Achilles Tendinitis

Your Achilles Tendon is the thick cord like structure you can feel at the back of your heel. It is part of your calf muscles (gastrocnemius and soleus muscles) and attaches these muscles to your heel bone (the calcaneus). When your calf muscles contract, your Achilles pulls on your heel bone to bend your foot and ankle towards the ground – a movement called plantar flexion.

Tendinitis is a condition that occurs when your tendon becomes inflamed or irritated. Achilles tendinitis, or inflammation in the Achilles tendon, is a relatively common condition. It can affect people at any age, however it tends to occur more frequently as you get older.

For most people, Achilles Tendinitis is short-lived and easily treated with rest and over-the-counter pain-relieving medications. Occasionally, the tendon becomes damaged by the inflammation, resulting in persistent pain or a tear (Achilles tendon rupture).

Symptoms

The signs and symptoms of Achilles tendinitis often develop gradually. They include:

  • Dull ache or pain when pushing off your foot during walking or when rising on your toes
  • Tenderness over your Achilles tendon
  • Stiffness that lessens as your tendon warms up
  • Mild swelling or a “bump” on your tendon
  • A crackling or creaking sound when you touch or move your Achilles tendon

You may notice that the affected tendon is sore when you get up in the morning or after you’ve rested, improves slightly once you start moving around, and then worsens again when you increase your activity level.

If you have sudden pain and swelling near your heel and are unable to bend your foot downward or walk normally, you may have ruptured your Achilles tendon (see Achilles tendon rupture). If you’ve ruptured the tendon completely, you won’t be able to rise on your toes on the injured leg. You may feel as if you’ve been kicked in the back of your ankle. See your doctor immediately if you suspect you have an Achilles tendon rupture.

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Causes

When you place a large amount of stress on your Achilles tendon too quickly, it can become inflamed from tiny tears that occur during the activity. A sudden increase in a repetitive activity that involves the Achilles tendon can be to blame. A number of other factors can cause Achilles tendinitis, including:

  • Improper conditioning. Achilles tendinitis is most common among athletes whose bodies aren’t properly conditioned for their sport or activity. Inadequate flexibility and strength of the calf muscles can contribute to overload of the tendon. Frequent stops and starts during the activity, as well as activities that require repeated jumping — such as basketball or tennis — also can increase your risk of Achilles tendinitis.
  • Too much, too soon. Achilles tendinitis resulting from overuse can occur when you begin a new exercise regimen. If you’re just beginning a new exercise program, be sure to stretch before and after exercising, and start slowly, increasing your activity over time. Don’t push yourself too quickly. If you’re a runner, excessive hill running can contribute to Achilles tendinitis.
  • Flattened arch. Flattening of the arch of your foot (excessive pronation) can place you at increased risk of developing Achilles tendinitis. This is because of the extra stress placed on you Achilles tendon when walking. If you have excessive pronation, be sure to wear shoes with appropriate support to avoid further aggravating your Achilles tendon.
  • Trauma or infection. In some cases, inflammation of the Achilles tendon is due to trauma or infection near the tendon.

Risk Factors

Some factors that may increase your likelihood of developing Achilles tendinitis include:

  • Age and overuse – as you get older the many years of wear and tear start to take a toll. The fibres that make up the tendon become injured and die, causing the tendon to become weak and prone to injury and inflammation.
  • Poor shoes – shoes that put excessive strain on the ligament can accelerate the inflammatory process.
  • Deformity – people with deformities of the feet, like flatfoot deformity, are more likely to develop Achilles tendinitis.
  • Weight

Investigations

In many cases, your doctor or physiotherapist can diagnose Achilles tendinitis just by listening to you and examining your feet.

When additional tests are required, your doctor may order:

  • Plain X-Rays – X-Rays do not usually show tendons, however in Achilles tendinitis there may be small calcium deposits in the tendon. This indicates long overuse and damage to the tendon fibres. In addition, there may be small bony spurs around the insertion of the tendon.
  • Ultrasound is a useful tool for assessing the swelling and inflammation in the Achilles tendon.
  • MRI – while MRIs show a great deal of detail about muscles and tendons they are not always required to diagnose achilles tendinitis.

Complications

Achilles tendinitis can progress to a degenerative condition called Achilles tendinosis. In this condition, the tendon begins to lose its organised structure, becoming weaker and more scarred. Continued stress to your Achilles tendon could cause it to tear (rupture), which may require surgery to correct the damage.

Treatment

If you’ve tried self-care measures, such as rest, ice and over-the-counter pain relievers, and they aren’t working for you, your specialist may suggest other Achilles tendinitis treatments:

  • Orthotic devices. A temporary foot insert (orthotic device) that elevates your heel within your shoe may relieve strain on the stretched tendon. Your specialist might also prescribe special heel pads or cups to wear in your shoes to cushion and support your heel, or a splint to wear at night that will keep the Achilles tendon stretched while you sleep.
  • Boot and crutches. In severe cases, a walking boot or gait aid (eg crutch) may be prescribed to allow the tendon to heal.
  • Surgery. Nonsurgical treatments, including physiotherapy and perhaps a change in your exercise program, should allow the tendon to heal and repair itself over a period of weeks. If these treatments aren’t effective, surgery to remove the inflamed tissue from around the tendon may be necessary; however, this is usually a last resort.

If left untreated and if the tendon continues to sustain small tears through exercise and repeated movement, the tendon can rupture under excessive stress.

Looking After Yourself

If you think you may have Achilles tendinitis, help speed your recovery and prevent further problems by trying these at-home care methods:

  • Rest. Avoid activities that increase the pain or swelling. Don’t try to work or play through the pain. Rest is essential to tissue healing. But this doesn’t mean complete bed rest. You can do other activities and exercises that don’t stress the injured tendon, especially low-impact activities, such as bicycling.
  • Ice. To decrease pain, muscle spasm and swelling, apply ice to the injured area for up to 20 minutes, several times a day. Ice packs, ice massage or ice water slush baths all can help. For an ice massage, freeze a plastic foam cup full of water so that you can hold the cup while applying the ice directly to the skin.
  • Compression. Because swelling can result in loss of motion in an injured joint, compress the area until the swelling has ceased. Wraps or compressive elastic bandages are best.
  • Elevation. Raise the affected ankle above the level of your heart to reduce swelling. It’s especially important to use this position at night.

Keep moving

Although rest is a key part of treating tendinitis, prolonged inactivity can cause stiffness in your joints. Move the injured ankle through its full range of motion and perform gentle Achilles tendon stretches to maintain joint flexibility.

Anti-inflammatory medications

You can also try nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen or products containing paracetamol to try to reduce the discomfort associated with tendinitis.

Be sure to talk to your doctor if you feel you need NSAIDs for an extended time because some of these drugs should be used for only short periods — around seven to 10 days — to avoid complications.

If you take NSAIDs frequently or take more than the recommended dose, these medications can cause stomach pain, stomach bleeding and ulcers. Rarely, prolonged use can disrupt normal kidney function. If you have liver problems, talk to your doctor before using products containing paracetamol.

Physiotherapy for Achilles Tendinitis

In the initial phase of treatment, the physiotherapist will prescribe strengthening and stretching exercises.

Tendinopathy can be treated long-term with ‘eccentric training’ of the Achilles. This involves balancing on the toes on a stair and lowering the heels of the ankle is flexed.

Surgery

Operations are rarely necessary for Achilles tendinitis, however will be considered when physiotherapy fails. Options include:

  • Debridement – trimming away any significantly damaged areas of the tendon. This is the most commonly used surgical option and often yields very good results.
    • If significant portions of the tendon are damaged, a tendon graft may be needed in conjunction with the debridement.
  • Removal of bursa
  • Osteotomy (bone reshaping)

Seeking Advice

Physiotherapy

The first port of call for suspected Achilles Tendinitis should be the physiotherapist. Your physio will be able to:

  • Diagnose your problem
  • Recommend treatment to control symptoms initially, then to improve function and reduce the likelihood of re-injury
  • Assist you in finding other support, for example gait aids from occupational therapists
  • Refer you to other doctors, either GPs, sport medicine specialists or orthopaedics

Your Family Doctor (GP)

Your Family Doctor will be able to diagnose and help treat your problem. He or she will be able to

  • tell you about your problem
  • advise you of the best treatment methods
  • prescribe you medications
  • and if necessary, refer you to Specialists (Consultants) for further treatment

When to seek medical advice

If you experience pain around your Achilles tendon that worsens with activity, call your doctor for an evaluation and to discuss treatment options.

See your doctor if you experience persistent pain near the back of your heel in the area of your Achilles tendon, and especially if the pain doesn’t markedly improve within one to two weeks despite self-care measures. See your doctor immediately if you experience signs or symptoms of an Achilles tendon rupture.

Prevention

While it may not be possible to prevent Achilles tendinitis, you can take measures to reduce your risk:

  • Increase your activity level gradually. If you’re just beginning an exercise regimen, don’t feel like you have to be marathon-ready in record time. Starting slowly will help you determine your limits and follow a sensible exercise program.
  • Take it easy. Avoid activities that place excessive stress on your tendons, especially for prolonged periods. If you participate in a strenuous activity, warm up first by exercising at a slower pace. If you notice pain during a particular exercise, stop and rest.
  • Choose your shoes carefully. The shoes you wear while exercising should provide adequate cushion for your heel and should have a firm arch support to help reduce the tension in the Achilles tendon. Replace shoes that show excessive wear. If your shoes are in good condition but don’t support your feet, try arch supports in both shoes.
  • Stretch daily. Take the time to stretch your calf muscles and Achilles tendon in the morning, before exercise and after exercise to maintain flexibility. This is especially important to avoid a recurrence of Achilles tendinitis.
  • Strengthen your calf muscles. Performing exercises such as toe raises, especially with a slow return to the ground after each toe raise, trains the muscle-tendon unit to withstand more loading force.
  • Cross-train. Alternate impact activities, such as running and jumping, with low-impact activities, such as cycling and swimming.

More Information

More information on arthritis, relevant treatments and support services can be found at the following sites:

Medical sources on First Metatarsal Fusion:

The latest research on first metatarsal joint fusion is accessible through the Cochrane Library and PubMed Database.

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