The largest tendon in the body is the Achilles tendon. The Achilles tendon which connects to the calf muscles to the heel bone is used when walking, jumping, or running. While the Achilles tendon can often withstand stress from jumping and running, it can become prone to tendinitis. Achilles tendinitis is characterized by pain along the back of the leg (near the heel).
Essentially, the condition is attributed to both degeneration and overuse.
Simply put, tendinitis is the inflammation of the tendon. Inflammation is considered the body’s natural response to disease or injury and it often results in pain, swelling, or irritation. There are two types of Achilles tendinitis, depending on the part of the tendon that is inflamed.
Noninsertional Achilles Tendinitis – This type of Achilles tendinitis occurs when the fibers found in the tendon’s middle portion thickens, swells, and has tiny (micro) tears. This type of tendinitis often affects young and active individuals.
Insertional Achilles Tendinitis – This type of tendinitis develops in the heel’s lower portion (where the tendon is attached to the heel bone). In both types of Achilles tendinitis, the damaged tendon fibers may also harden (calcify). However, bone spurs can also develop in people with insertional Achilles tendinitis. This type can affect anyone, even those patients who are not active.
In most cases, Achilles tendinitis is not associated with any specific injury. The injury often occurs secondary to repetitive tendon stress. In other words, it can develop when the tendon is made to do too much or too soon. However, the condition can also be attributed to the following:
- Drastic increase in the intensity or amount of exercise – For instance, increasing the distance you cover by a few miles without giving the body a chance to gradually adjust.
- Tight Calf muscles – Individuals with tight muscles who start an aggressive exercise program drastically can put unnecessary stress and strain on the Achilles tendon.
- Bone spur – Extra bone growths can end up rubbing against the tendon and cause a lot of pain.
Telltale indicators of Achilles tendinitis can include:
- Stiffness and pain along the Achilles tendon (especially noticeable in the mornings)
- Pain at the back of the heel or along the tendon (often worsens with activity)
- Severe pain (often manifests a day after exercising)
- Pain on squatting
- Thickening of the tendon
- Swelling (can get worse with activity)
- Bone spur (in the case of insertional tendinitis)
If a sudden “pop” is felt in the heel or the back of the calf, it can be due to a torn (ruptured) Achilles tendon. There is a weakness in pushing off with the foot. In similar scenarios, getting immediate medical attention is recommended.
To accurately diagnose the condition, the ankle and the foot will be examined. The doctor will look for the following signs:
- Swelling (at the back of the heel) 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)
- Maximum tenderness
- Pain in the middle of tendon (in non-insertional tendinitis)
- Limited motion range of the ankle (a noticeable decrease in the ability to flex the foot)
To rule out other possible underlying conditions, the following imaging tests might be required:
- Magnetic Resonance Imaging (MRI) – While an MRI scan will not be used to diagnose Achilles tendinitis, it is considered vital when planning the surgery. An MRI scan can also show the severity of the tendon damage. If surgery is required, the procedure will be based on the tendon damage severity.
- Ultrasound scan – Ultrasound scans can detect the fluid or small tears within the tendon.
- X-rays – X-rays can be used to check if the lower part of the Achilles tendon has hardened or calcified or there may be visible bone spurs.
Nonsurgical Treatment Options
Basically, nonsurgical treatment interventions can help alleviate the pain. However, it will usually take months before the symptoms subside completely.
- Rest – The first step to effectively reduce the pain is to minimize (or completely stop) doing activities that will only make the pain worse. For instance, those who do high-impact exercises should switch to low-impact, non-repetitive ones at least for the time being to lessen tendon stress.
- Ice – Placing ice on the painful area can be beneficial and can be done as needed. This can be done for at least 20 minutes each time and should be stopped when the skin starts to feel numb.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) – Medications like naproxen and ibuprofen can help reduce the swelling and alleviate the pain. However, NSAIDs can’t minimize the thickening of the tendon.
- Physical therapy – Physical therapy such as ultrasound treatment is considered beneficial for patients with Achilles tendinitis although it has been proven to work better for non-insertional tendinitis than insertional tendinitis.
- Supportive shoes and orthotics – Pain from insertional Achilles tendinitis will often get better with the help of orthotic devices and supportive shoes. However, if the pain is severe, a walking boot to immobilize the ankle joint might be recommended. It will give the tendon a chance to rest before any therapy can commence.
- Judicious injections or platelet-rich plasma (PRP) have been known to improve healing of partial tears associated with Achilles tendinitis.
Surgery is often considered when the pain does not subside even after 6 months of conservative treatment. In addition, the specific type of surgery that will be carried out will depend on the severity of the tendon damage and the location of the tendinitis.
- Gastrocnemius recession – This procedure is a surgical lengthening of the gastrocnemius (calf) muscles. Since tight calf muscles can increase strain on the Achilles tendon, this surgery is beneficial for those who have difficulty flexing their feet even after consistent stretching.
- Debridement and repair – This is often the procedure done when there is less than 50 per cent tendon damage. The primary goal of the procedure is to remove the tendon’s unhealthy portion which may delay healing.
- Debridement with tendon transfer – This procedure is carried out when there is more than 50 per cent tendon damage. In some cases, when more than 50 per cent of the tendon requires removal, the remaining portion is no longer strong enough to function on its own. To ensure the remaining tendon does not rupture with activity, an Achilles tendon transfer is done using part of the big toe (flexor halluces) tendon.
While there is no foolproof way to prevent Achilles tendinitis, the following measures can help reduce one’s risk significantly:
- Gradually increase activity level – When starting an exercise regimen, start slowly and ensure any increase in the duration or intensity of training is gradual.
- Take it easy – When possible, refrain from doing activities that will put excessive stress on the tendon. When participating in any strenuous activity, ensure to warm up first.
- Choose proper-fitting footwear – Shoes worn during exercise should provide adequate heel cushioning and should come with a firm arch support to minimize tension in the Achilles tendon.
- Stretch daily – The calf muscles and the Achilles tendon should be stretched before and after exercise in order to maintain flexibility.
- Cross-train – To help reduce one’s risk, consider alternating between high-impact activities (i.e. running and jumping) and low-impact ones (i.e. swimming and cycling).