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Achilles Tendinitis


Achilles Tendinitis

Achilles tendinitis is a common condition that causes pain along the back of the leg near the heel.

 
Achilles Tendon
 
     

What is Achilles Tendinitis

Simply defined, tendinitis is inflammation of a 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 tendinitis, based upon which part of the tendon is inflamed.

Noninsertional Achilles Tendinitis

In noninsertional Achilles tendinitis, fibers in the middle portion of the tendon have begun to break down with tiny tears (degeneration), swell, and thicken.

Tendinitis of the middle portion of the tendon more commonly affects younger, active people. There is usually history of injury. It can also occurs after achilles tendon rupture or injury.

 
Non insertional Achilles Tendinitis
 
 
Noninsertional Achilles tendinitis
 

Insertional Achilles Tendinitis

Insertional Achilles tendinitis involves the lower portion of the heel, where the tendon attaches (inserts) to the heel bone.

In both noninsertional and insertional Achilles tendinitis, damaged tendon fibers may also calcify (harden). Bone spurs (extra bone growth) often form with insertional Achilles tendinitis.

Tendinitis that affects the insertion of the tendon can occur at any time, even in patients who are not active.

 
Insertional Achilles Tendinitis
 
 
Insertional Achilles tendinitis
 

Cause

Achilles tendinitis especially non insertional can be related to a previous injury. The problem can also result from repetitive stress to the tendon. This often happens when we push our bodies to do too much, too soon, but other factors can make it more likely to develop tendinitis, including: A bone spur that has developed where the tendon attaches to the heel bone. This is called Haglund’s Deformity.

 
X-Ray Haglunds deformity and insertional Achilles tendinitis
 
     
     

Symptoms

Common symptoms of Achilles tendinitis include:

1. Pain and stiffness along the Achilles tendon in the morning
2. Pain along the tendon or back of the heel that worsens with activity
3. Severe pain the day after exercising
4. Thickening of the tendon
5. Bone spur (insertional tendinitis)
6. Swelling that is present all the time and gets worse throughout the day with activity
Treatment

Nonsurgical Treatment

  • Rest

    Decrease or stop the activities that make the pain worse. If you regularly do high-impact exercises (such as running), switching to low-impact activities will put less stress on the Achilles tendon. Cross-training activities such as biking, elliptical exercise, and swimming are low-impact options to help you stay active.

  • 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 and should be stopped earlier if the skin becomes numb.

  • Non-steroidal anti-inflammatory medication

    Drugs such as brufen and naproxen reduce pain and swelling. They do not, however, reduce the thickening of the degenerated tendon. Using the medication for more than 1 month should be reviewed with your doctor.

  • Exercise

    The following exercise can help to strengthen the calf muscles and reduce stress on the Achilles tendon.

 
Streching exercises for Tendoachilles
 
     
  • Calf stretch 

    Lean forward against a wall with one knee straight and the heel on the ground. Place the other leg in front, with the knee bent. To stretch the calf muscles and the heel cord, push your hips toward the wall in a controlled fashion. Hold the position for 10 seconds and relax. Repeat this exercise 20 times for each foot. A strong pull in the calf should be felt during the stretch.

  • Physical Therapy

    Physical therapy is very helpful in treating Achilles tendinitis. It has proven to work better for noninsertional tendinitis than for insertional tendinitis.

  • Eccentric Strengthening Protocol

    Eccentric strengthening is defined as contracting (tightening) a muscle while it is getting longer. Eccentric strengthening exercises can cause damage to the Achilles tendon if they are not done correctly. At first, they should be performed under the supervision of a physical therapist. Once mastered with a therapist, the exercises can then be done at home. These exercises may cause some discomfort, however, it should not be unbearable.

 
Streching exercises for Tendoachilles 1
 
     
  Bilateral heel drop  
 
Stand at the edge of a stair, or a raised platform that is stable, with just the front half of your foot on the stair. This position will allow your heel to move up and down without hitting the stair. Care must be taken to ensure that you are balanced correctly to prevent falling and injury. Be sure to hold onto a railing to help you balance.
Lift your heels off the ground then slowly lower your heels to the lowest point possible. Repeat this step 20 times. This exercise should be done in a slow, controlled fashion. Rapid movement can create the risk of damage to the tendon. As the pain improves, you can increase the difficulty level of the exercise by holding a small weight in each hand.
 
     
  Single leg heel drop  
 

This exercise is performed similarly to the bilateral heel drop, except that all your weight is focused on one leg. This should be done only after the bilateral heel drop has been mastered.
 
  •  

Heel lifts are also very helpful for patients with insertional tendinitis 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 gives the tendon a chance to rest before any therapy is begun. Extended use of a boot is discouraged, though, because it can weaken your calf muscle.

Surgical Treatment

Surgery should be considered to relieve Achilles tendinitis only if the pain does not improve after 6 months of nonsurgical treatment. The specific type of surgery depends on the location of the tendinitis and the amount of damage to the tendon.

  • Debridement and repair (tendon has less than 50% damage).

    The goal of this operation is to remove the damaged part of the Achilles tendon. Once the unhealthy portion of the tendon has been removed, the remaining tendon is repaired with sutures, or stitches to complete the repair.

    In insertional tendinitis, the bone spur is also removed. Repair of the tendon in these instances may require the use of metal or plastic anchors to help hold the Achilles tendon to the heel bone, where it attaches.After débridement and repair, most patients are allowed to walk in a removable boot or cast within 2 weeks, although this period depends upon the amount of damage to the tendon.
 
Open Surgery for Achilles tendinitis
 
     
     
  • Debridement with tendon transfer (tendon has greater than 50% damage)
     In cases where more than 50% of the Achilles tendon is not healthy and requires removal, the remaining portion of the tendon is not strong enough to function alone. To prevent the remaining tendon from rupturing with activity, an Achilles tendon transfer is performed. The tendon that helps the big toe point down is moved to the heel bone to add strength to the damaged tendon. Although this sounds severe, the big toe will still be able to move, and most patients will not notice a change in the way they walk or run.
    Depending on the extent of damage to the tendon, some patients may not be able to return to competitive sports or running.

Recovery

Most patients have good results from surgery. The main factor in surgical recovery is the amount of damage to the tendon. The greater the amount of tendon involved, the longer the recovery period, and the less likely a patient will be able to return to sports activity.

Physical therapy is an important part of recovery. Many patients require 12 months of rehabilitation before they are pain-free.

 
chronic achilles tendon damage
 
picture showing FHL retrieval1
 
Picture showing FHL retrieval 1
 
Picture of  FHL weave giving strength to Achilles
 
MRI Scan of same patient before and 5 years after surgery showing FHL hypertrophy