Achilles Tendonitis

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Achilles Tendon Disorders

Topics discussed on this web page:
The diagnosis and treatment of: Achilles Tendinitis Achilles Tendinosis Achilles Tendon Ruptures What is the Achilles Tendon?

The Achilles Tendon is the large tendon running from the calf muscles (the gastrocnemius and soleus muscles) located in the back of the leg to the back of the heel. This muscle and tendon combination is responsible for allowing your foot to push off the ground when you're walking, running, and jumping.

What is Achilles Tendinitis? Because it's used so much in gait, the tendon is susceptible to injury. In the earliest stages, the tendon becomes inflamed. At this point we would name the problem "Achilles Tendinitis", because adding the suffix -itis to the end of a word means that tissue is inflamed. What is Achilles Tendinosis? "Achilles Tendinosis" is a term used when the inflammatory condition of the tendon progresses and actual degeneration of the tendon develops from small tears within the tendon. These tears have a difficult time healing because of the limited circulation and the chronic irritation to the tendon.

What is an Achilles Tendon rupture? As the small tears in the tendon worsen, the entire tendon tends to weaken. Eventually it may simply "give way" and tear in half. This is a tendon rupture. Where are these problems seen? The most common location for the problem to develop is approximately 2/3 of the way down the tendon, about 2.5 inches, or about 5 cm from where it attaches to the heel bone. This location is predisposed to injury because this area has less blood flow than other portions of the tendon. How do you develop these conditions? Sometimes Achilles Tendinitis is a result of sudden trauma, as you might encounter from playing sports, but you can also have Achilles tendon pain as a result of small, unnoticed, day-to-day irritations that inflame the tendon over time by a cumulative effect. In those with no history of trauma, Achilles Tendonitis is sometimes associated simply with long periods of standing. There are several factors that can cause the gradual development of Achilles Tendinitis. Improper shoe selection, particularly using high heels over many years, increases your odds of developing the condition. This is because high-heeled shoes cause your calf muscles to contract, leaving the tendon with a lot less slack in it. Inadequate stretching before engaging in athletic or other physically-demanding activities also predisposes you to develop the problem. This is especially true in "weekend athletes", individuals who

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tend to partake in excessive physical activities on an intermittent basis. Biomechanical abnormalities like excessive pronation (too much flattening of the arch) also tends to cause this condition. And it is much more common individuals with equinus. It is more common in the middle-aged, the out-of-shape, smokers, and in those who use steroids. Men get the condition more frequently than women. Those involved in jumping and high-impact sports are particularly vulnerable.

What does Achilles Tendinitis feel like? Symptoms vary because you can injure various areas of the muscle-tendon complex. The pain may be an acute or chronic sharp, stabbing, piercing, shooting, burning or aching. It is often most noticeable immediately after getting out of bed in the morning, or after periods of inactivity, like sitting down for lunch. After a couple minutes of walking around, it will often then settle down somewhat, before becoming symptomatic again after excessive time standing or walking. But regardless of how the pain is perceived, Achilles tendon pain should not be left untreated due to the danger that the tendon can become weak, frayed, thickened, and eventually it may rupture. What does Achilles Tendinosis feel like? Symptoms are similar to Achilles Tendinitis, though discomfort associated with Achilles Tendinosis tends to stay rather constant because the tendon is damaged. What do Achilles Tendon ruptures feel like? Ruptures may hurt a great deal, but they are frequently characterized by a surprisingly non-painful dull whack, like someone hitting the back of the tendon with a tennis racket. There is often an inability to continue walking, though some are able to continue walking by the body's ability to recruit other muscles in the calf to take over the Achilles Tendon's job. How can you diagnose Achilles Tendinitis? A podiatrist can usually make the diagnosis by clinical history and physical examination alone. Pain with touching or stretching the tendon is typical. There may also be a visible swelling to the tendon. The patient frequently has difficulty plantarflexing (pushing down the ball of the foot and toes, like one would press on a gas pedal), particularly against resistance. In most cases X-rays don't show much, as they tend to show bone more than soft tissues. But X-rays may show associated degeneration of the heel bone that is common with Achilles Tendon problems. For example, heel spurs, calcification within the tendon, avulsion fractures, periostitis (a bruising of the outer covering of the bone) may all be seen on X-ray. In cases where we are uncertain as to the extent of the damage to the tendon, though, an MRI scan may be necessary, which images the soft tissues better than X-rays. When the tendon is simply inflamed and not severely damaged, the problem may or may not be visible on MRI. It depends upon the severity of the condition.

How do you diagnose Achilles Tendinosis? Again, X-rays are usually not of great help because they image bone. Calcifications of the tendon, however, may be visible with X-ray. Better imaging of soft tissues may be performed with MRI, and tendinosis is often visible with MRI. To the right is an example of an MRI that demonstrates degeneration of the Achilles Tendon.

How do you diagnose Achilles Tendon rupture? Clinically, a history and physical examination is usually enough to diagnose an Achilles Tendon rupture.

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A visible gap or depression in the affected area is unique to ruptures, however, and there is a greater loss of function and ability to plantarflex, or push down, the foot against resistance. The so-called "Thompson Test" may be helpful, too. This is where the calf muscle is squeezed by the doctor and the foot should plantarflex.

But while Achilles Tendon ruptures can usually be diagnosed with a clinical examination alone, MRI is probably the easiest way to identify beyond doubt the presence of a rupture. The MRI the right demonstrates an obvious rupture.

How can you treat Achilles Tendinitis? Complete rest is vital, and ice is of great help the first 2 days of the injury. (Apply ice 15 minutes every hour). Taping, padding, heel lifts, anti-inflammatory medications, immobilization, physiotherapy, massage, shoe modifications are all helpful in the acute stage. Steroid injections weaken tendon and should not be used in most cases. Extra-corporeal shockwave therapy (or ESWT) can also be used to promote healing of Achilles Tendinitis, as well, particularly where it attaches to your heel bone. (For information on this, visit our partner's website, www.shockwavetherapy.ca. For chronic, difficult-to-treat cases, orthoses, custom-made appliances for the shoes, may be necessary to address any biomechanical abnormality. Good shoes and, in athletes, a strict pre-activity stretching regimen are also helpful in the long term. How do you treat an Achilles Tendinosis? Early stages may be responsive to conservative care as described in the Achilles Tendinitis section above. As degeneration progresses, though, reconstructive surgery of the tendon may be required. How do you treat Achilles Tendon Rupture? We would most likely suggest surgical repair of the tendon, particularly of fresh injuries. Older injuries are also usually treated surgically, though some patients will improve by simply casting the leg and allowing the tendon to scar together. Diminished strength and function, is more frequently seen in patients who are casted without surgery, and the tendon is more likely to re-rupture, so the inclination is to surgically repair ruptures in most cases involving younger, healthier patients. Following surgical repair of Achilles Tendon injuries, the patient is usually casted, then when the cast is removed, the patient is followed up with stretching, strengthening exercises, and physiotherapy. Long-term morbidity (chronic abnormal function) following ruptures is common, particularly if the tendon injury isn't treated promptly, in the elderly and obese, in individuals who have used steroids, in individuals with rheumatological (arthritic) conditions, and in those who haven't followed sound post-surgical physical therapy guidelines.

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