What is Achilles Tendonitis?

Marathon training season is now upon us. The all too familiar Achilles tendonitis sneaks up on even the most experienced runner. Here is what you need to know about your Achilles heel.

What is Achilles tendonitis?

Achilles tendonitis is a common condition that occurs when the large tendon that runs down the back of your lower leg becomes irritated and inflamed.
The Achilles tendon connects your calf muscles to your heel bone and is used when you walk, run, climb stairs, jump, and stand on your tiptoes. The Achilles tendon is the largest tendon in the body.
The Achilles tendon can withstand great stresses during running and jumping. However, it is also prone to tendonitis, a painful condition associated with overuse and degeneration.

Are there different types of tendonitis?

Tendonitis is inflammation of the tendon. Inflammation is the body’s natural response to injury or disease and often causes swelling, pain, or irritation.
There are two types of Achilles tendonitis, based upon which part of the tendon is inflamed.

Non-insertional Achilles Tendonitis

In non-insertional Achilles tendonitis, fibres in the middle portion of the tendon begin to break down with tiny tears and then swell and thicken. This commonly affects younger, active people.

Insertional Achilles Tendonitis

Insertional Achilles tendonitis involves the lower portion of the heel, where the tendon attaches to the heel bone. Tendonitis that affects the insertion of the tendon comes from years of overuse. This usually is seen in long distance runners and sprinters.

What causes Achilles tendonitis?

Achilles tendonitis is usually not related to a single injury. The problem results from repetitive stress to the tendon. The usual causative factors are:

• When we push our bodies to do too much, too soon
• Sudden increase in the amount or intensity of exercise activity
• Tight calf muscles—Having tight calf muscles and suddenly starting an aggressive exercise program can put extra stress on the Achilles tendon
• Bone spur—Extra bone growth where the Achilles tendon attaches to the heel bone can rub against the tendon and cause pain

What are the symptoms of Achilles tendonitis?

Common symptoms of Achilles tendonitis include:

• Pain and stiffness along the Achilles tendon in the morning
• Pain on the back of the heel that worsens with activity
• Severe pain the day after exercising
• Thickening of the tendon
• Bone spur (insertional tendonitis)
• Swelling that is present all the time and gets worse throughout the day with activity

If you experience a sudden “pop” in the back of your calf or heel, you may have torn your Achilles tendon. See your doctor immediately if you think you may have torn your tendon.

What happens when you meet your specialist?

After you describe your symptoms and discuss your concerns, your ankle and foot will be examined.
The doctor will be looking for

• Swelling and thickening along the Achilles tendon or at the back of your heel
• Painful bony spurs at the back of your heel
• The point of maximum tenderness. Pain in the middle of the tendon, (non-insertional tendonitis) or pain at the back of your heel at the lower part of the tendon (insertional tendonitis)
• Tight Achilles tendon.

Tests

Your doctor may order imaging tests to make sure your symptoms are caused by Achilles tendonitis.

X-rays

X-ray tests provide clear images of bones. X-rays show evidence of a Haglund deformity, calcification of the tendon or a bone spur.

Magnetic Resonance Imaging (MRI)

Although magnetic resonance imaging (MRI) is not necessary to diagnose Achilles tendonitis, it is important for planning surgery. An MRI scan can show how severe the damage is in the tendon. If surgery is needed, your doctor will select the procedure based on the amount of tendon damage.

What are the treatment options?

1.Nonsurgical Treatment

In most cases, nonsurgical treatment options will provide pain relief, although it may take 3 to 6 months for symptoms to completely subside.

Rest. The first step in reducing pain is to decrease or even stop the activities that make the pain worse.
Ice. Placing ice on the most painful area of the Achilles tendon is helpful and can be done as needed throughout the day. This can be done for up to 20 minutes.
Non-steroidal anti-inflammatory medication. Drugs such as ibuprofen and naproxen reduce pain and swelling. Contact your doctor if you have to use them for a long duration.
Exercise. The following exercises can help to strengthen the calf muscles and reduce stress on the Achilles tendon.

1. Calf stretch
2. Physical Therapy including Eccentric Strengthening Protocol

Supportive shoes and orthotics. Pain from insertional Achilles tendonitis is often helped by certain shoes, as well as orthotic devices. Shoes that are softer at the back of the heel can reduce irritation of the tendon.

Heel lifts are also very helpful for patients with insertional tendonitis because they can move the heel away from the back of the shoe, where rubbing can occur. They also take some strain off the tendon. Like a heel lift, a silicone Achilles sleeve can reduce irritation from the back of a shoe.

If your pain is severe, your doctor may recommend a walking boot for a short time. This rests the tendon while keeping you mobile before any therapy is begun.

Extracorporeal shockwave therapy (ESWT). During this procedure, high-energy shockwave impulses stimulate the healing process in damaged tendon tissue. ESWT is noninvasive and has minimal risk. Ask your specialist about this. This procedure is available at the Highgate Private Hospital.

Platelet-rich plasma injection(PRP). PRP is plasma with many more platelets than what is typically found in blood. The concentration of platelets and therefore the concentration of growth factors can be 5 to 10 times greater than usual. Injecting this into the tendons can accelerate its regeneration and therefore healing.
For a PRP preparation, blood must first be drawn from a patient. The platelets are separated from other blood cells and their concentration is increased during a process called centrifugation. Then the increased concentration of platelets is injected into the affected tendon.
This exciting new treatment for Achilles tendon disorders is offered at the Highgate Private Hospital. Please ask your specialist about this.

2.Surgical Treatment

Surgery should be considered to relieve Achilles tendonitis only if the pain does not improve after 6 months of nonsurgical treatment. The specific type of surgery depends on the location of the tendonitis and the amount of damage to the tendon.
1.Gastrocnemius recession. This is a surgical lengthening of the calf (gastrocnemius) muscles. Because tight calf muscles place increased stress on the Achilles tendon, this procedure is useful for patients who still have difficulty flexing their feet, despite consistent stretching.
2.Debridement of the tendon where all the degenerative tissue is excised followed by a repair (when less than 50% of the tendon is damaged).
3.Debridement of the tendon with tendon transfer (when the tendon has greater than 50% damage).

Recovery

Most patients have good results from surgery. The main factor in surgical recovery is the amount of damage to the tendon. Greater the tendon damage longer the recovery period.
Physical therapy is an important part of recovery. Many patients require 12 months of rehabilitation before they are pain-free.

Summary

Achilles tendon is one of the most important tendons in your body. The tendon helps you to push off during walking, running, jumping and climbing stairs. Pain and discomfort in the Achilles tendon is usually a sign of repetitive trauma, degeneration and inflammation. Don’t ignore this as this can become chronic and lead to a tear. Consult your doctor, physiotherapist and specialist surgeon for a comprehensive treatment plan.