Sore Achilles Tendon

Overview

Achilles TendonitisAchilles Tendonitis is an inflammation of the Achilles tendon, which attaches the calf muscles (gastrocnemius and soleus) to the heel bone (calcaneus). Pain can be felt on the back of the heel at the attachment of the tendon, along the length of the tendon, or at the base of the calf where the tendon attaches to the muscle. Swelling is not always present with this injury, but it may occur in severe cases.

Causes

Like any muscle or tendon in the body, the older we get, the more likely we are to sustain an injury. So middle-aged men and women are most at risk, with a slightly higher risk factor attributed to males. Those who participate in more intense athletic activities like high impact sports (tennis, running, basketball) are most susceptible to the injury. Certain underlying medical conditions can also be a contributing factor. Diabetics are more at risk of suffering from Achilles Tendinitis, as are those who are not in great physical shape. Some antibiotics, particularly fluoroquinolones can make one more likely to suffer a strained Achilles Tendon.

Symptoms

The main symptom of Achilles tendonitis is a feeling of pain and swelling in your heel as you walk or run. Other symptoms include tight calf muscles and limited range of motion when flexing the foot. This condition can also make the skin in your heel feel overly warm to the touch.

Diagnosis

Examination of the achilles tendon is inspection for muscle atrophy, swelling, asymmetry, joint effusions and erythema. Atrophy is an important clue to the duration of the tendinopathy and it is often present with chronic conditions. Swelling, asymmetry and erythema in pathologic tendons are often observed in the examination. Joint effusions are uncommon with tendinopathy and suggest the possibility of intra-articular pathology. Range of motion testing, strength and flexibility are often limited on the side of the tendinopathy. Palpation tends to elicit well-localized tenderness that is similar in quality and location to the pain experienced during activity. Physical examinations of the Achilles tendon often reveals palpable nodules and thickening. Anatomic deformities, such as forefoot and heel varus and excessive pes planus or foot pronation, should receive special attention. These anatomic deformities are often associated with this problem. In case extra research is wanted, an echography is the first choice of examination when there is a suspicion of tendinosis. Imaging studies are not necessary to diagnose achilles tendonitis, but may be useful with differential diagnosis. Ultrasound is the imaging modality of first choice as it provides a clear indication of tendon width, changes of water content within the tendon and collagen integrity, as well as bursal swelling. MRI may be indicated if diagnosis is unclear or symptoms are atypical. MRI may show increased signal within the Achilles.

Nonsurgical Treatment

Initial treatment of mild Achilles tendinitis involves rest, stretching exercises, and non-prescriptive medications to relieve pain and reduce inflammation. These medications include nonsteroidal anti-inflammatory drugs (NSAID) such as ibuprofen or naproxen. Relief of pain and swelling may be achieved with the application of ice for15 minutes at a time. Sleeping with the affected foot propped up on a pillow may also relieve swelling. Adequate time must be given to rest and recovery, meaning months or weeks, to prevent re-injury of the Achilles tendon. Most people make a full recovery and are able to return to their regular sports and exercise programs.

Achilles Tendonitis

Surgical Treatment

Following the MRI or ultrasound scan of the Achilles tendon the extent of the degenerative change would have been defined. The two main types of operation for Achilles tendinosis are either a stripping of the outer sheath (paratenon) and longitudinal incisions into the tendon (known as a debridement) or a major excision of large portions of the tendon, the defects thus created then being reconstructed using either allograft (donor tendon, such as Wright medical graft jacket) or more commonly using a flexor hallucis longus tendon transfer. In cases of Achilles tendonosis with more minor degrees of degenerative change the areas can be stimulated to repair itself by incising the tendon, in the line of the fibres, which stimulates an ingrowth of blood vessels and results in the healing response. With severe Achilles tendonosis, occasionally a large area of painful tendon needs to be excised which then produces a defect which requires filling. This is best done by transferring the flexor hallucis longus muscle belly and tendon, which lies adjacent to the Achilles tendon. This results in a composite/double tendon after the operation, with little deficit from the transferred tendon.

Prevention

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.
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