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Achilles Tendon

Recognizing Achilles Tendinitis: The Essentials

The largest tendon in the body is the Achilles tendon. It connects the calf muscles to the heel bone and is used in walking, running, and jumping. While the Achilles tendon can often withstand stress secondary to jumping and running, it can become susceptible to tendinitis, a condition associated with degeneration and overuse.

Simply put, tendinitis is the inflammation of the tendon. The condition characterised by pain along the back of the leg (below the calf down to the heel) is called Achilles tendinitis.

Causes

In most cases, Achilles tendinitis is not attributed to any specific injury. The condition is often secondary to repetitive tendon stress. However, other factors have been known to contribute to the development of the condition. Some of the factors include:

  • Drastic increase in the intensity or amount of activity (for instance, suddenly increasing the distance covered without giving the body ample time to adjust)
  • Tight calf muscles
  • Bone spurs

Symptoms

Some of the common symptoms of Achilles tendinitis include:

  • Stiffness and pain along the Achilles tendon (especially in the mornings)
  • Pain in the back of the heel or along the tendon (often worsens with activity)
  • Thickening of the tendon
  • Bone spurs at the heel (calcaneum)
  • Swelling (often gets worse with activity)

Diagnosis

During the physical examination, the doctor will look for telltale indicators of Achilles tendinitis, including:

  • Swelling at the back of the heel or along the Achilles tendon
  • Enlargement or thickening of the Achilles tendon
  • Bony spurs at the back of the heel or at the lower part of the tendon
  • Tenderness
  • Pain in the middle of the tendon
  • Limited range of motion of the ankle

To help ensure the diagnosis is accurate, imaging tests may also be ordered.

  1. X-rays – X-ray tests are used to provide clear images of the bones. X-rays can also show whether or not the lower part of the Achilles tendon has hardened or calcified. Calcification often indicates insertional Achilles tendinitis. In severe cases of noninsertional Achilles tendinitis, calcification can occur in the tendon’s middle portion as well.
  2. Ultrasound – This non-invasive method has the advantage of being a dynamic scan. Fluid collection can be detecte, a partial tear of the tendon can also be diagnosed. In addition injections can be given accurately guided by ultrasound
  3. Magnetic Resonance Imaging (MRI) – While MRI is not required to diagnose the condition, it is considered important when planning for surgery. An MRI scan can show how severe the tendon damage is. If surgery will be required, the procedure carried out will be based on the severity of the tendon damage.

Treatment

Nonsurgical Interventions

In many cases, nonsurgical treatment interventions can provide relief from pain. However, oftentimes, even with early treatment, the pain can linger for more than 3 months. Nonsurgical treatment options can include:

  1.  Rest and ice – The first step in minimizing pain is to decrease or completely stop activities that can worsen it.
  2.  Exercise modification – For instance, patients who perform high-impact exercises on a consistent basis should switch to low-impact activities that will not put much stress on the Achilles tendon. Cross-training activities like swimming, biking, and elliptical exercises are considered some of the best options.
  3.  Eccentric Strengthening Protocol – Eccentric strengthening protocol involves tightening (contracting) a muscle while it is getting longer. However, these exercises should only be done under the supervision of a physical therapist as it may cause damage to the Achilles tendon when not done properly. Once mastered, the exercises can be done at home.
  4.  Orthotics and supportive shoes – Pain from Achilles tendinitis will sometimes respond to certain shoes and orthotic devices. For instance, footwear that is softer at the back of the heel can help reduce tendon irritation. Heel lifts can also help minimize strain on the tendon. It has also been known to be especially beneficial for patients with insertional tendinitis as it moves the heel away from the shoe’s back (where rubbing can occur).

If the pain is severe, a walking boot might be recommended for a short period. It will give the tendon a chance to rest before any therapy can begin. However, extended use of the boot is discouraged as it can weaken the calf muscle.

Surgical Interventions

Surgery will be considered if the pain will not improve after 6 months of conservative treatment. The type of surgery that will be performed will depend on the amount of tendon damage and the location of the tendinitis.

1. Gastrocnemius Recession

In essence, this procedure is the surgical lengthening of the gastrocnemius (calf) muscles. Since tight calf muscles can put stress on the Achilles tendon, the procedure is considered beneficial for patients who experience difficulty flexing their feet even after consistent stretching. In gastrocnemius recession, one of the the two muscles that comprise the calf will be lengthened to enhance the ankle’s motion. The procedure can be done with a traditional open incision or it can be carried out with smaller incisions and an endoscope.

2. Injections

Platelet–rich plasma can be injected into the Achilles tendon sheath. It is blood cells derived from a patient’s blood and is purported to include stem cells which heal the inflammed tendon.
Steroids should not be injected into the Achilles tendon as there is a significant risk of complete rupture, especially in the middle-aged or older person.

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