Achilles tendinitis, also known as Achilles tendonitis, is inflammation of the Achilles tendon. The Achilles tendon connects your calf muscles to the back of your heel bone. It allows extension of your foot downward, away from your body, which lets your heel lift off the ground as you move forward when walking. Every time you take a step you rely on your Achilles tendon.
Poorly conditioned athletes are at the highest risk for developing Achilles tendonitis, also sometimes called Achilles tendinitis. Participating in activities that involve sudden stops and starts and repetitive jumping (e.g., basketball, tennis, dancing) increases the risk for the condition. It often develops following sudden changes in activity level, training on poor surfaces, or wearing inappropriate footwear. Achilles tendonitis may be caused by a single incident of overstressing the tendon, or it may result from a series of stresses that produce small tears over time (overuse). Patients who develop arthritis in the heel have an increased risk for developing Achilles tendonitis. This occurs more often in people who middle aged and older. The condition also may develop in people who exercise infrequently and in those who are just beginning an exercise program, because inactive muscles and tendons have little flexibility because of inactivity. It is important for people who are just starting to exercise to stretch properly, start slowly, and increase gradually. In some cases, a congenital (i.e., present at birth) condition causes Achilles tendonitis. Typically, this is due to abnormal rotation of the foot and leg (pronation), which causes the arch of the foot to flatten and the leg to twist more than normal.
The most common site of Achilles Tendonitis is at the heel to 4 inches above the heel. The diagnosis of this problem is made when the following signs are present. Pain in the Achilles tendon with up and down movement of the foot at the ankle. Pain in the Achilles tendon when you squeeze the tendon from side to side. If you are unable to move the foot either up or down, or you have intense pain when trying to walk, you may have a tear of the Achilles tendon, and you should see a doctor immediately. Also if you have severe pain in the calf, with or without discolorations of the skin, you may have a blood clot, and this is a medical emergency; see a doctor immediately. If you do not fall into either of these categories then try the following suggestions.
To diagnose the condition correctly, your doctor will ask you a few questions about the pain and swelling in your heel. You may be asked to stand on the balls of your feet while your doctor observes your range of motion and flexibility. The doctor may also touch the area directly. This allows him to pinpoint where the pain and swelling is most severe.
In most cases, nonsurgical treatment options will provide pain relief, although it may take a few months for symptoms to completely subside. Even with early treatment, the pain may last longer than 3 months. If you have had pain for several months before seeking treatment, it may take 6 months before treatment methods take effect. 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. Placing ice on the most painful area of the Achilles tendon is helpful and can be done as needed throughout the day. This can be done for up to 20 minutes and should be stopped earlier if the skin becomes numb. A foam cup filled with water and then frozen creates a simple, reusable ice pack. After the water has frozen in the cup, tear off the rim of the cup. Then rub the ice on the Achilles tendon. With repeated use, a groove that fits the Achilles tendon will appear, creating a "custom-fit" ice pack. Drugs such as ibuprofen and naproxen reduce pain and swelling. They do not, however, reduce the thickening of the degenerated tendon. Using the medication for more than 1 month should be reviewed with your primary care doctor. The following exercise can help to strengthen the calf muscles and reduce stress on the Achilles tendon. 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 20 times for each foot. A strong pull in the calf should be felt during the stretch. Physical therapy is very helpful in treating Achilles tendinitis. It has proven to work better for noninsertional tendinitis than for insertional tendinitis. Eccentric strengthening is defined as contracting (tightening) a muscle while it is getting longer. Eccentric strengthening exercises can cause damage to the Achilles tendon if they are not done correctly. At first, they should be performed under the supervision of a physical therapist. Once mastered with a therapist, the exercises can then be done at home. These exercises may cause some discomfort, however, it should not be unbearable. Stand at the edge of a stair, or a raised platform that is stable, with just the front half of your foot on the stair. This position will allow your heel to move up and down without hitting the stair. Care must be taken to ensure that you are balanced correctly to prevent falling and injury. Be sure to hold onto a railing to help you balance. Lift your heels off the ground then slowly lower your heels to the lowest point possible. Repeat this step 20 times. This exercise should be done in a slow, controlled fashion. Rapid movement can create the risk of damage to the tendon. As the pain improves, you can increase the difficulty level of the exercise by holding a small weight in each hand. This exercise is performed similarly to the bilateral heel drop, except that all your weight is focused on one leg. This should be done only after the bilateral heel drop has been mastered. Cortisone, a type of steroid, is a powerful anti-inflammatory medication. Cortisone injections into the Achilles tendon are rarely recommended because they can cause the tendon to rupture (tear).
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.
Regardless of whether the Achilles injury is insertional or non-insertional, a great method for lessening stress on the Achilles tendon is flexor digitorum longus exercises. This muscle, which originates along the back of the leg and attaches to the tips of the toes, lies deep to the Achilles. It works synergistically with the soleus muscle to decelerate the forward motion of the leg before the heel leaves the ground during propulsion. This significantly lessens strain on the Achilles tendon as it decelerates elongation of the tendon. Many foot surgeons are aware of the connection between flexor digitorum longus and the Achilles tendon-surgical lengthening of the Achilles (which is done to treat certain congenital problems) almost always results in developing hammer toes as flexor digitorum longus attempts to do the job of the recently lengthened tendon. Finally, avoid having cortisone injected into either the bursa or tendon-doing so weakens the tendon as it shifts production of collagen from type one to type three. In a recent study published in the Journal of Bone Joint Surgery(9), cortisone was shown to lower the stress necessary to rupture the Achilles tendon, and was particularly dangerous when done on both sides, as it produced a systemic effect that further weakened the tendon.