achilles tendon pain

feet and ankles

Achilles Tendinitis

feet and ankles

What is Achilles tendinitis?

Achilles tendinitis implies an inflammatory response, but this is very limited because there is little blood supply to the Achilles tendon. More appropriate descriptions are inflammation of the surrounding sheath (paratenonitis), degeneration within the substance of the tendon (tendinosis) or a combination of the two. ​

What are the symptoms of Achilles tendinitis?

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.

What causes Achilles tendinitis?

The cause of paratenonitis is not well understood although there is a correlation with a recent increase in the intensity of running or jumping workouts. It can be associated with repetitive activities which overload the tendon structure, postural problems such as flatfoot or high-arched foot, or footwear and training issues such as running on uneven or excessively hard ground or running on slanted surfaces. Tendinosis is also associated with the aging process.

Anatomy

The Achilles tendon is the largest tendon in the body. It is formed by the merging together of the upper calf muscles and inserts into the back of the heel bone. Its blood supply comes from the muscles above and the bony attachment below. The blood supply is limited at the “watershed” zone approximately 1 to 4 inches above the insertion into the heel bone. Paratendonitis and tendinosis develop in the same area.

How is Achilles tendinitis diagnosed?

There is enlargement and warmth of the tendon 1 to 4 inches above its heel insertion. Pain and sometimes a scratching feeling may be created by gently squeezing the tendon between the thumb and forefinger during ankle motion. There may be weakness in push-off strength with walking. Magnetic resonance imaging (MRI) can define the extent of degeneration, the degree to which the tendon sheath is involved and the presence of other problems in this area, but the diagnosis is mostly clinical.

What are treatment options?

Most cases are successfully treated non-surgically although this is time-consuming and frustrating for active patients. Treatment is less likely to be successful if symptoms have been present more than six months. Nonsurgical management includes nonsteroidal anti-inflammatory medications, rest, immobilization, limitation of activity, ice, contrast baths, stretching and heel lifts.

If symptoms fail to resolve, a formal physical therapy program may be of benefit. An arch support may help if there is an associated flatfoot. A cast or brace to completely rest this area may be necessary. Extracorporeal shockwave therapy and platelet-rich plasma injections​ have variable reports of success. Nitroglycerin medication applied to the overlying skin may be of benefit.

Achilles Tendonitis

feet and ankles

What is Achilles tendonitis?

Achilles tendonitis implies an inflammatory response, but this is very limited because there is little blood supply to the Achilles tendon. More appropriate descriptions are inflammation of the surrounding sheath (paratenonitis), degeneration within the substance of the tendon (tendinosis) or a combination of the two. ​

What are the symptoms of Achilles tendinitis?

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.

What causes Achilles tendinitis?

The cause of paratenonitis is not well understood although there is a correlation with a recent increase in the intensity of running or jumping workouts. It can be associated with repetitive activities which overload the tendon structure, postural problems such as flatfoot or high-arched foot, or footwear and training issues such as running on uneven or excessively hard ground or running on slanted surfaces. Tendinosis is also associated with the aging process.

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Anatomy

The Achilles tendon is the largest tendon in the body. It is formed by the merging together of the upper calf muscles and inserts into the back of the heel bone. Its blood supply comes from the muscles above and the bony attachment below. The blood supply is limited at the “watershed” zone approximately 1 to 4 inches above the insertion into the heel bone. Paratendonitis and tendinosis develop in the same area.

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How is Achilles tendinitis diagnosed?

There is enlargement and warmth of the tendon 1 to 4 inches above its heel insertion. Pain and sometimes a scratching feeling may be created by gently squeezing the tendon between the thumb and forefinger during ankle motion. There may be weakness in push-off strength with walking. Magnetic resonance imaging (MRI) can define the extent of degeneration, the degree to which the tendon sheath is involved and the presence of other problems in this area, but the diagnosis is mostly clinical.

What are treatment options?

Most cases are successfully treated non-surgically although this is time-consuming and frustrating for active patients. Treatment is less likely to be successful if symptoms have been present more than six months. Nonsurgical management includes nonsteroidal anti-inflammatory medications, rest, immobilization, limitation of activity, ice, contrast baths, stretching and heel lifts.

If symptoms fail to resolve, a formal physical therapy program may be of benefit. An arch support may help if there is an associated flatfoot. A cast or brace to completely rest this area may be necessary. Extracorporeal shockwave therapy and platelet-rich plasma injections​ have variable reports of success. Nitroglycerin medication applied to the overlying skin may be of benefit.

Achilles Tendinosis

HRC-Achilles-main-Foot

What is Achilles tendinosis?

When the Achilles tendon degenerates and become inflamed, the condition is called Achilles tendinosis.  The tendon can swell and may cause pain. This condition is common in athletes, runners and patients who have calf tightness. Achilles tendinosis may occur in the middle of the tendon. This is known as midsubstance Achilles tendinosis. It may also occur at the point where the tendon connects to the heel bone. This is known as insertional Achilles tendinosis.

What are the symptoms of Achilles tendinosis?

Many changes can be seen when the Achilles tendon becomes inflamed. Patients have pain and/or tightness in the tendon behind the ankle. Most of the time there is no trauma or injury, but rather a slow progression of pain. Patients may have difficulty climbing stairs or running. Patients may also have pain after sitting for long periods or after sleeping. Many patients will notice a bump either in the tendon (midsubstance Achilles tendinosis) or right behind the heel bone (insertional Achilles tendinosis). Some may also get irritation from shoes rubbing against the bump and feel better when wearing backless shoes. Patients also commonly have less pain while wearing a shoe with a slight heel versus shoes that are flat.

What causes Achilles tendinosis?

Achilles and calf tightness is a common cause of Achilles tendinosis. In addition, insertional Achilles tendinosis is often associated with a heel bone spur. This spur may rub against the Achilles tendon and lead to breakdown and small tears. It is similar to a rope being rubbed against a sharp rock. This is also known as Haglund’s Syndrome. Pain and swelling occur as the cumulative effects of chronic wear and tear on the tendon. 

How is Achilles tendinosis diagnosed?

A thorough history is taken and an examination is performed. Patients will usually have pain right on the tendon or at the back of the heel. They may also have swelling and thickening of the tendon. X-rays may be taken to see if there are any bone spurs.  An MRI or ultrasound may also be performed to further evaluate how much of the tendon is affected and to look for any tears.

What are treatment options?

Treatment depends on the length and severity of the symptoms. Many patients improve without surgery. Rest and oral medications may help reduce the swelling and pain. Heel cups can improve pain by taking some of the stress off of the Achilles tendon when walking. A walking boot or other brace may be recommended.

Often formal physical therapy is recommended to work on stretching and improve mobility within the calf muscle.  Other treatments may include ultrasound, massage, shockwave therapy and topical nitroglycerin patches. Recently, platelet rich plasma has been discussed as a treatment for Achilles tendinosis. This involves taking one’s own blood and isolating growth factors that are involved in healing. This serum is then injected into the inflamed tendon.

In some cases, surgery may be required.  The specifics of the surgery depend upon the location and extent of the tendinosis.