The Achilles tendon is the largest and strongest tendon in the human body. It is the “cord” in the back of the leg that inserts into the back of the heel. The Achilles tendon got its name, according to Greek legend, when the Greek warrior, Achilles, was dipped into the river Styx by Thetis, his mother. This rendered him invincible with the exception of his unsubmerged heel. Unfortunately, he went on to get mortally wounded during the siege of Troy when he was struck in that heel by an arrow.
Achilles tendinitis is inflammation and partial tearing of the Achilles tendon. It can occur with overuse of the tendon such as when starting or increasing the intensity of an exercise program or performing impact loading activities that include a lot of running and/or jumping.
On presentation, patients often complain of pain in the Achilles tendon with initial morning activity with an increase of pain during exercise. Early symptoms of Achilles tendinitis may include sharp, transient pain with or without activity. Over time, less activity will stimulate symptoms. Some patients will even experience pain at rest.
There are two different types of Achilles tendinitis: insertional and non-insertional. Insertional Achilles tendinitis occurs within or around the tendon at its insertion into the heel. Non-insertional Achilles tendinitis occurs above the insertion.
Haglund’s deformity, or “pump bump,” is a swelling and/or bony bump that occurs in the back of the heel. This can occur alone or with Achilles tendinitis. A Haglund’s deformity often causes discomfort when tight shoewear with a constricting heel counter is worn.
On examination, routine x-rays are taken which may demonstrate calcification within the Achilles tendon and a Haglund’s deformity. MRI imaging is not routinely performed but may demonstrate a partial tear, thickening or degeneration of the tendon or calcification. Ultrasound is not customarily performed.
During the physical exam, the Achilles tendon is palpated to detect signs of pain, swelling, thickening, warmth and redness. The range of motion of the ankle is also examined to check for tightness of the Achilles tendon and to determine if the Achilles tendon itself is involved versus the area around the Achilles tendon causing “peritendonitis.” Strength will also be tested. Sometimes the area just in front of or in back of the Achilles tendon insertion is painful which indicates bursitis, which is an inflammation of one of the fluid filled sacs that lie in between the heel and the tendon and between the tendon and the skin. The calf may also be squeezed to make sure that the Achilles tendon is intact and has not torn all the way through. If the Achilles tendon has ruptured, patients report that they felt or heard a “pop” in the back of the heel or had the sensation that someone kicked them. With Achilles tendon rupture, surgical repair gives the patient the best chance at getting as much function back as they had prior to their injury.
Conservative management however, is the treatment of choice for Achilles tendinitis. Eighty to eighty-five percent of patients improve with conservative care, however it can be time consuming as it may take 6 to 12 months to recover. One of the most important factors influencing recovery time is the length of time symptoms are present. If Achilles tendinitis has been endured for six months or more, it is difficult to treat without surgery.
Conservative treatment includes anti-inflammatory medications like ibuprofen or naproxen, rest, decreased activity, gentle stretching exercises, heel lifts worn inside shoes during the day, night splinting or bracing the leg at night while sleeping and occasionally immobilization in a cast when the pain is severe. Steroid injections may occasionally help but are not routinely performed because they increase the risk of rupture. Orthotics, shoe inserts that can be custom made or purchased over-the-counter, may also be recommended if problems with the arch alignment of the foot is playing a part in Achilles tendinitis symptoms. When patients are pain-free, they may slowly restart activity keeping in mind to again cease activity if the pain recurs.
If conservative treatment fails, surgery in indicated. An incision is made at the back of the leg and heel. If the Achilles tendon is only involved then we meticulously remove diseased tendon and repair the good tendon. Another tendon may need to be transferred to assist the Achille’s tendon. If a Haglund’s deformity is present it is removed. If the tendon is diseased at its insertion then detach the Achilles tendon from the heel, cut the bump off, debride the tendon and then reattach the tendon back to the heel using very strong sutures.
After surgery, the leg is splinted with the foot pointing 20 degrees down to take stress off the repair. Crutches, a walker or a wheelchair are usually given to assist patients with walking as no weight can be put on the foot for at least one month after surgery. After four weeks, usually a removable cast is placed on the patient and some weight bearing can be initiated. After eight weeks, patients may start to wear sneakers during the day but will need to wear the removable cast while sleeping at night so the Achilles tendon continues to heal at the proper length. Range of motion exercises start at 4 weeks post operatively. Physical therapy is considered at three months after surgery to help patients regain strength and coordination. Swelling may be present for up to six months after surgery.
Complications can be associated with surgery including risk of infection, incisions that are slow to heal, rupture of the Achilles tendon if weight is placed on it too soon, swelling or blood clot(s) in the legs. Casting may cause abnormal pressure on the skin leading to an ulcer.
Although Achilles tendinitis can be disabling, it is a common, but treatable ailment. With diligence and persistence, patients may again be able to experience their active lifestyle. If you or someone you know is suffering from Achilles tendinitis, seek help today to start the path to recovery.
Reference: Surgery of the Foot and Ankle, Seventh Edition, Volume Two, edited by Michael J. Coughlin, MD and Roger A. Mann, MD.
Written by: David J. Pochatko, MD, a fellowship trained Foot and Ankle Orthopedic Surgeon for Northtowns Orthopedics. We specialize in the surgical and non-surgical treatment of foot and ankle problems, injuries and deformities. We also see many people who have had a failed previous surgery and need revision of that surgery.
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