Reviewed by DR. D. DATTA.
Ex. Emergency Medical Officer.
Tendon is a fibrous band of connective tissue that connects muscles with a bone.
In the posterior aspect of the upper part of leg there are two calf muscles (gastrocnemius and soleus), at the lower part of the leg they unite to form a band of fibrous tissue that is called Achilles tendon.
The Achilles tendon is inserted into the heel bone (calcaneus also called calcaneum). A small sac of fluid called retrocalcaneal bursa is present above the insertion of the tendon in between the heel bone and tendon.
Another bursa present behind the tendon and the skin is called subcutaneous calcaneal bursa. These bursae protect the tendon against rubbing with the heel bone.
With the help of this tendon
1 The heel is lifted off the ground.
2 This tendon is involved in activities such as walking, climbing stairs, standing on toe tips, running and jumping.
It is the strongest, largest and longest tendon in the body, 6 to 10 inches long.
This tendon is strong enough to bear 4 times of one’s body weight. But this tendon is poorly supplied with blood.
Inflammation of the Achilles tendon is called Achilles tendinitis.
(Inflammation means swelling, pain, redness or localized rise of temperature in response to some injury).
Types of Achilles tendinitis–
Noninsertional– here the fibers of achilles tendon above its insertion to the heel are affected. It is commonly seen in younger age groups. There may be swelling and thickening of the tendon.
Insertional– here the lower portion of the achilles tendon where it is attached with heel bone is involved. Bone spur may grow at the site of tendon insertion.
In both types there may be calcification in the tendon.
Causes of Achilles tendinitis
1 When there is overuse or sudden excessive use of this tendon it may become irritated and inflamed.
For example, running some distance too fast. Suddenly increasing the distance you run by a few miles more.
Exercise or playing only on the weekend.
Therefore, this condition commonly occurs in runners, tennis, basketball players, and hill climbers.
2 Achilles tendinitis also occurs in people with Haglund’s deformity because of the rubbing of the tendon with the heel bone. (Haglund’s deformity is a bony prominence at the upper part of the calcaneus bone).
3 Tight calf muscles- Tight calf muscles may lead to achilles tendinitis by causing extra stress on the tendon.
Symptoms of achilles tendinitis
1 Symptoms usually start after activities which involve overuse or excessive use of the achilles tendon such as running, stair climbing, participating in games like tennis, badminton.
2 Pain and tenderness along the tendon.
3 Stiffness along the tendon especially in the morning.
4 Pain in the tendon and back of heel when walking, running or when standing on your toes.
5 Thickening of the tendon.
6 Swelling in the back of the heel.
7 Localized rise of temperature at the back of the heel and along the tendon.
8 Pain in wearing shoes.
Risk factors of achilles tendinitis
1 More common in male.
2 Incidence increases with age.
3 Obesity.
4 More common in cold climates.
5 People with psoriasis and high blood pressure.
6 Wearing badly fitted shoes.
Complications of achilles tendinitis – this may lead to achilles tendinosis or achilles tendon rupture.
Prevention of achilles tendinitis
1 Exercise slowly and increase physical activity gradually.
2 Before exercise warm up first.
3 Wear perfect shoes that don’t cause excessive tension in the achilles tendon.
4 Exercise daily, not only on the weekend.
Diagnosis of achilles tendinitis
Physical examination- After taking history of your problems the doctor will examine you.
1 Whether there is swelling or pain along the line of tendon.
2 Any bony spur at the site of insertion of the tendon.
3 Whether stretching of calf muscles causes pain.
4 If there is limited movement of the ankle joint.
5 If you feel pain while trying to stand on your toes.
Imaging tests- to diagnose Achilles tendinitis and to determine its severity doctor may advise some imaging tests.
1 X-ray- X-rays cannot visualize the achilles tendon. But it can detect bony spur at the insertion site of tendon, calcification in any part of the tendon if present.
2 Ultrasound and color Doppler-
This non-invasive procedure uses ultrasound waves to detect tendon damage, inflammation and range of tendon movement. Color Doppler can detect the amount of blood supply to the tendon.
3 MRI- MRI is also a non-invasive procedure that can diagnose the severity of tendon damage (rupture and degeneration) and whether surgery is necessary for tendon repair.
Treatment of achilles tendinitis
In the majority of cases non surgical management will provide significant pain relief. Several months of treatment may be necessary for complete relief.
1 Rest- Decrease the stress on the tendon by reducing or completely stopping those activities for some time which cause pain.
2 Alternate high impact activities such as running with low impact activities such as swimming to diminish the stress on the tendon.
3 Application of ice wrapped with a cloth on the painful area for maximum 20 minutes several times a day is helpful for pain relief.
4 Medications- Painkillers such as ibuprofen, naproxen can reduce pain and swelling. But prolonged use is not recommended for side effects.
5 Physical therapy- Exercise under guidance of your physical therapist can benefit and cause significant improvement and pain relief.
6 Night splinting- during night while sleeping braces are applied to hold foot and toes, with toes pointing upwards as a result calf muscles remain flexible.
7 Supportive shoes and orthotic devices- in case of insertional achilles tendinitis softer shoes or shoes that are open at the back of heel prevent irritation of the tendon.
8 Extracorporeal shockwave therapy (ESWT)- High and low energy ESWT seems to be beneficial and can repair damaged tendon tissues.
Surgery- surgical treatment of Achilles tendinitis is considered when there is no improvement of pain even after 6 months of non-surgical therapy.
Surgical options are
1 Debridement- that is removal of the damaged tissues of the tendon or the bone spur and reattachment of the tendon with the heel bone by strong stitches.
2 Gastrocnemius resection- when tight calf muscles cause achilles tendinitis then surgical resection of gastrocnemius muscle causes lengthening of calf muscles. The stress of the Achilles tendon is relieved.
3 When a major part of the achilles tendon is damaged, then the tendon which causes downward movement of the big toe is moved and attached to the heel bone. With the help of other tendons attached to the big toe, the patient can still move the big toe and walk.
Achilles tendinosis.
Retrocalcaneal bursitis.
Achilles paratenonitis.
Achilles tendon rupture.
