. Changes in activity may help manage the symptoms. Decrease or stop any activity that causes you pain. Run or walk on smoother and softer surfaces. Switch to biking, swimming, or other activities that put less stress on the Achilles tendon. Your health care provider or physical therapist can show you stretching exercises for the Achilles tendon. They may also suggest the following changes in your footwear, a brace or boot or cast to keep the heel and tendon still and allow the swelling to go down, heel lifts placed in the shoe under the heel, shoes that are softer in the areas over and under the heel cushion. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen can help with pain or swelling. Talk with your health care provider. If these treatments do not improve symptoms, you may need surgery to remove inflamed tissue and abnormal areas of the tendon. Surgery also can be used to remove the bone spur that is irritating the tendon. Extracorporeal shock wave therapy (ESWT) may be an alternative to surgery for people who have not responded to other treatments. This treatment uses low-dose sound waves.

Achilles Tendinitis

Surgical Treatment

Surgery should be considered to relieve Achilles tendinitis only if the pain does not improve after 6 months of nonsurgical treatment. The specific type of surgery depends on the location of the tendinitis and the amount of damage to the tendon. Gastrocnemius recession. This is a surgical lengthening of the calf (gastrocnemius) muscles. Because tight calf muscles place increased stress on the Achilles tendon, this procedure is useful for patients who still have difficulty flexing their feet, despite consistent stretching. In gastrocnemius recession, one of the two muscles that make up the calf is lengthened to increase the motion of the ankle. The procedure can be performed with a traditional, open incision or with a smaller incision and an endoscope-an instrument that contains a small camera. Your doctor will discuss the procedure that best meets your needs. Complication rates for gastrocnemius recession are low, but can include nerve damage. Gastrocnemius recession can be performed with or without d?bridement, which is removal of damaged tissue. D?bridement and repair (tendon has less than 50% damage). The goal of this operation is to remove the damaged part of the Achilles tendon. Once the unhealthy portion of the tendon has been removed, the remaining tendon is repaired with sutures, or stitches to complete the repair. In insertional tendinitis, the bone spur is also 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, where it attaches. After d?bridement and repair, most patients are allowed to walk in a removable boot or cast within 2 weeks, although this period depends upon the amount of damage to the tendon. D?bridement with tendon transfer (tendon has greater than 50% damage). In cases where more than 50% of the Achilles tendon is not healthy and requires removal, the remaining portion of the tendon is not strong enough to function alone. To prevent the remaining tendon from rupturing with activity, an Achilles tendon transfer is performed. The tendon that helps the big toe point down is moved to the heel bone to add strength to the damaged tendon. Although this sounds severe, the big toe will still be able to move, and most patients will not notice a change in the way they walk or run. Depending on the extent of damage to the tendon, some patients may not be able to return to competitive sports or running. 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, and the less likely a patient will be able to return to sports activity. Physical therapy is an important part of recovery. Many patients require 12 months of rehabilitation before they are pain-free.

Prevention

If you’re just getting started with your training, be sure to stretch after running, and start slowly, increasing your mileage by no more than 10% per week. Strengthen your calf muscles with exercises such as toe raises. Work low-impact cross-training activities, such as cycling and swimming, into your training.