Achilles Tendinitis

Overview

The Achilles tendon is the largest and strongest tendon in the body. Achilles tendonitis is a painful and often debilitating inflammation of the Achilles tendon, also called the heel cord. The Achilles tendon is located in the back of the lower leg, attaches to the heel bone (calcaneus), and connects the leg muscles to the foot. It gives us the ability to rise up on our toes and facilitates the act of walking. Achilles tendonitis can make walking almost impossible.

There are three stages of tendon inflammation:

1. Peritenonitis -- characterized by localized pain during or following activity. As this condition progresses, pain often develops earlier on during activity, with decreased activity, or while at rest.
2. Tendinosis -- a degenerative condition that usually does not produce symptoms. It may cause swelling or a hard knot of tissue (nodule) on the back of the leg.
3. Peritenonitis with tendinosis -- results in pain and swelling with activity. As this condition progresses, partial or complete tendon rupture may occur. Achilles tendonitis is more common in athletes. It occurs in approximately 6-18% of runners.

Causes

Athletes who are in poor condition are most likely to develop Achilles tendonitis. Sports that involve sudden stops and starts and repetitive jumping (e.g., baseball, basketball, football, tennis, running, dancing) increases the risk for the condition. It often develops following sudden changes in activity level, training on poor surfaces, or wearing inappropriate footwear.

Achilles tendonitis may be caused by a single incident of overstressing the tendon, or it may result from a series of stresses that produce small tears over time. Individuals who exercise irregularly or those that are beginning an exercise program, are also susceptible due to the fact that inactive muscles and tendons have little flexibility because of inactivity. It is important for people who are just starting to exercise to stretch properly, start slowly, and increase gradually.

In some cases, a congenital (i.e., present at birth) condition causes Achilles tendonitis. Typically, this is due to abnormal rotation of the foot and leg (pronation), which causes the arch of the foot to flatten and the leg to twist more than normal.

This condition causes the lower leg muscles to stretch more than normal. Like a rubber band, the further the muscles stretch, the tighter they become. The force on the Achilles tendon and the heel bone increases, resulting in Achilles tendonitis. Because the arch of the foot naturally flattens over time, especially in athletes, Achilles tendonitis often develops later in life.

Switching from high-heeled shoes to sneakers for exercise can cause Achilles tendonitis. The Achilles tendon and lower leg muscles gradually adapt to a shortened position because the shoes prevent the heel from stretching all the way to the ground. When this occurs, wearing sneakers or flat shoes forces the Achilles tendon to stretch further than it is accustomed to, causing inflammation. If high heels are worn everyday, stretching should be done every morning and night to keep the Achilles tendon lengthened.

Signs and Symptoms

The symptoms generally develop gradually. The pain may be mild at first but get worse with continued activity. Repeated or continued stress on the Achilles tendon increases inflammation and may cause it to rupture.

Walking may be impossible if partial or complete rupture results in traumatic damage and severe pain. This may take a long recovery period. Patients with tendinosis may experience a sensation of fullness in the back of the lower leg or develop a hard knot of tissue (nodule).

Treatment

Treatment for Achilles tendonitis depends on the severity of the injury. Physical activity that produces the symptoms should be discontinued if heel pain, tenderness, swelling, or discomfort in the back of the lower leg occurs.

Consult a medical professional if the problem returns or persists. If pain develops even with proper stretching and training techniques, the patient should consult a podiatrist, or foot doctor, to check for hyperpronation and adequate arch support. The addition of an orthotic may be enough to maintain good arch and foot alignment and eliminate pain. If damage to the tendon is minor, the injury may respond to a simple course of treatment known as RICE (rest, ice, compression, elevation). Patients are advised to:

• rest the tendon by keeping off their feet as much as possible;
• apply ice packs for 20 minutes at a time every hour for a day or two to reduce swelling;
• compress the ankle and foot with a firmly (not tightly) wrapped elastic bandage; and
• elevate the foot whenever possible to minimize swelling.

To reduce pain and swelling, a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen may be used.

A flexible cast may be used to immobilize the foot and reduce swelling, and crutches may be used to keep weight off the foot. This treatment may be necessary for up to 8 weeks.

If the injury responds to this treatment, the patient may then be advised to wear low-heeled shoes and perform rehabilitation exercises (e.g., physical therapy) to gradually stretch the tendon before full activity is resumed.

Surgery is necessary for severe Achilles tendonitis, tendon rupture, or tearing away from the heel bone. Length rehabilitation may be necessary also. Surgery involves removing the tendon's inflamed outer covering and reattaching the torn tissues.

Following surgery, patients undergo passive range of motion physical therapy and progressive strengthening exercises for 2-3 weeks. Most activities can be resumed in 6-10 weeks and competitive sports usually can be resumed after 3-6 months.

Prevention

Always warm up when beginning a physical activity (e.g., jumping jacks, light jogging) and stretch properly before beginning the activity. Wear proper footwear and condition the foot properly in order to avoid Achilles tendonitis. Cold muscles are inflexible and working them hard without stretching causes excessive stress to the muscles and tendons. If it is uncomfortable, the activity should be discontinued immediately.

Apply ice to the affected area to relieve inflammation. If the problem persists or recurs, seek medical evaluation. It may be advisable to consult a physical trainer to determine whether a flaw in technique is contributing to the problem.