The Achilles (pronounced a-kill-ees) Tendon is the largest tendon in the human body. It is the large rope-like structure behind the heel and ankle. Tendonitis is an inflammation of a tendon. Achilles Tendonitis is inflammation of the Achilles Tendon. This problem is most commonly seen in athletes, but it can also be seen in non-athletes.
Symptoms of Achilles Tendonitis
In Achilles Tendonitis, patients present complaining of pain in the back of the heel that is most evident on getting up and taking the first few steps in the morning or after sitting for a while. The pain is fairly intense and can be sharp/shooting, burning or the patient states that it feels like the tendon is tight and about to tear. After a few minutes, the pain may decrease. In the athlete, the pain may also be seen during their running. It may not start at the onset of the run, but at some point into the run, they start to feel pain and the pain gradually increases as the run continues.
The Achilles Tendon and Mechanism of Injury
As previously stated, the Achilles Tendon is a large, strong rope-like tendon that attaches the Gastrocnemius (calf) Muscle Complex to the heel. It allows for Plantarflexion (downward flexion) of the foot. It is the strongest plantarflexor of the foot and ankle. The Achilles attaches to the back of the heel. For those in tune to the exact anatomic relationships, it should be noted that 90% of the Achilles tendon attaches into the back of the heel and the remainder flattens and continues coursing around the back and bottom of the heel as a sheet- or band-like structure called the Plantar Fascia. The Plantar Fascia is the thick ligament that extends the length of the arch. For more information on the Plantar Fascia, see the section under Plantar Fasciitis. Because of this unique relationship between the Plantar Fascia and the Achilles Tendon, the inflammatory processes of Achilles Tendonitis and Plantar Fasciitis are directly related and can sometimes be seen together.
Early on in the injury, the inflammation may be confined to the thin, silky surrounding tissues of the tendon sheath. When this is the only condition that exists, it is referred to as Synovitis (or inflammation of the synovium pronounced sin-ov-yum). When both the Tendon and the Synovium are involved, this is referred to as Tenosynovitis.
When the causative factor occurs in Achilles Tendonitis, there is an increase in the usual tension of the tendon. This causes microscopic tears to occur within the body of the tendon. As the microscopic tears occur, inflammation occurs. As these tears continue chronically, a condition called Achilles Tendonosis can occur. This is a thickening of the Achilles tendon around the site of the chronic tearing. This may cause a visible lump to form in the tendon. It also causes the tendon to feel tighter.
Causes of Achilles Tendonitis
- A dramatic increase in activity level. This is commonly seen in athletes when they increase their training regimen either in preparation for an event or as a permanent change in routine. Too dramatic an increase can cause the onset of Achilles tendonitis. This can also be seen in non-athletes as a change in the amount of standing and walking at work, etc. It can also be seen at the dramatic start of a new exercise/walking for exercise routine. A change in jobs to one requiring more standing and walking may start the inflammation of the Achilles tendon.
- As with the inflammatory process seen in Plantar Fasciitis, Achilles Tendonitis can also be seen with a dramatic decrease in activity. In those people who have always been active, when there is a decrease in activity level, they may start to notice the symptoms of Achilles Tendonitis.
- A change in weight-usually an increase. This causes an increase in the strain on the Achilles Tendon.
- Very commonly, the problem is caused by trauma. Direct impact on the tendon as in a tackle in Football or other sports can lead to pain and inflammation. A rapid strain on the tendon as in stepping in a hole and flexing the ankle quickly and very hard can also cause the inflammation to start in the tendon.
- The most common cause of Achilles tendonitis in the non-athlete is improper shoegear. A large sector of the population that can develop Achilles tendonitis are people who wear high heels regularly. This includes women who wear dress shoes with high heels (anything higher than ½ inch can be a causative factor) or men who wear cowboy boots. The constant wear of high heels causes a longterm contracture of the tendon. The inflammation starts when this person is not wearing the heels. They feel tightness and burning in the Achilles tendon.
Common conservative Treatments for Achilles Tendonitis. As this injury is so similar to Plantar Fasciitis and associated with the same biomechanical faults, the treatments are similar. They include:
- Changes in shoes to include more supportive sport/walking shoes. If the problem was precipitated due to chronic high heels, a gradual change to better shoes is often helpful.
- Oral anti-inflammatories such as Advil, Motrin and Aleve.
- Prescription strength anti-inflammatories prescribed by a physician.
- Anti-inflammatory injections (sometimes cortisone-type medications) into the area of inflammation. This practice is not condoned by most of the Podiatric and Orthopedic Community as it will cause further weakening of the tendon. Repeated injections at the site prevent normal healing of the microtears and can lead to complete or larger rupture of the Achilles Tendon. This is a very debilitating consequence and can be life-changing. I prefer to perform no anti-inflammatory injections of any kind for Achilles Tendonitis. There is much too much in the literature to show the relationship between injections at the site and eventual rupture of the tendon.
- Stretching exercises similar to those performed by runners and athletes. When done correctly, this stretches the entire posterior compartment of the lower extremity.
- Rest/Ice/Elevation also known as RICE. This will help ease the inflammation.
- Taping of the foot and ankle to correct any biomechanical fault that may be causing the strain on the tendon.
- Longterm conservative treatment should include custom-molded functional orthotics. We sometimes incorporate a heel lift into the device and lower it over time to allow the tendon to gradually lengthen.
- Immobilization in a below-knee cast or cast boot (cam-walker) is sometimes recommended. I do not condone this treatment as it may allow the pain to lessen and the tears to heal, but when the boot or cast comes off 6 weeks later, the tendon is weaker from immobilization and the causative factor is still present.
Surgical Treatments for Achilles Tendinitis
These are reserved for the most chronic and debilitating cases. If there is thickening of the tendon or the tears become visible on MRI or Diagnostic Ultrasound, surgical correction may become necessary. As the condition worsens, the tearing of the tendon from the back of the heel bone may cause a spur to form. This spur may become painful. In the older patient, the combination of the spur and loss of flexibility of the tendon may cause pain. This would also require surgical correction that may include removal of the spur.
Cryoanalgesia is also used as an effective treatment for Achilles Tendonitis. It should be noted that this procedure is used to alleviate the pain but does not fix the tension on the tendon. As part of the treatment course, the patient is placed into proper orthotics and appropriate shoegear. The heel is lowered with serial heel lifts (made thinner and thinner over time) to allow gradual tension increase in the tendon. As this occurs, there is continued pain. In the athlete or the active non-athlete, this pain can be debilitating even during the course of treatment. In these patients, cryo is a great option because we can get rid of the pain as the tendon is slowly stretched with exercise and orthotics and shoegear modification.
The procedure is performed on two small nerves above the ankle. These nerves feel the pain associated with Achilles tendonitis at the area of insertion. If a prolonged conduction block of these nerves is performed, the pain is relieved. The two nerves involved are the Posterior Achilles branches of the Tibial and Sural nerves. These branches are very small and are located on either side of the ankle just in front of the tendon. The cryo procedure is performed about 10cm above the ankle joint. This provides the best pain relief.
As the entire procedure is performed with Digital Ultrasound Guidance of the cryoprobe, in most cases, the procedure can be performed on both nerves through a single incision. Most patients relate an immediate relief of the sharp/shooting pain seen on post-sedentary (getting up after sitting for a while) and morning ambulation. The pain seen during activity that gradually increases with continued activity also decreases significantly. It is still present, but not enough to prevent activity/exercise. As the pain is relieved, we must actually encourage the patient to gradually increase activity level.
The procedure is performed through the same 3mm incision as at other sites. The incision heals without pain in 3 days or so. The patient may resume normal activity level without exercise or physical activity within 2-3 days. The non-athlete may return to normal exercise in a week or so. The athlete is encouraged to take 2 weeks off from exercise regimen, but when they resume the activity, it is at full activity.