All About Achilles Tendon Problems
A tendon is a structure that is made up completely of highly organized collagen strands that connects a muscle to bone. Although any tendon in the body is susceptible to injury, the Achilles’ tendon happens to be the one that is injured most often.
What is the Achilles’ Tendon?
The Achilles’ tendon is the largest tendon in the human body. The Achilles’ tendon actually connects your calf muscle in the back of your leg to the back of your heel bone in your foot. You can easily feel the Achilles’ tendon, which is the firm, tight heel cord just above the heel bone behind your ankle. If you squeeze your hand along the tendon and move up the back of your leg toward your knee, you can feel where it blends into the calf muscle. Your Achilles’ tendon makes it possible for you to stand up on your toes when your calf muscle contracts. It also allows you to balance when you walk and push off when you run.
Who is this Achilles guy anyway?
According to Greek mythology, when Achilles was born his mother tried to make him immortal by dipping him in the river Styx. However, when she dipped him in, she forgot the spot on the heel she held him by, which left one small area unprotected. In the end, Achilles was struck by an arrow in his vulnerable heel and was killed. Achilles shares his vulnerability with the rest of us entirely mortal runners, and that is why the tendon which connects the calf muscle to the heel bone bears his name today. The Achilles tendon is the largest tendon in the entire human body and is very strong, but it is also the tendon we rupture the most often. Anyone who is active can suffer from Achilles tendonitis, a common overuse injury and inflammation of the tendon.
What is Achilles’ Tendonitis?
Achilles tendinitis is inflammation within the tendon itself. Achilles tendinitis can occur anywhere within the tendon, all the way from the heel bone up to the calf muscle. However, most often the Achilles tendinitis occurs in a specific area just above the heel bone. This area, where the tendon is easiest to feel with your hand, happens to have decreased blood flow as compared to the rest of the tendon. For this reason, an overused tendon may become weaker, inflamed and injured in this area.
Fortunately, in the majority of cases Achilles tendinitis is short lived. It may begin with a small injury or particularly strenuous workout. However, runners, triathletes and other active athletes will often continue to exercise, in spite of the pain. When this occurs, a normal inflammatory response that is supposed to cause healing in the tendon can backfire. When chronic inflammation of the Achilles’ tendon begins, the inflammatory cells can actually cause damage within the tendon and degenerate the collagen that makes up the substance of the heel cord. This degeneration of the Achilles’ tendon is referred to by doctors as Achilles’ tendonosis.
What is Achilles’ Tendonosis
Achilles’ tendonosis is degeneration of the collagen that makes up the tendon. It is caused by chronic inflammation and irritation of the substance of the tendon. As it progresses, the fibers of the tendon start to become disorganized. They become weaker and more prone to microscopic tears. Over time, the tearing of the Achilles’ tendon can progress and make it even weaker. It then becomes prone to rupture or complete tearing. In some cases, the Achilles’ tendon may rip away from its attachment at the back of the heel bone. Incredibly, sometimes this sort of injury is not even painful.
If you notice a lump or firm knot in the back of the Achilles’ tendon just above the heel bone, this is most likely to the development of Achilles’ tendonosis. It may or may not be painful if you squeeze it. Because this sort of mass in the Achilles’ tendon is usually degeneration that makes the tendon weaker, it is very important that you seek treatment to avoid damage to the tendon.
You Might Have Achilles Tendonitis/Tendonosis if you have any of the following symptoms:
Achilles Pain: you have an ache, stiffness, soreness or tenderness in the Achilles’ tendon anywhere between the heel bone and calf muscle at the back of the leg. In its early stages, you may only notice this pain when you run. Or it is possible that you will only notice some soreness in the back of the leg when you get out of bed, early in the morning. Many people will ignore this pain because the soreness seems to disappear as the day goes on once they start walking. However, runners will often notice that this pain hurts more and the soreness returns in the middle of their long runs and speed workouts.
Achilles Tenderness: if you press anywhere along the course of the tendon and you have anything ranging from mild tenderness to intense pain, this should be concerning. You should never have any pain or tenderness when you press along the Achilles’ tendon anywhere. If you notice tenderness in the Achilles’ tendon, you should see a sports medicine foot and ankle specialist immediately.
Achilles Deformity: any abnormal appearance to the tendon should be of concern. The Achilles’ tendon is normally firm and perfectly smooth. If you feel any lump, bump, knot or nodule anywhere along the tendon, this is not normal. Achilles’ tendonosis is the most common reason for these types of abnormal changes in the tendon. However, there are other problems that can cause these deformities such as a ganglion cyst or other tendon tumors.
What Causes Achilles Tendonitis?
Achilles tendinitis is not really a condition that affects couch potatoes. In general, Achilles tendinitis is an over-use problem. It is common in people who exercise vigorously and continuously. When Achilles tendinitis starts to develop, there is often a sudden increase in either the duration or intensity of activity. This happens frequently in marathon runners to start a new marathon training program and bump up their mileage. It is also common in triathletes that progress from the Olympic distance to Ironman distance events. It is also seen in otherwise sedentary individuals who began a seasonal basketball league. Cyclists who take up a new intense spring cycling training program (particularly with lots of hill climbing) are also susceptible. While Achilles tendonitis is mostly caused by activity, there are other factors that can put you at risk of Achilles tendon injury. Some medications can weaken the tendon and increase the risk of Achilles tendon injury and ruptures (complete tear). If you are taking steroids (prednisone) or flouroquinalone antibiotics (Cipro, Levaquin, etc.) you should not exercise unless you have discussed this with your treating doctor. You may have seen in the news where the FDA recently posted a strong “Black Box” warning about these antibiotics and the associated risk of tendon ruptures. A torn Achilles tendon is serious. Interestingly, it is not always painful. However, there is usually significant weakness and difficulty standing up on the toes if this has occurred. Any suspected torn tendon can be serious and should be evaluated by a foot and ankle surgeon, preferably one who treats runners. In some cases surgery may be needed to repair the tendon.
Diagnosis of Achilles Tendonitis
When you suspect you have Achilles Tendonitis, your foot doctor will begin by taking a complete history from you. A physical exam will also be performed. X-rays are generally taken on the first visit as well to determine the shape of the heel bone, joint alignment in the rearfoot, and to look for calcium deposits in the Achilles tendon. The history, exam and x-rays may sufficient for your foot surgeon to get an idea of the treatment that will be required. In some cases, it may be necessary to get an ultrasound or MRI to further evaluate the Achilles tendon. While calcium deposits can show up on xray, tears, inflammation, degeneration and other tendonosis related changes will show up much better on ultrasound and MRI. The results of these tests can usually be explained on the first visit. You then will have a full understanding of how the problem started, and what you can do to treat it and prevent it from getting worse. You will also know which treatment will be most helpful in making your Achilles pain go away.
How is Achilles Tendonitis Treated?
Treatment of Achilles Tendonitis:
Surgery for Achilles tendonitis should always be the last resort. We believe that biologic treatments that preserve normal tendon anatomy are very helpful, particularly for runners, athletes, and active professionals with buy schedules. All non-surgical approaches attempt to calm down the inflammation and heal any degeneration of the tendon. Some non-surgical treatments include:
• Oral Anti-inflammatory Medications. NSAID’s (non-steroidal anti-inflammatory medications) such as Motrin, Aleve, and Steroids (like prednisone) may help control the pain and stop the inflammation.
• Topical Anti-inflammatory Medications. NSAID’s in cream or lotion form may be applied directly to the inflamed area. With these, there is no concern for stomach upset or other problems associated with oral medication.
• Ice. Ice can applied be applied right to the inflamed area and help calm it down. Try applying ice to the affected area for 20 minutes of each hour. Just make sure you don’t put ice directly against the skin.
• Exercises. Stretching exercises may relieve some of the tension in the Achilles tendon that started the problem. If you have Equinus Deformity (or a tight heel cord) this is critical to prevent it from coming back again.
• Heel lifts. Heel lifts placed inside the shoe can decrease the pressure and tension to the Achilles tendon.
• Heel pads. Placing gel pads on the tendon (at the back of the heel) may help reduce irritation.
• Shoe modification. Wearing open-backed shoes, or shoes that have soft backs. This will also help stop the irritation, depending on the location of the tendonitis. Avoid hiking boots and ski boots that rub on the area.
• Physical therapy. Physical therapy, such as ultrasound, massage and stretching can all reduce inflammation without surgery.
• Orthotic devices. Custom arch supports known as foot orthotics control abnormal motion in the foot that can allow the heel to tilt over and stress the Achilles tendon. Orthotics can decrease symptoms and help prevent it from happening again.
• Immobilization. In some cases, a walking cast boot or plaster/fiberglass cast is necessary to take pressure off the tendon, while allowing the area to calm down and heal.
• ESWT. Extra-corporeal Shock Wave Therapy. uses high energy sound waves to break up diseased tissue in the Achilles tendon and stimulate your own body’s own healing processes to repair the diseased area. It is usually done in an outpatient surgery center. There is no incision and no stitches with ESWT.
• PRP. Platelet Rich Plasma. (sometimes called “PRP” for short or “autologous platelet concentrate”) is a therapeutic injection which uses your body’s own natural healing cells to repair the tendon. A small sample of blood is drawn from the patient and the healing factors found in the platelets are concentrated in a centrifuge. By injecting the concentrated growth factor solution right into the damaged Achilles tendon, a powerful healing can be stimulated. This can be done in the office. No hospital or surgery required.
When Is Surgery Needed?
If and (only if) non-surgical attempts at tendinosis treatment fail, will it make sense to consider surgery. Surgery for Achilles tendonitis can include many different procedures. Some of these include removal of the diseased or degenerated portion of the tendon, reinforcing the tendon with a tendon graft, removing any excess bone at the back of the heel (calcaneal exostectomy), and occasionally detachment and re-attachment of the Achilles tendon. If the foot structure and shape of the heel bone is a primary cause of the tendonitis, surgery to re-align the heel bone (calcaneal osteotomy) may be considered. Sometimes surgery is performed to lengthen the Achilles tendon. Regardless of which exact surgery is planned, the goal is always to decrease pain and correct the deformity. The idea is to get you back to the activities that you really enjoy. Your foot and ankle surgeon will determine the exact surgical procedure that is most likely to correct the problem in your case. But if you decide to have surgery, you and your surgeon can work together to develop a plan that will help assure success.
How to Prevent Achilles Tendon Problems
The best way to prevent Achilles tendonitis is to stretch and warm up before intense workouts. A little self-restraint, the right pair of running shoes, and a good training program can help you stay injury free. Always stretch before speed workouts, hill repeats and long runs. Stretching helps to keep the tendon pliable, preventing micro-tears. In addition, stretching can improve blood flow, enabling a speedy recovery if you do become injured.
Stretching is most effective after a short warm-up; never stretch aggressively when your muscles are cold. This can increase your risk of problems. Include an Achilles tendon stretch in your workout routine as follows:
Stand upright about one large pace away from the wall with your feet parallel and about shoulder width apart. Keep your feet in line as shown in the image. Place your hands against the wall, at shoulder height. Move your right leg half a pace forward. Lunge forward on your right leg so that the knee is brought directly above the ankle. Stretch your left leg back as far as is comfortable with the foot and heel remaining flat on the floor. Slowly lean forward to stretch the left leg calf muscles and tendon. Hold the stretch for 10 seconds, relax, and repeat on the other leg. This is for prevention… do not stretch if you have pain.
If you have had a history of Achilles’ tendon problems you might want to consider a little prophylactic cryotherapy whenever you start exercising again. An ice bath is an excellent way to decrease inflammation and prevent this sort of recurring problem after you run. Just fill your bathtub with cold water and throw in a couple of trays of ice cubes. Sitting in an ice bath is not for the faint of heart. However, you can also kneel in the bathtub and get the same effects with much less discomfort. Just ice your legs and knees in this way for about 10 to 15 minutes after your long runs and hard workouts.
When to see a Foot Specialist for Achilles Tendonitis?
Any time you have pain, tenderness or swelling along the Achilles tendon, you should see an Achilles expert. You must seek help right away. What is so concerning is that the micro-tears associated with chronic inflammation is that it usually gets progressively worse. It is best to stop the problem in its tracks and let the healing begin.
If you are an athlete and the doctor’s office you call for an appointment says they can’t see you right away, call someone else who will see you quickly. Whatever you do, don’t wait.
Dr. Christopher Segler is renowned Sports Medicine Podiatrist in San Francisco. He is a runner and triathlete. His podiatry practice focuses on prevention and fast recovery of lower extremity injuries sustained by athletes in training. Because he competes in Ironman events, he understands the importance of getting the best medical help without missing work or skipping a workout. To help runners get back on track, he offers podiatry house calls in the SF Bay Area. You can reach him at 415-308-0833.