Achilles Tendonitis Information
Overview
Your Achilles tendon is located at the back of your foot, just above your heel. It connects your heel to the two muscles of your calf and helps your foot push forward every time you take a step. If the tendon becomes swollen or irritated due to overuse, it can lead to the painful condition called Achilles tendonitis. If Achilles tendonitis goes untreated, it can become a chronic (ongoing) condition that makes just walking around almost impossible. Achilles tendonitis is a very common running injury. But it can also affect basketball players, dancers, or people who put a lot of repeated stress on their feet. It can be very painful.
Causes
The Achilles tendon is a strong band of connective tissue that attaches the calf muscle to the heel bone. When the muscle contracts, the tendon transmits the power of this contraction to the heel, producing movement. The Achilles tendon moves through a protective sheath and is made up of thousands of tiny fibres. It is thought that Achilles tendonitis develops when overuse of the tendon causes the tiny fibres that make up the tendon to tear. This causes inflammation, pain and swelling. As the tendon swells it can begin to rub against the sheath surrounding it, irritating the sheath and causing it too to become inflamed and swollen. It has a poor blood supply, which can make it susceptible to injury and can make recovery from injury slow. Factors that can lead to the development of Achilles tendonitis include, tight or weak calf muscles, rapidly increasing the amount or intensity of exercise. Hill climbing or stair climbing exercises. Changes in footwear, particularly changing from wearing high-heeled shoes to wearing flat shoes. Wearing inadequate or inappropriate shoes for the sporting activity being undertaken. Not adequately warming up and stretching prior to exercise. A sudden sharp movement that causes the calf muscles to contract and the stress on the Achilles tendon to be increased. This can cause the tendon fibres to tear.
Symptoms
Morning pain is a hallmark symptom because the achilles tendon must tolerate full range of movement including stretch immediately on rising in the morning. Symptoms are typically localized to the tendon and immediate surrounding area. Swelling and pain at the attachment are less common. The tendon can appear to have subtle changes in outline, becoming thicker in the A-P and M-L planes. With people who have a tendinopathy of the achilles tendon that has a sensitive zone, combined with intratendinous swelling, that moves along with the tendon and of which sensitivity increases or decreases when the tendon is put under pressure, there will be a high predictive value that in this situation there is a case of tendinosis.
Diagnosis
Examination of the achilles tendon is inspection for muscle atrophy, swelling, asymmetry, joint effusions and erythema. Atrophy is an important clue to the duration of the tendinopathy and it is often present with chronic conditions. Swelling, asymmetry and erythema in pathologic tendons are often observed in the examination. Joint effusions are uncommon with tendinopathy and suggest the possibility of intra-articular pathology. Range of motion testing, strength and flexibility are often limited on the side of the tendinopathy. Palpation tends to elicit well-localized tenderness that is similar in quality and location to the pain experienced during activity. Physical examinations of the Achilles tendon often reveals palpable nodules and thickening. Anatomic deformities, such as forefoot and heel varus and excessive pes planus or foot pronation, should receive special attention. These anatomic deformities are often associated with this problem. In case extra research is wanted, an echography is the first choice of examination when there is a suspicion of tendinosis. Imaging studies are not necessary to diagnose achilles tendonitis, but may be useful with differential diagnosis. Ultrasound is the imaging modality of first choice as it provides a clear indication of tendon width, changes of water content within the tendon and collagen integrity, as well as bursal swelling. MRI may be indicated if diagnosis is unclear or symptoms are atypical. MRI may show increased signal within the Achilles.
Nonsurgical Treatment
Most cases are successfully treated non-surgically although this is time-consuming and frustrating for active patients. Treatment is less likely to be successful if symptoms have been present more than six months. Nonsurgical management includes nonsteroidal anti-inflammatory medications, rest, immobilization, limitation of activity, ice, contrast baths, stretching and heel lifts. If symptoms fail to resolve after two to three months, a formal physical therapy program may be of benefit. An arch support may help if there is an associated flatfoot. A cast or brace to completely rest this area may be necessary. Extracorporeal shockwave therapy and platelet-rich plasma injections? have variable reports of success. Nitroglycerin medication applied to the overlying skin may be of benefit.
Surgical Treatment
Not every Achilles tendon injury or condition requires surgery. It is generally understood by doctors and surgeons, that surgery will introduce more scar tissue into the Achilles tendon. This added scar tissue will be problematic, requiring physical therapy and conservative treatment options post-surgery. If not dealt with properly, your ankle and Achilles tendon could end up in worse condition than before the surgery! This is why surgery is only performed as a last resort.
Prevention
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.
Your Achilles tendon is located at the back of your foot, just above your heel. It connects your heel to the two muscles of your calf and helps your foot push forward every time you take a step. If the tendon becomes swollen or irritated due to overuse, it can lead to the painful condition called Achilles tendonitis. If Achilles tendonitis goes untreated, it can become a chronic (ongoing) condition that makes just walking around almost impossible. Achilles tendonitis is a very common running injury. But it can also affect basketball players, dancers, or people who put a lot of repeated stress on their feet. It can be very painful.
Causes
The Achilles tendon is a strong band of connective tissue that attaches the calf muscle to the heel bone. When the muscle contracts, the tendon transmits the power of this contraction to the heel, producing movement. The Achilles tendon moves through a protective sheath and is made up of thousands of tiny fibres. It is thought that Achilles tendonitis develops when overuse of the tendon causes the tiny fibres that make up the tendon to tear. This causes inflammation, pain and swelling. As the tendon swells it can begin to rub against the sheath surrounding it, irritating the sheath and causing it too to become inflamed and swollen. It has a poor blood supply, which can make it susceptible to injury and can make recovery from injury slow. Factors that can lead to the development of Achilles tendonitis include, tight or weak calf muscles, rapidly increasing the amount or intensity of exercise. Hill climbing or stair climbing exercises. Changes in footwear, particularly changing from wearing high-heeled shoes to wearing flat shoes. Wearing inadequate or inappropriate shoes for the sporting activity being undertaken. Not adequately warming up and stretching prior to exercise. A sudden sharp movement that causes the calf muscles to contract and the stress on the Achilles tendon to be increased. This can cause the tendon fibres to tear.
Symptoms
Morning pain is a hallmark symptom because the achilles tendon must tolerate full range of movement including stretch immediately on rising in the morning. Symptoms are typically localized to the tendon and immediate surrounding area. Swelling and pain at the attachment are less common. The tendon can appear to have subtle changes in outline, becoming thicker in the A-P and M-L planes. With people who have a tendinopathy of the achilles tendon that has a sensitive zone, combined with intratendinous swelling, that moves along with the tendon and of which sensitivity increases or decreases when the tendon is put under pressure, there will be a high predictive value that in this situation there is a case of tendinosis.
Diagnosis
Examination of the achilles tendon is inspection for muscle atrophy, swelling, asymmetry, joint effusions and erythema. Atrophy is an important clue to the duration of the tendinopathy and it is often present with chronic conditions. Swelling, asymmetry and erythema in pathologic tendons are often observed in the examination. Joint effusions are uncommon with tendinopathy and suggest the possibility of intra-articular pathology. Range of motion testing, strength and flexibility are often limited on the side of the tendinopathy. Palpation tends to elicit well-localized tenderness that is similar in quality and location to the pain experienced during activity. Physical examinations of the Achilles tendon often reveals palpable nodules and thickening. Anatomic deformities, such as forefoot and heel varus and excessive pes planus or foot pronation, should receive special attention. These anatomic deformities are often associated with this problem. In case extra research is wanted, an echography is the first choice of examination when there is a suspicion of tendinosis. Imaging studies are not necessary to diagnose achilles tendonitis, but may be useful with differential diagnosis. Ultrasound is the imaging modality of first choice as it provides a clear indication of tendon width, changes of water content within the tendon and collagen integrity, as well as bursal swelling. MRI may be indicated if diagnosis is unclear or symptoms are atypical. MRI may show increased signal within the Achilles.
Nonsurgical Treatment
Most cases are successfully treated non-surgically although this is time-consuming and frustrating for active patients. Treatment is less likely to be successful if symptoms have been present more than six months. Nonsurgical management includes nonsteroidal anti-inflammatory medications, rest, immobilization, limitation of activity, ice, contrast baths, stretching and heel lifts. If symptoms fail to resolve after two to three months, a formal physical therapy program may be of benefit. An arch support may help if there is an associated flatfoot. A cast or brace to completely rest this area may be necessary. Extracorporeal shockwave therapy and platelet-rich plasma injections? have variable reports of success. Nitroglycerin medication applied to the overlying skin may be of benefit.
Surgical Treatment
Not every Achilles tendon injury or condition requires surgery. It is generally understood by doctors and surgeons, that surgery will introduce more scar tissue into the Achilles tendon. This added scar tissue will be problematic, requiring physical therapy and conservative treatment options post-surgery. If not dealt with properly, your ankle and Achilles tendon could end up in worse condition than before the surgery! This is why surgery is only performed as a last resort.
Prevention
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.
