Achilles Tendon Injuries

The Achilles tendon is a strong tendon that connects the calf muscles to the heel. The calf is formed by two muscles: the underlying soleus muscle and the thick outer gastrocnemius muscle. When they contract, the pull on the Achilles tendon causes the foot to point down (plantar flexion) and to rise up onto the toes. This powerful muscle group helps when you sprint, jump, or climb.

Achilles Tendonitis

Achilles tendinitis is a common condition that occurs when the large tendon that runs down the back of your lower leg becomes irritated and inflamed. Tendinitis is a condition associated with overuse and degeneration.

Achilles tendinitis is typically not related to a specific injury, but from repetitive stress to the tendon. This often happens when we push our bodies to do too much, too soon, but other factors can make it more likely to develop tendinitis. Common reasons for development of tendonitis include increasing the distance you run or walk or change in topography.

Achilles tendinitis pain can occur within the tendon itself or at the point where it attaches to the heel bone, called the Achilles tendon insertion.

Non insertional Achilles Tendinosis

With aging and overuse, the Achilles tendon is subject to degeneration within the substance of the tendon. The term degeneration means that wear and tear occurs in the tendon over time and leads to a weakening of the tendon. Degeneration in a tendon usually shows up as a loss of the normal arrangement of the fibers of the tendon. Tendons are made up of strands of a material called collagen (think of a tendon as similar to a nylon rope with the strands of collagen being the nylon strands). Some of the individual strands of the tendon become disorganized due to the degeneration, other fibers break, and the tendon loses strength. The healing process in the tendon can cause the tendon to become thickened as scar tissue tries to repair the tendon. This process can continue to the extent that a nodule forms within the tendon. This condition is called tendinosis. The area of tendinosis in the tendon is weaker than normal tendon and is usually painful.

Tendinosis generally occurs at the midportion of the tendon and is called non insertional Achilles tendinosis.  The fibers in the middle portion of the tendon have begun to break down with tiny tears (degenerate), swell, and thicken.

Insertional Achilles Tendinopathy

Insertional Achilles tendinitis involves the lower portion of the heel, where the tendon attaches (inserts) to the heel bone. There may be prominence of the heel bone called a Haglund’s deformity or calcifications (bone spurs) that develop.

Diagnostic Imaging

X-rays are useful to rule out fractures. X-rays can be particularly helpful for insertional Achilles tendinopathy.

X-rays can show whether the lower part of the Achilles tendon has calcified, or become hardened. This calcification indicates insertional Achilles tendinitis.

Ultrasounds or MRIs can be used to confirm the diagnosis and extent of damage. 

Treatment Options

Non-Operative Treatment

In most cases, nonsurgical treatment options will provide pain relief, although it may take a few months for symptoms to completely subside. Even with early treatment, the pain may last 3-6 months. If symptoms are present for longer, it may take longer for symptoms to resolve.

Rest. The first step in reducing pain is to decrease or even stop the activities that make the pain worse. If you regularly do high-impact exercises (such as running), switching to low-impact activities will put less stress on the Achilles tendon. Cross-training activities such as biking, elliptical exercise, and swimming are low-impact options to help you stay active.

• Placing ice on the most painful area of the Achilles tendon is helpful and can be done as needed throughout the day. This can be done for up to 20 minutes and should be stopped earlier if the skin becomes numb.
• Non-steroidal anti-inflammatory medication. Drugs such as ibuprofen and naproxen reduce pain and swelling. Using the medication for more than 1 month should be reviewed with your primary care doctor.
• Physical therapy program including massage, graston technique, and an eccentric Strengthening Protocol. Eccentric strengthening is defined as contracting (tightening) a muscle while it is getting longer.
• Cortisone injections. Cortisone, a type of steroid, is a powerful anti-inflammatory medication. Cortisone injections into the Achilles tendon are rarely recommended because they can cause the tendon to rupture (tear).

Supportive shoes and orthotics. Pain from insertional Achilles tendinitis is often helped by certain shoes, as well as orthotic devices. For example, shoes that are softer at the back of the heel can reduce irritation of the tendon. In addition, heel lifts can take some strain off the tendon. Heel lifts are also very helpful for patients with insertional tendinitis because they can move the heel away from the back of the shoe, where rubbing can occur. They also take some strain off the tendon. Like a heel lift, a silicone Achilles sleeve can reduce irritation from the back of a shoe.

Surgical treatment

Débridement and repair (tendon has less than 50% damage). The goal of this operation is to remove the damaged part of the Achilles tendon. Once the unhealthy portion of the tendon has been removed, the remaining tendon is repaired with sutures, or stitches to complete the repair.

In insertional tendinitis, the bone spur is also removed. Repair of the tendon in these instances may require the use of suture anchors to help hold the Achilles tendon to the heel bone, where it attaches.

Débridement with tendon transfer (tendon has greater than 50% damage). In cases where more than 50% of the Achilles tendon is not healthy and requires removal, the remaining portion of the tendon is not strong enough to function alone. To prevent the remaining tendon from rupturing with activity, an Achilles tendon transfer is performed. The tendon that helps the big toe point down is moved to the heel bone to add strength to the damaged tendon. Although this sounds severe, the big toe will still be able to move, and most patients will not notice a change in the way they walk or run.

Depending on the extent of damage to the tendon, some patients may not be able to return to competitive sports or running.

Recovery

Most patients have good results from surgery. The main factor in surgical recovery is the amount of damage to the tendon. The greater the amount of tendon involved, the longer the recovery period, and the less likely a patient will be able to return to sports activity.

Physical therapy is an important part of recovery. Many patients require 12 months of rehabilitation before they are pain-free.