Achilles tendinitis is a common condition that causes pain on the back of the leg near the heel. The achilles tendon is the largest tendon in the body connecting your calf
muscles to your heel bone. Your achilles tendon is used when you walk, run or jump. It is made to withstand a high amount of stress from these activities, but when it is overused, you can develop
tendinitis. Tendinitis is defined as inflammation of a tendon. When you are injured, your body's natural response causes inflammation. You may experience pain, swelling, or tenderness at the injured
site. There are two types of achilles tendinitis, insertional and non-insertional achilles tendinitis.
Achilles tendinitis can be caused by overly tight calf muscles, excessive running up hill or down hill, a sudden increase in the amount of exercise, e.g. running for a longer distance, wearing
ill-fitting running shoes, such as those with soles that are too stiff, or wearing high heels regularly, or changing between high heels all day and flat shoes or low running shoes in the evening.
Overuse is common in walkers, runners, dancers and other athletes who do a lot of jumping and sudden starts/stops, which exert a lot of stress on the Achilles tendon. Continuing to stress an inflamed
Achilles tendon can cause rupture of the tendon - it snaps, often with a distinctive popping sound. A ruptured Achilles tendon makes it virtually impossible to walk. An Achilles tendon rupture is
usually treated by surgical repair or wearing a cast.
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.
When diagnosing Achilles tendinitis, a doctor will ask the patient a few questions about their symptoms and then perform a physical examination. To perform a physical exam on the Achilles tendon, the
doctor will lightly touch around the back of the ankle and tendon to locate the source of the pain or inflammation. They will also test the foot and ankle to see if their range of motion and
flexibility has been impaired. The doctor might also order an imaging test to be done on the tendon. This will aid in the elimination of other possible causes of pain and swelling, and may help the
doctor assess the level of damage (if any) that has been done to the tendon. Types of imaging tests that could be used for diagnosing Achilles tendinitis are MRI (Magnetic resonance imaging), X-ray,
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.
Surgery for an acute Achilles tendon tear is seemingly straightforward. The ends of the torn tendon are surgically exposed and sutures are used to tie the ends together. The sutures used to tie
together the torn tendon ends are thick and strong, and are woven into the Achilles both above and below the tear. While the concepts of surgery are straightforward, the execution is more complex.
Care must be taken to ensure the tendon is repaired with the proper tension -- not too tight or too loose. The skin must be taken care of, as excessive handling of the soft tissues can cause severe
problems including infection and skin necrosis. Nerves are located just adjacent to the tendon, and must be protected to prevent nerve injury. If surgery is decided upon, it is usually performed
within days or weeks of the injury. The idea is to perform the repair before scar tissue has formed, which would make the repair more difficult. Some surgeons may recommend delaying surgery a few
days from the initial injury to allow swelling to subside before proceeding with the repair.
Regardless of whether the Achilles injury is insertional or non-insertional, a great method for lessening stress on the Achilles tendon is flexor digitorum longus exercises. This muscle, which
originates along the back of the leg and attaches to the tips of the toes, lies deep to the Achilles. It works synergistically with the soleus muscle to decelerate the forward motion of the leg
before the heel leaves the ground during propulsion. This significantly lessens strain on the Achilles tendon as it decelerates elongation of the tendon. Many foot surgeons are aware of the
connection between flexor digitorum longus and the Achilles tendon-surgical lengthening of the Achilles (which is done to treat certain congenital problems) almost always results in developing hammer
toes as flexor digitorum longus attempts to do the job of the recently lengthened tendon. Finally, avoid having cortisone injected into either the bursa or tendon-doing so weakens the tendon as it
shifts production of collagen from type one to type three. In a recent study published in the Journal of Bone Joint Surgery(9), cortisone was shown to lower the stress necessary to rupture the
Achilles tendon, and was particularly dangerous when done on both sides, as it produced a systemic effect that further weakened the tendon.