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Achilles Tendonitis

Achilles tendonitis is an inflammatory response to injury of the Achilles tendon. The Achilles tendon (calcaneal tendon) attaches the gastrocnemius, soleus, and plantaris muscles in the calf to the heel bone (calcaneus). It is the largest tendon in the body and is visible at the back of the ankle. Like all tendons, it is made from strong, dense connective fibers. Because of its position and function it is used during walking, running, jumping and similar actions. It is therefore vulnerable to damage from overuse and normal degeneration due to aging.

There are two types of tendonitis (sometimes called tendinitis, or tendinopathy). Non-insertional Achilles tendonitis occurs when fibers in the middle portion of the tendon begin to degenerate by fraying, weakening, and breaking. The healing process can produce areas of thick scar tissue.

Insertional Achilles tendonitis occurs where the tendon inserts into the heel bone. Bony spurs often grow as a result, and the damaged tendon fibers can harden in a process called calcification.

Younger, more active people tend to develop noninsertional Achilles tendonitis, while insertional tendonitis can affect people of any age or level of activity.

Tendonitis usually develops as a result of repetitive overuse of the tendon, without allowing adequate time for healing. A sudden increase in the intensity of training, or a change in surface, can overstress the tendon and cause damage. Sometimes the tendon is injured as a result of sudden trauma, but normally the damage accrues over time.

Extra bone in the form of a bone spur, where the tendon inserts into the heel, will irritate the tendon with every movement.

Exercising without properly warming up the calf muscles, or having tight calf muscles, will increase the risk of injuring the tendon.

A small percentage of people may develop Achilles tendonitis as a result of taking statins for another condition.

A foot with a naturally flat arch will increase the risk, as will other irregularities of lower limb structure.

  • Pain, worse some time after activity, felt in the back of the heel
  • Pain especially when running, jumping, or climbing hills or stairs
  • Stiffness and pain along the path of the tendon, especially in the morning or after periods of inactivity, better with mild exercise
  • Bone spur
  • Swelling at the back of the ankle, or on the back of the heel
  • Thickened tissues at the back of the ankle
  • A sensation of a ‘pop’ at the back of the calf or heel. If this happens it is probable that you have ruptured the tendon and you should seek immediate medical assistance.
Your doctor will take a thorough medical history, and ask questions pertaining to your symptoms. You will then have a physical examination of the foot and ankle. The doctor will be looking specifically for signs of swelling and thickening, and areas of tenderness or pain. The range of motion of your ankle will be assessed.

X-ray tests will probably be taken so that any calcification of the Achilles tendon can be seen. If the X-rays show damage that may require surgery, an MRI (magnetic resonance imaging) scan might also be performed.

If surgery is not considered necessary, conservative (non-surgical) methods can provide relief from symptoms of Achilles tendonitis, but may need to be followed for several months to achieve a full recovery.

Resting the tendon is the first step. Avoid all activities that aggravate the condition. Low-impact exercises such as swimming or stationary bicycling, instead of high-impact running and jumping sports, will allow you to remain active and fit while the tendon is healing.

During the acute stage of the injury applying ice to the painful area will help to relieve pain and swelling. Crush ice in a bag and wrap the bag in a towel before placing next to the skin. Ice the tendon several times a day.

NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen (Advil) or naproxen (Aleve) can be taken as needed and as directed.

A compression bandage worn on the ankle will restrict movement of the tendon, and elevating the foot above the level of your heart will reduce swelling.

Wearing an orthotic insert can help relieve pain. Heel lifts reduce pressure of the heel on the back of the shoe. An Achilles sleeve is a silicon insert that works in a similar way, protecting the tendon from rubbing against the shoe. If the damage is quite severe you may be advised to temporarily wear a walking boot, which will allow the tendon tissues to heal. Prolonged use of a boot can lead to weakened calf muscles.

Physiotherapy works very well, especially for non-insertional Achilles tendonitis. Your physiotherapist will design a series of exercises for you, to stretch and strengthen your calf muscles. Occasionally ESWT (extracorporeal shockwave therapy) is used in an effort to stimulate healing of damaged tendon tissues. Results are mixed, however, so this treatment is not always offered, although it may be tried before surgery is decided upon.

A fairly new procedure called PPP (platelet rich plasma) injection is being researched. It consists of an injection of your own blood plasma into chronically damaged tendon tissues. The plasma is thought to contain factors that stimulate healing.

If surgery is necessary, the particular procedure will depend on the location and severity of the damage. Debridement consists of removing the damaged areas of tissue and repairing the remaining tendon. Any bone spurs would be removed at the same time. Sometimes it might be necessary to strengthen the tendon by taking a tendon from the big toe and attaching it to the Achilles tendon. Another procedure involves lengthening the gastrocnemius muscle in the calf.

Surgery is usually successful in resolving Achilles tendonitis, but recovery times can take up to a year.

Exercises should only be done with the prior approval of your doctor. Be sure to exercise both legs in order to avoid creating an imbalance between them.
Calf stretch:
Stand facing a wall and place hands on it for support. Lean forwards until stretch is felt in the calves. Hold for 30 seconds. Bend at knees and hold for a further 30 seconds. Repeat 5 times.
Achilles tendon stretch:
Stand with your toes on the edge of a step and your heels over the edge. Have a support such as a wall next to you. Slowly raise your heels as high as you can, then lower your heels to their lowest point. Be careful to do this slowly and steadily in order to avoid further damage to the Achilles tendon. Repeat 20 times.

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