|The Achilles tendon is the largest and
strongest tendon in the body. It is located in the back of the lower leg,
attaches to the heel bone (calcaneus), and connects the leg muscles to the
foot. The Achilles tendon gives us the ability to rise up on our toes,
facilitating the act of walking, and Achilles tendonitis can make walking
almost impossible. Problems that affect the Achilles tendon are common among active
people and is one of the most common injuries among the ranks of
gymnasts. Achilles tendonitis is more common in athletes and overall
incidence of the condition is unknown. It occurs in approximately 6 to 18% of
runners. These problems cause pain at the back of the calf, and
may result in a rupture of the Achilles tendon in severe cases.
The Achilles Tendon is a strong, fibrous band that connects the calf muscle to the
heel. The calf is actually formed by two muscles, the underlying
soleus and the thick outer gastrocnemius. Together, they form
the gastroc-soleus muscle group. When they contract, they pull
on the Achilles Tendon causing your foot to point down and helping you
raise up on your toes. This powerful muscle group helps when you
sprint, jump, or climb. Several different problems can
occur that affect the Achilles tendon, some rather minor and some
Tendocalcaneal Bursitis -
A bursa is a fluid filled sac designed to limit friction between
rubbing parts. These sacs, or bursae, are found in many places
in the body. When a bursa becomes inflamed it is called a
bursitis. Tendocalcaneal bursitis is an inflammation in the
bursa behind the heel bone. This bursa limits friction where the
thick fibrous Achilles tendon that runs down the back of the calf
glides up and down behind the heel.
Achilles Tendonitis - A
violent strain can cause injury to the calf muscles or the Achilles tendon. This can happen during a strong contraction of the
muscle, as when running or sprinting. Landing on the floor or
mat after a tumbling pass can force the foot upward, also causing
injury. The strain can affect different portions of the muscles
or tendon. For instance, the strain may occur in the belly of
the muscle. Or it may happen where the muscles join the Achilles
tendon (called the musculotendinous junction).
Chronic overuse may contribute to changes in the Achilles tendon as
well, leading to degeneration and thickening of the tendon.
Achilles Tendon Rupture - In
severe cases, the force may even rupture the tendon. The classic
example is the middle aged tennis player or weekend warrior who places
too much stress on the tendon and experiences a rupture of the tendon.
In some instances, the rupture may be preceded by a period of
tendonitis which renders the tendon weaker than normal.
|Poorly conditioned athletes are at the highest risk for
developing Achilles tendonitis. Participating in activities 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. Problems
with the Achilles tendon seems to occur in different ways.
Initially, irritation of the outer covering of the tendon
called the paratenon causes a paratendonitis. The word paratendonitis simply indicates that there is
inflammation around the tendon. Inflammation of the tendocalcaneal
bursa (described above) may also be present with the
paratendonitis. Either of these conditions may be due to
repeated overuse, or ill-fitting shoes that rub on the tendon or bursa.
General Causes of Achilles Tendonitis
overuse of the Achilles tendon
overly tight calf muscles or Achilles tendons (insufficient warmup)
excessive running up hill
sudden increase in the intensity of training
wearing ill-fitting running shoes, such as those with soles that are too stiff
wearing incorrect shoes or changing shoe
types (such as wearing high heels all day and then changing into low
The condition also develops in people who exercise infrequently
and those who are just beginning an exercise program, because 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
As we age, a tendon is subject to degeneration
within the substance of the tendon. The term degeneration means
that wear and tear occurs in the tendon over time and leads to a
situation where the tendon is weaker than normal. Degeneration in
a tendon usually shows up as a loss of the normal arrangement of the
fibers of the tendon. Tendons are made up of strands of a
material called collagen (think of a tendon as similar
to a nylon rope and the strands of collagen as the nylon strands).
Some of the individual strands of the tendon become jumbled due to the
degeneration, other fibers break, and the tendon loses strength.
The healing process in the tendon causes the tendon to become thickened
as scar tissue tries to repair the tendon. This process can
continue to the extent that a nodule forms within the
tendon. This condition is called tendonosis. The area
of tendinosis in the tendon is weaker than normal tendon. The
weakened, degenerative tendon sets the stage for the possibility of
actual rupture of the Achilles tendon.
complete proper and adequate stretching and
strengthening exercises prior to participating in any sports. The
'push wall' method is particularly useful in this aspect
always increase the intensity and duration
of training gradually
if the Achilles tendons or calf muscles are
tight, it is a good idea to do stretching exercises twice a day,
even if you are not undertaking any exercise activities
allow adequate recovery time before the next
sporting event - this allows the tissue sufficient time to repair,
as there is a lot of wear and tear to muscles and tendons after each
wear properly fitted running, and other sports, shoes
a sedentary lifestyle, walking with your
toes pointing out (ie. duck-footed) and wearing shoes with heals can shorten
the Achilles tendons. Short, tight tendons are subject to strain during almost
any activity. When this occurs, pain is felt anywhere from the heel to the
stretch your Achilles tendons with a
simple wall exercise. Stand facing a wall. Place the ball of your right foot
against the wall with your heel resting on the floor. Lean forward, pressing
your right hip toward the wall. Stretch the whole foot for a few seconds.
Repeat with left foot. Perform this exercise a few times a day.
Tendocalcaneal bursitis usually begins with
pain and irritation at the back of the heel. There may be
visible redness and swelling in the area. The back of the shoe
may further irritate the condition,
making it difficult to tolerate shoewear. Achilles tendonitis
usually occurs further up the leg, just above the heel bone itself. In
most cases, symptoms of Achilles tendonitis develop gradually. Pain may be mild
at first and worsen with continued activity. Repeated or continued stress on the
Achilles tendon increases inflammation and may cause it to rupture. Partial or
complete rupture results in traumatic damage and severe pain, making walking
virtually impossible and requiring a long recovery period. The Achilles tendon in this area may be noticeably thickened and
tender to the touch. Pain is present with walking especially
when pushing off on the toes. Finally, Achilles tendon rupture
is usually an unmistakable event. Some bystanders may report
actually hearing the snap, and the victim of a rupture usually
describes a sensation like someone kicked me in the calf.
Following rupture there may be swelling in the calf and there is
usually no ability to raise up on the toes.
Symptoms of Achilles Tendonitis
swollen tendon, associated with warmth and tenderness, which may be painful to touch
tightness of the Achilles tendon
pain on rising up on the toes and pain with pushing off on the toes
a painful heel for the first few minutes of walking after waking up in the morning
range of motion of the ankle may be limited
a sensation of fullness in the back of the lower leg or
develop a hard knot of tissue (nodule).
Diagnosis is almost always by clinical
history and physical examination. In cases where there is
question whether or not the Achilles tendon has been ruptured, an MRI
scan may be necessary to confirm the diagnosis, (but this is seldom
the case.) The MRI (Magnetic Resonance Imaging) machine uses
magnetic waves rather than X-rays, to show the soft tissues of the
body. With this machine, we are able to slice through
the area we are interested in and see the tendons and ligaments very
clearly. This test does not require any needles or special dye,
and is painless.
If you have Achilles tendon pain and you
are over 40, have your cholesterol checked. High cholesterol levels can
stiffen blood vessels in the tendon and predispose it to injury.
Non-surgical treatment for tendocalcaneal
bursitis and Achilles tendonitis usually starts with combination of
rest, anti-inflammatory medications such as aspirin or ibuprofen, and
physical therapy measures. Several physical therapy treatment
choices are available in the early stages of Achilles tendonitis or
tendocalcaneal bursitis. The rehabilitation following
rupture of the tendon is quite different.
Ice can be used in the first moments after this type of injury, and
to calm an inflamed bursae. A bag of crushed or cubed ice
held on to the ankle with an elastic wrap works well. Initially,
this should be used for periods of 15 minutes every hour. A cold
temperature whirlpool may be chosen for your condition. The cold water
helps reduce swelling and pain, and the moving water in the whirlpool
provides a massage action. In supervised physical therapy,
your therapist may continue to be treat with either an ice bag, cold
pack, or ice massage.
An injury like this needs to be rested (ideally in an elevated
position). This can be done by limiting activities like walking on the sore leg. Certainly
spared from the harsh pounding of tumbling. (A small (1/4 inch)
heel lift placed in your shoe can minimize stress by putting slack in
the calf muscle and Achilles tendon. Be sure to place a similar
sized lift in the other shoe to keep everything aligned.)
Cortisone injection in this condition is not
indicated, due to the increased risk of rupture of the tendon following injection.
Non-surgical treatment for an Achilles tendon
rupture is somewhat controversial.
It is clear that
treatment with a cast will allow the vast majority of tendon ruptures to heal, but the incidence of
re-rupture is increased in those patients treated with casting for 8
weeks when compared with those undergoing surgery. In addition,
the strength of the healed tendon is significantly less in patients
who elect cast treatment. For these reasons, many orthopedists
feel that Achilles tendon ruptures in younger active patients should
be surgically repaired.
Surgical treatment for Achilles tendonitis is
not usually necessary or most patients. However, in some
cases of persistent tendonitis / tendonosis a procedure called debulking
of the Achilles tendon may be suggested to help treat the problem.
This procedure is usually done through an incision on the back of the
ankle near the Achilles tendon. The tendon is identified and any
inflamed paratenon tissue (the covering of the tendon) is removed.
The tendon is then split and the degenerative portion of the tendon is
removed. The split tendon is then repaired and allowed to heal.
It is unclear why, but removing the degenerative portion of the tendon
seems to stimulate repair of the tendon to a more normal state.
Surgery may also be suggested if you have a
ruptured Achilles tendon. Repair of the torn Achilles tendon by
re-attaching the two ends of the torn tendon. This procedure is
usually done through an incision on the back of the ankle near the Achilles
tendon. There are numerous ways that have been used to
actually repair the tendon, but most all involve sewing the two ends of
the tendon together in some fashion. There are some repair
techniques that have been developed to minimize the size of the incision.
In the past, the complications of surgical
repair of the Achilles tendon made surgeons think twice before
suggesting surgery. The complications arose because the skin where
the incision must be made is thin and has a poor blood supply.
This can lead to an increase in the chance of the would not healing and
infection setting in. Now that this is better recognized, the
complication rate is lower and surgery is recommended more often.
After surgery, you will most likely be placed
in a cast, or brace, to protect the repair - and the skin incision.
A cast or brace will probably be required for 6-8 weeks. Following
removal of the cast, a shoe with a fairly high heel may be recommended
for several weeks longer. Physical therapy will probably be
recommended for regaining the motion of the ankle and the strength in the calf muscles.