Achilles tendonitis is a common condition that causes pain along the back of the leg near the heel.
The Achilles tendon is the largest tendon in the body. It serves as a connector between the heel bone and the calf muscles at the rear of the lower leg. The tendon’s important function makes it crucial to running, walking, jumping, climbing, etc. While the Achilles tendon is indeed very strong and must endure great amounts of stress during these activities, it is also at risk for certain conditions, namely tendonitis. This condition has been linked to gradual deterioration and overuse.
Definition
Put simply, Achilles tendonitis is swelling of the Achilles tendon. This swelling is simply the human body’s natural reaction to disease or injury, though it often comes with additional inflammation, irritation and/or pain.
There are two kinds of this tendonitis, depending on the part of the Achilles tendon is affected:
Non-insertional
In this form of Achilles tendonitis, the fibers located in the middle area of the tendon are affected. These fibers start to degenerate, that is, wear down via small tears, thickening and swelling. Non-insertional Achilles tendonitis is found more often in young, active people.
Insertional
This form of Achilles tendonitis affects the lower part of the tendon, where it is attached to the heel. Excess bone growths (called “bone spurs”) are associated with insertional tendonitis, and the affected fibers may also harden or “calcify”. Insertional tendonitis is found in all age groups, including both active and inactive people.
Insertional Achilles tendonitis
Causes
This form of tendonitis is not generally related to any particular injury, but the condition can come from too much consistent stress to the Achilles tendon. This stress can occur when people force themselves to take on too much physical activity before they’re ready (such as running a marathon without sufficient training or stretching).
The main factors that can cause this condition are as follows:
- Tightened calf muscles
- Bone spurs rubbing up against the tendon
- Abrupt increase in exercise levels
- Tightened calf muscles
- Bone spurs rubbing up against the tendon
- Abrupt increase in exercise levels
Symptoms
Symptoms of Achilles tendonitis may vary, but generally they include:
- Pain in the area of the Achilles tendon (especially in the morning)
- Stiffness along the tendon
- Bone spurs
- Pain or stiffness that gets worse with increased activity
- Thickening in the Achilles tendon
- Intense pain the day after athletic activity
- Inflammation (including inflammation that may worsen with increased activity)
- Sudden “popping” in the back of the heel or calf muscle (may indicate rupturing as a result of tendonitis)
If you think you have ruptured your Achilles tendon at any point, seek medical attention as soon as possible.
Treatment
Non-surgical Treatment Options
For the most part, non-surgical methods will alleviate pain from tendonitis. However, significant relief may not occur until after a few months of treatment. Even if the condition is treated as early as possible, resulting pain may linger for up to three months or longer. Treatment that is delayed may result in relief taking twice as long to achieve.
There are several non-surgical treatment methods, most of which can go together:
Rest
If you have Achilles tendonitis, the first thing you’ll need to do is stop or at least decrease the amount of activity that worsens your symptoms. For example, high-impact activities like running or jumping should be swapped for those that cause much less impact to the tendon. Good options are biking, swimming and elliptical exercises (all athletic, but with much less stress on the Achilles tendon).
Ice Packs
Resting and putting ice on the affected area will help ease pain and keep down swelling. This can be done throughout your day as needed.
Medication
Certain medications, like the non-steroidal, anti-inflammatory ibuprofen aspirin, and naproxen, can also help in easing pain and reducing swelling. Still, the downside is that they only treat symptoms and do not actually stop the affected tendon from thickening or becoming further damaged. Speak with your doctor before you take medication for a month or longer.
Exercises
While strenuous exercises should certainly be decreased, various other exercises can actually help to reduce the amount of stress on the tendon and even build up strength in the surrounding muscles. Physical therapy has been shown to help non-insertional tendonitis more than it does insertional tendinitis.
Here are some exercises you can do:
Calf stretches – To do these, simply face a wall and lean in with your arms outstretched against it. Keep one leg straight with its heel flat on the floor while keeping the other leg ahead of you with its knee bent (the heel should also be flat). Then, slowly push both hips towards the wall until you feel a stretch down your back leg. Hold this for 10 seconds and then release. Repeat 20 times on each side.
Bilateral heel drops – Begin by standing at the edge of a stable, raised platform (a stair step will do). Keep the front half of your feet on the platform (keep a hand on the railing or wall to maintain balance and prevent falling). Then, slowly lift and lower your heels (as low as you can get them) so that you feel a stretch in the lower leg. Repeat this exercise 20 times, keeping it slow and controlled to prevent further damage and injury (never do this move suddenly). As your symptoms gradually improve, you can up the difficulty level by grasping a light weight in each of your hands.
Single leg heel drops – This move is essentially the same as the above bilateral heel drops, only in this you are only focusing on one leg at time (only do this after you have gotten the bilateral heel drop down). Repeat 20 times on each side.
Orthotic shoes and lifts
Specialized types of shoes and lifts (orthotics) can provide extra support while reducing pain. These primarily help with insertional Achilles tendonitis since they lessen irritation where the Achilles tendon inserts into the heel. Shoes may be softer to lessen impact during walking and other activities, while lifts allow for greater support and prevent the heel from rubbing up against the shoe back.
An “Achilles sleeve” may also be considered, since this provides extra support to the ankle while decreasing irritation against the shoe back. For patients with more severe pain, however, a “walking boot” may be the better option, at least for a short period of time (it allows the tendon to rest, but extensive use can actually weaken the muscles).
Surgical Options
Only when symptoms do not improve with non-surgical methods should surgery be considered (at least six months of non-surgical treatment should be attempted first). There are different types of surgery for Achilles tendonitis, and the one chosen for you will largely rely on the amount of damage already done to the tendon as well as the location of the problem. Here are the different types of surgery for this condition:
Debridement and repair
This procedure is an option when less than half of the Achilles tendon is damaged. Debridement and repair involves the removal of the damaged part (debridement) and subsequent repair of the remaining tendon with sutures. If it is a case of insertional tendonitis, any resulting bone spurs are also removed during surgery. If needed, plastic or metal “anchors” are then used to hold down the tendon to the bone of the heel while it heals. Depending on the severity of the damage, the majority of patients are able to walk with a cast or boot in within two weeks following surgery.
Gastrocnemius recession
In this procedure, the calf muscles are surgically lengthened to provide better flexibility and stress relief. After all, tightened calf muscles cause the Achilles tendon to be unnecessarily stressed, and some people may even be unable to flex their feet fully no matter how much they stretch. Though complications may include some nerve damage, the risk is low and most of these surgeries are successful.
Debridement, with Tendon Transfer
Should more than half of the Achilles tendon be damaged, the remaining tendon will not be able to function on its own after the damaged portion is removed. In order to prevent rupture from occurring, a “tendon transfer” can be performed after the debridement. In this procedure, the tendon in the big toe is “transferred” back to the heel bone, where it will provide extra strength and support. The good news is that patients will still be able to move their big toes, and they should not notice a difference in general movements, like running or walking.
Recovery
Even though it is used more as a final option, most patients do very well with surgery and make speedy recoveries. Of course, the actual recovery time will depend on the amount of damage and where in the tendon damage is located. The more severe the damage, the longer the recovery time. More severe cases will also prevent patients from returning to athletic activities for some time, sometimes permanently.
A crucial part of recovery after surgery is physical therapy, which your surgeon will discuss and plan with you. Most people have to keep up with physical therapy for about a year following the procedure.
Complications from Surgery
Some patients experience medium to high pain following surgery, and this is considered the most commonly occurring complication. Nevertheless, a more serious complication to be informed about is infection in the area, which can often be challenging to treat. Your doctor will discuss the complications with you prior to surgery.
