Achilles Tendonitis

Achilles tendonitis is diagnosed by a history and physical examination of the patient who describes pain at the back of the ankle with walking and/or running activities. The pain generally will be associated with an increase in running or jumping intensity or frequency. The pain from Achilles tendonitis is often so severe that running is impossible and even walking is uncomfortable.

Must Know About This

• Surgery is rarely indicated .
• There is non-surgical treatment that works.
• Responds very well to conservative treatment as long as it is diagnosed and treated early.

Good to Know About This

• Diagnosed by a history and physical examination.
• Most Common in older active adults. May occur in teenagers active in running and jumping.
• Stretching can help, but this often aggravates Achilles tendonitis.

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More About This

The Achilles tendon is the largest tendon in the human body. It is located at the back of the ankle joint and can be felt as a large, cord-like structure attaching to the back of the foot. Since tendons serve to attach muscles to bone, the Achilles tendon also attaches the large calf muscles, the gastrocnemius and soleus, to the back of the heel bone, the calcaneus.

The muscle mass and strength of the gastrocnemius and soleus muscles are greater than all of the other muscles of the lower leg combined. Therefore, the pull of these muscles on the Achilles tendon is very large since these muscles help balance the body while standing, push the body forward during walking, spring the body forward during running, and spring the body upward during jumping. Because of the large amount of stress which the Achilles tendon is subjected to during running and jumping activities, the Achilles tendon is prone to The most common form of injury to the Achilles tendon is called Achilles tendonitis, which is an inflammatory condition causing pain in the Achilles tendon. Achilles tendonitis generally occurs in people who are active in sports activities. Types of sports that commonly are associated with Achilles tendonitis are basketball, tennis, running, football, soccer, volleyball and other running and jumping sports.

Achilles tendonitis tends to occur more frequently in older athletes than in younger athletes. As a person ages into their thirties and especially into their forties and fifties, the ligaments and tendons of the body tend to lose some of their stretchiness and are not as strong as before. This predisposes older individuals who are active in running and jumping activities, to tendon injuries such as Achilles tendonitis. However, Achilles tendonitis can also occur in teenagers who are very active in running and jumping sports.

Diagnosis

Achilles tendonitis is diagnosed by a history and physical examination of the patient who describes pain at the back of the ankle with walking and/or running activities. The pain generally will be associated with an increase in running or jumping intensity or frequency. It is also often associated with a change from running in a thick heeled shoe to a thin heeled shoe, such as going from training shoes to racing flats and/or racing spikes in cross-country and/or track. The pain from Achilles tendonitis is often so severe that running is impossible and even walking is uncomfortable.

During the physical examination, the podiatrist will feel and push lightly around the Achilles tendon to see if it is tender or has any irregularities in its surface. Achilles tendonitis may cause the tendon to be thickened in areas, may cause swelling of the area around the tendon, and can even feel like the tendon has a painful bump on it. In addition, the person with Achilles tendonitis will limp while barefoot, but walk more normally with heeled shoes on. X-rays are not helpful in diagnosing Achilles tendonitis but may be taken to rule-out other pathology. MRI scans are only indicated if a partial or complete rupture of the Achilles tendon is suspected by the podiatrist.

Treatment

Achilles tendonitis generally responds very well to conservative treatment as long as it is diagnosed and treated early. Surgery is rarely indicated unless the Achilles tendonitis is particularly severe and chronic, or if the tendon has ruptured completely.

Initially, the podiatrist may treat the Achilles tendonitis by putting heel lifts into the patient’s shoes. In addition, the patient may be asked to avid barefoot walking or walking in low-heeled shoes. Non-steroidal anti-inflammatory drugs such as ibuprofen (Motrin, Advil) and naproxen (Naprosyn, Aleve) may also be prescribed to calm the inflammatory process in the tendon. Icing may be suggested to help decrease the inflammation and pain in the tendon. Stretching exercises for the calf muscles may also be given to the patient to help loosen the calf muscle and Achilles tendon so that the tendon is not under as much stress during normal daily walking activities. The stretching should not be done however if it causes pain in the Achilles tendon.

Initially, the patient with Achilles tendonitis will be asked to modify their activities to decrease their running and jumping activities and do alternative physical activities, such as swimming, which don’t put as much stress on the Achilles tendon. As the tendon starts to feel better, the podiatrist will allow a gradual return to normal running and jumping activities. If normal return to activities is not possible within a few weeks, then many times the podiatrist may additionally prescribe physical therapy and/or functional foot orthotics to help the tendon heal more rapidly. The foot orthotics generally are used during both the sports activities and walking activities to allow for more normal foot and Achilles tendon function. If the physician is concerned about a partial tear of the tendon the patient may be placed in a below the knee cast. It can take several weeks or even months for the tendon to heal depending upon the severity of the injury to the tendon. It is not uncommon for a patient to return to activities too quickly and re-injure the tendon. Careful monitoring of a return to full activity is important and the patient must have patience during this period of time.

Achilles tendonitis and spurs have a non-surgical treatment that works.

If you have pain in the back of your heel and are thinking about having an invasive surgical procedure – STOP.

There is a proven treatment that works for permanently relieving the pain using sound waves.

The sound waves actually are shock waves and now using the same technology that dissolves kidney stones, your heal can be treated in one 20 min treatment.

This technology is proven. With literally 100?s of articles that support cure rates of 70 to 95% published in the past 10 years, there is no disputing this technology and its results.

How does it work?

The machines produce high intensity shockwaves that are delivered into the back of the heel. In a single treatment session, 3200 shocks are delivered. The patient does not feel pain during the treatment. (local anesthesia is used) The treatment takes 20 min. The patient walks out of the office and can walk normally the next day in regular shoes.

What is happening here?

The Achilles tendon hurts when too much stress is put on it. Stress can come from overuse, or lack of stretching resulting in tightness of the tendon. The pain can exist at the insertion of the tendon or slightly higher. In either case, a spur can be located at the insertion. An x-ray can be used to see if you have a spur.

What does it mean if you have a spur?

Spurs are a sign that there has been excessive pulling on a bony insertion over a long period of time. Sometimes spurs are very large and sometime small. Sometimes spurs are located on the bottom of the foot and the back of the heel. This is because a tight Achilles tendon can pull back on the heel helping to actually create plantar heel pain (plantar fasciitis) and sometimes flattening the foot.

Stretching can help, but this often aggravates Achilles tendonitis.

Resting can help and should be tried as a conservative treatment.

Is there any other NEW treatment that can help this problem?

YES.  PEMF pads are electromagnetic therapy pads that can be worn at night or during the day. These really work well at improving blood flow.

Is there any NEW surgical information or alternatives?

YES – the Topaz Procedure.

The Endocspic Gastrocenemious Recession is fast becoming a procedure of choice for the treatment of Achilles tendonitis and plantar fasciitis in patients with over tight leg muscles. Often, the tight gastroc is overlooked by the foot professional at a primary cause of foot deformity and pain. Testing for this is very simple: dorsiflex the foot with the knee extended. If you do not have at least 10 degrees of dorsiflexion, then you are tight.

The EGR is simple to perform (less than 15 min) and is done under local anesthesia. It is performed through two very small 1 cm incisions in the back of the leg. As an endoscope is place into one of the incisions, a special blade is used to separate the aponeurotic band that joins the gastroc muscle to the tendon. See Photo.

The advantages are numerous: small incisions. Fast healing time to most activities in 3 weeks. Walking right away in surgical boot for 1-2 weeks and then tennis shoes.

Many other biomechanical advantages are obtained with EGR surgery. These include less forefoot pain, slows down deformity of forefoot bunions and hammertoes. Improves many forms of flat foot.

The EGR is now performed in place of Achilles tendon lengthening procedures closer to insertion. This is because of the lengthy healing time (6 months) for the Achilles tendon and increased risk of post op traumatic tearing with procedures performed close to the insertion.

Can the ECSW non-invasive shock wave procedure cure Achilles tendonitis without surgery?

YES.  The ECSW is much better at treating insertional tendonitis vs high tendonitis. But it does work for tendonitis. See illustration for identification of high tendonitis vs insertional tendonitis.

What type of person usually gets insertional tendonitis of the Achilles?

Usually heavier people with have larger spurs on the back of the heel. But many different body types have this problem.

Why Feet for Life Centers?

Dr. Michael Horwitz performes more of these procedures than anyone in the Midwest. Averaging 5 EGR’s a week on children and adults. Knowing what to look for and how to perform this procedure non-traumatically takes practice. Dr. Horwitz is a true leader in the treatment of heel pain. Feet for life Drs have performed over 450 ECSW procedures in the past 5 years and lead the country in the treatment of heel pain with this modality.