Achilles tendonitis is a relatively common condition characterized by tissue damage and pain in the Achilles tendon. The muscle group at the back of the lower leg is commonly called the calf. The calf comprises of 2 major muscles, one of which originates from above the knee joint (gastrocnemius), the other of which originates from below the knee joint (soleus). Both of these muscles insert into the heel bone via the Achilles tendon. During contraction of the calf, tension is placed through the Achilles tendon. When this tension is excessive due to too much repetition or high force, damage to the tendon occurs. Achilles tendonitis is a condition whereby there is damage to the tendon with subsequent degeneration and inflammation. This may occur traumatically due to a high force going through the tendon beyond what it can withstand or, more commonly, due to gradual wear and tear associated with overuse.
Achilles tendonitis most commonly occurs due to repetitive or prolonged activities placing strain on the Achilles tendon. This typically occurs due to excessive walking, running or jumping activities. Occasionally, it may occur suddenly due to a high force going through the Achilles tendon beyond what it can withstand. This may be due to a sudden acceleration or forceful jump. The condition may also occur following a calf or Achilles tear, following a poorly rehabilitated sprained ankle or in patients with poor foot biomechanics or inappropriate footwear. In athletes, this condition is commonly seen in running sports such as marathon, triathlon, football and athletics.
Paratenonitis presents in younger people. Symptoms start gradually and spontaneously. Aching and burning pain is noted especially with morning activity. It may improve slightly with initial activity, but becomes worse with further activity. It is aggravated by exercise. Over time less exercise is required to cause the pain. The Achilles tendon is often enlarged, warm and tender approximately 1 to 4 inches above its heel insertion. Sometimes friction is noted with gentle palpation of the tendon during ankle motion. Tendinosis presents similarly but typically in middle-aged people. If severe pain and limited walking ability are present, it may indicate a partial tear of the tendon.
Confirming Achilles tendonitis may involve imaging tests. X-rays provide images of the bones of the foot and leg. Magnetic resonance imaging (MRI) is useful for detecting ruptures and degeneration of tissue. Ultrasound shows tendon movement, related damage, and inflammation.
Make sure that the tendon is not torn through and through. If it is severed, you must see a doctor immediately so that the tendon can be repaired. Severe injuries can sever a tendon, without a skin laceration being present. Testing involves moving the toes and foot to see if the tendon moves. If the tendon does not appear to move, it may be severed (comparing the injured tendon and its movement to the same tendon on the uninjured foot may help). Very sharp pain, a sudden pop, or an obvious gap in the structure of the tendon are all signs of a rupture, and should be seen by a doctor as soon as possible. If there is extreme swelling of the leg, and pain (out of proportion to the amount of trauma received), you may have sustained a vascular injury. A doctor must see this type of injury immediately. If you are not sure, see a doctor. If you have multiple injured areas see a doctor immediately, in order to prevent excessive swelling and pain. If the above exam is negative, then you may proceed with self-treatment. (However, if you are not sure of the extent of your injury, you should consult your doctor immediately). The sooner you begin to treat your injury by following “R.I.C.E.”, the better you will feel. Rest is very important. Take off your shoe, get off your feet, and relax. Ice should be applied as soon as possible. Never apply ice directly on the injured area, as the cold may make the pain worse. Ice should be applied close to the injured site, between the heart and the injury, so that as the blood flows under the ice, it will be cooled. This cool blood flowing into the injured area will help to reduce the swelling and pain. Apply the ice, wrapped in a cloth or over an elastic bandage, to the foot for 15 minutes, every 1-2 hours, for up to 3 days after an injury. If the ice is uncomfortable, or causes increased pain, do not continue to use it, and see a doctor. If you have poor circulation do not use ice, as this may cause a serious problem. c. Compression is used to limit swelling, and to give support to the injured area. Compression should be applied to the entire foot, starting first at the toes and working back to the ankle. If it is applied just to the injured area, increased swelling will occur in front and behind the wrapping. Compression should be applied with a 3-inch elastic bandage, beginning around the base of all the toes, and then going around the foot and ankle. Continue over the calf muscle when possible. Compression reduces motion in the injured area and foot, and this decreases the pain, and allows for quicker healing. The bandage should not be so tight that it causes increased pain or throbbing in the toes or foot. It should be comfortable! Do not remove the elastic bandage for the first 12 hours, unless it becomes too tight, or the pain increases, or the toes become pale, blue, or cool. If any of these things happen, immediately remove all bandages, and leave them off for several hours. The normal color and temperature of the toes should return immediately. If not, see a doctor immediately! Continue until the swelling and pain subsides; it could take from several days to several weeks. d. Elevation of the leg will aid in reducing swelling and pain. Blood rushes to an injured area to bring increased blood cells, that aid in healing. Gravity will also force blood to the injured area. Too many cells and too much fluid will apply pressure to the injured nerves and tissues, and cause increased pain and delayed healing. Keep your foot elevated so that it is at least parallel to the ground, or higher if it is comfortable. Do this for at least 48 hours, or until the throbbing subsides, when you lower the leg.
Treating this surgically, there are numerous methods to repair the tendon. Most commonly, Achilles tendon is exposed through an incision at the back of the ankle. After identifying both ends of ruptured tendon, the edges got trimmed and then both ends were sutured together with optimal tension. To get a better outcome with fixation, an anchor may have to be in place in calcaneus, provided the rupture is very low. Care must be taken to avoid injuries to the nerves located adjacent to the tendon.
Although Achilles tendinitis cannot be completely prevented, the risk of developing it can be lowered. Being aware of the possible causes does help, but the risk can be greatly reduced by taking the following precautions. Getting a variety of exercise – alternating between high-impact exercises (e.g. running) and low-impact exercise (e.g. swimming) can help, as it means there are days when the Achilles tendon is under less tension. Limit certain exercises – doing too much hill running, for example, can put excessive strain on the Achilles tendon. Wearing the correct shoes and replacing them when worn – making sure they support the arch and protect the heel will create less tension in the tendon. Using arch supports inside the shoe, if the shoe is in good condition but doesn’t provide the required arch support this is a cheaper (and possibly more effective) alternative to replacing the shoe completely. Stretching, doing this before and after exercising helps to keep the Achilles tendon flexible, which means less chance of tendinitis developing. There is no harm in stretching every day (even on days of rest), as this will only further improve flexibility. Gradually increasing the intensity of a workout – Achilles tendinitis can occur when the tendon is suddenly put under too much strain, warming up and increasing the level of activity gradually gives your muscles time to loosen up and puts less pressure on the tendon.