All About Achilles Tendonitis

Overview

Achilles TendonThe Achilles tendon is the largest tendon in the body. Tendons are long, tough cords of tissue that connect muscle to bone. The Achilles tendon is located in the back of the foot and connects your heel bone to your calf muscle. It helps you to walk, run and jump. The Achilles tendon is able to endure stress, but sometimes injury can occur to the tendon when overly stressed. Overuse of the Achilles tendon may cause the tendon to swell, become irritated, inflamed and cause pain. This is Achilles tendinitis. It is a common sports injury related to running, but can happen to anyone who puts a lot of stress on their feet (e.g.: basketball players and dancers). If you do not get treatment for Achilles tendinitis, the problem can become chronic and make it difficult for you to walk.


Causes

There are several factors that can contribute to achilles tendonitis. First, you should know that the biggest contributor to chronic achilles tendonitis is ignoring pain in your achilles tendon and running through the pain of early achilles tendonitis. If your achilles tendon is getting sore it is time to pay attention to it, immediately. Sudden increases in training can contribute to achilles tendonitis. Excessive hill running or a sudden addition of hills and speed work can also contribute to this problem. Two sole construction flaws can also aggravate achilles tendonitis. The first is a sole that is too stiff, especially at the ball of the foot. (In case you are having difficulty locating the “ball” of your foot, I mean the part where the toes join the foot and at which the foot bends) If this area is stiff than the “lever arm” of the foot is longer and the achilles tendon will be under increased tension and the calf muscles must work harder to lift the heel off the ground. The second contributing shoe design factor which may lead to continuing achilles tendon problem is excessive heel cushioning. Air filled heels, while supposedly are now more resistant to deformation and leaks are not good for a sore achilles tendon. The reason for this is quite simple. If you are wearing a shoe that is designed to give great heel shock absorption what frequently happens is that after heel contact, the heel continues to sink lower while the shoe is absorbing the shock. This further stretches the achilles tendon, at a time when the leg and body are moving forward over the foot. Change your shoes to one without this “feature”. Of course another major factor is excessive tightness of the posterior leg muscles, the calf muscles and the hamstrings may contribute to prolonged achilles tendonitis. Gentle calf stretching should be performed preventatively. During a bout of acute achilles tendonitis, however, overly exuberant stretching should not be performed.


Symptoms

Recurring localized pain, sometimes severe, along the tendon during or a few hours after running. Morning tenderness about an inch and a half above the point where the Achilles tendon is attached to the heel bone. Sluggishness in your leg. Mild or severe swelling. Stiffness that generally diminishes as the tendon warms up with use.


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.

Achilles Tendon


Surgical Treatment

Treating this surgically, there are numerous methods to repair the tendon. Most commonly, Achilles tendon is exposed through an incision at the back of the ankle. After identifying both ends of ruptured tendon, the edges got trimmed and then both ends were sutured together with optimal tension. To get a better outcome with fixation, an anchor may have to be in place in calcaneus, provided the rupture is very low. Care must be taken to avoid injuries to the nerves located adjacent to the tendon.


Prevention

Although Achilles tendinitis cannot be completely prevented, the risk of developing it can be lowered. Being aware of the possible causes does help, but the risk can be greatly reduced by taking the following precautions. Getting a variety of exercise – alternating between high-impact exercises (e.g. running) and low-impact exercise (e.g. swimming) can help, as it means there are days when the Achilles tendon is under less tension. Limit certain exercises – doing too much hill running, for example, can put excessive strain on the Achilles tendon. Wearing the correct shoes and replacing them when worn – making sure they support the arch and protect the heel will create less tension in the tendon. Using arch supports inside the shoe, if the shoe is in good condition but doesn’t provide the required arch support this is a cheaper (and possibly more effective) alternative to replacing the shoe completely. Stretching, doing this before and after exercising helps to keep the Achilles tendon flexible, which means less chance of tendinitis developing. There is no harm in stretching every day (even on days of rest), as this will only further improve flexibility. Gradually increasing the intensity of a workout – Achilles tendinitis can occur when the tendon is suddenly put under too much strain, warming up and increasing the level of activity gradually gives your muscles time to loosen up and puts less pressure on the tendon.

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