Achilles Tendinitis is the back ankle pain in the feet. This is because of the irritation caused to the Achilles Tendon which connects the calf muscles to the heel bone. If you are an athlete, sportsperson, or one who exercise or starting one, continue reading to keep your ankle safe.
In the last three decades, fitness awareness and sports activities are on the rise. So are the complications related to them like Achilles Tendinitis.
Achilles is a Greek war hero’s name whose body is vulnerable except his heel. There is also a similar phrase ‘Achilles heel’ which refers to one’s weak spot.
Tendon or Sinew is a flexible strong band of fibrous collagen connective tissue which is capable of withstanding tension. When this gets affected it is called by the name Achilles Tendinitis or Achilles Tendinopathy.
Tendons are similar to ligaments. Both are made of collagen. But ligaments connect bones to bones and tendons connect muscles to bones. Achilles tendon is the largest tendon in the human body.
Runners around the world are prone to Achilles Tendinitis than others of their own age in the ratio of 10: 1. But some surveys and researches attribute Achilles Tendinitis not only to sporting activity but also to other factors.
During normal walking pronation and supination of about 5 degrees occurs of the feet when it lands on the ground. This causes the tendon to be inserted in the heel bone of about 1 to 4 inches inward. This also overtime causes Achilles Tendinitis.
Achilles Tendinitis is also common among people who only exercise or play weekend sports. This is because of the sudden activity of the body. Also, those who increase the exercising level suddenly experience Achilles Tendinitis.
Not only runners but also sportspersons like volleyball and football players are affected by Achilles Tendinitis. If you are one among them it is time to check your heels and ankle.
Exercise is one of the cures for Achilles tendinitis but the same exercises are done in the wrong way or paced up suddenly causes it. Trauma, lifestyle without any exercises and some medications like steroids or fluoroquinolone like ciprofloxacin could cause Achilles Tendinitis.
The tendon tissue is typically designed to withstand tension. But when you overwork or due to some injury or wrong usage of it over a period of time causes Achilles Tendinitis.
Types Of Achilles Tendinitis:
There are two types of Achilles tendinitis based on the affected area of the tendon.
Insertional Achilles affects the lower part of the tendon where it connects the calf muscle to the heel bone. This is because of the insertion of the tendon inwards about 5 degrees into the heel bone due to pronation of supination of landing the foot.
Non-Insertional Achilles affects the middle part of the tendon. This occurs among the youth who tend to have more leg activity too soon.
Achilles Tendon disorders are also classified into two other types:
This is the initial stage of the disorder in the Achilles tendon. They cause inflammation of the tendon that is solved in a short period with self-treatments such as rest and stretching.
This is the advanced form of Achilles Tendinitis. When the tendon degenerates further it is called Achilles Tendonosis. This is characterized by not only swelling of the tendon but of severe pain. This is caused by the enlargement of the tendon of approximately 1 to 4 inches above its heal insertion.
This is a more complicated condition because the tendon has lost its normal structure and impaired with the ability to perform strenuous activities. If left untreated there are risks of chronic degeneration and even full tear of the tendon.
Causes Of Achilles Tendinitis:
There are several causes of Achilles Tendinitis. It could be from age to medications.
Common causes of Achilles Tendinitis:
Men are prone to be affected by Achilles Tendinitis than women.
The wear and tear of daily life coupled with stress makes the tendon damage over time. This could be the main reason for aged people to suffer from Achilles Tendinitis.
Achilles Tendinitis occurs more frequently in cold weather than in warm weather.
- Wearing high heel shoes or slippers for a prolonged time.
- No proper exercise as per age and body conditions.
- Work which affects the legs and mostly the calf muscles for a long period of time
- Having flat feet or fallen arches can cause more strain on the tendon
- Tight calf muscles could also increase the possibilities of Achilles Tendinitis
- Obesity is one of the main reason to put more strain on the tendon
- Extra bone growth and having bone spurs on the back of the heels also causes rubbing discomfort to the tendon.
- Differences in the anatomy of the foot, ankle, and leg
- Exercising or running in worn-out shoes or out of form or out of size shoes.
- Running often in high terrain, slanted, hard and uneven surfaces are prone to Achilles Tendinitis.
- Without proper stretching and warm up before running or exercising.
- Playing only weekend sports and that too for a long period of time.
- Straining more of the calf muscles with particular types of exercises or sports
- Playing sports like tennis where sudden stops and changes are more
- Unprecedented or sudden increase in the time, power, and force of running or other exercises without increasing them gradually
- The sudden increase of stairs climbing on the course of work or for other purposes
- Increased physical activity suddenly like running very fast near the finish line
- People suffering from psoriasis or high blood pressure are prone to developing Achilles tendinitis.
- Certain types of antibiotics called fluoroquinolones like ciprofloxacin, Factive, Gemifloxacin among others can cause Achilles tendinitis.
Symptoms Of Achilles Tendinitis:
Symptoms of the Achilles tendinitis differs with the severity of the damage to the tendon. Mild ache on the back of the leg after some sports or other activity is the starting point of Achilles Tendinitis.
The common causes of Achilles Tendinitis:
- Swelling around the ankles
- Pain in the calf muscles and ankle
- Stiff calf muscles
- Bumps around the Achilles tendon part of the leg
- More hot heels when compared to the other parts of the body
- Limited range of movement when flexing the feet
- The lower part of the leg feels stiff, weak and becomes slow to move
- Stiffness and pain more in the morning which gradually increases or decreases depending on the activities
- The Achilles tendon sores a few centimeters at the heel joining part
- The insertion of tendon into the heel of 10 to 4 inches
- The Achilles Tendon enlarge to form bumps
- The Achilles Tendon tears with a snapping or popping sound in severe conditions or because of hyper activities.
Diagnoses Of Achilles Tendinitis:
On the first symptom or when the pain becomes severe, it is time to see the doctor.
Common diagnoses by the doctor:
- The doctor may ask you several questions relating to the history of the pain and swelling.
- The doctor touches your affected part to determine the location of pain, swelling and tenderness.
- The flexibility, range of motion alignment and reflexes of your foot and ankle are checked by the doctor for determining the severity of the damage.
- For checking the flexibility you may be asked to stand on balls of your feet
Once the severity of the damage is found the following clinical examinations are done to assess the condition.
Clinical diagnoses for Achilles Tendinitis:
X-rays are taken to eliminate any other possibilities of damage which have similar symptoms.
This is because the tough tissues which form the tendons cannot be viewed in the x-rays.
The sound waves from this device give the clear picture of the tissues of the tendon. Ultrasound can also give the real-time images of the color, and motion of the tendons.
This advanced method of ultrasound could also evaluate the blood flow around the tendon. There is little blood flow in the tendons and hence the flow around the tendons could evaluate the damage to the tendons.
In severe cases of damages, MRI or the Magnetic Resonance Imaging is done to produce the detailed images of the Achilles Tendon.
MRI is done to know the extent of the tear in the tendon. This could be highly useful for the surgical purpose.
Projection Radiography shows the calcification deposits within the tendon. These deposits are found in the calcaneal insertion of the tendon. This is the cause for nearly 60 percent of the damaged patients.
Pathophysiology Of Achilles Tendinitis:
Since there is no cell activity or little blood supply in the Achilles Tendon the injury will take time to slow down or heal completely.
The nutrients and blood flow are increased after the damage by the Paratendon. Paratendons are the sheath of the tendons. Cells from the surrounding structures of the Achilles tendon migrate into the tendon to assist in healing the damage. Blood is also entered into the tendon through some of these cells to increase healing.
Also, a recent research has found that these nerve fibers around the Achilles tendon are the cause of the pain. Hence directly injecting anesthetic around these vessels could decrease the pain.
Treatment For Achilles Tendinitis:
Achilles Tendinitis normally responds to self-care measures. But if the symptoms and signs still prevail for more than a week, immediately a doctor should be consulted for clinical treatments.
Treatments for Achilles Tendinitis should be given within a period of six months from the time of the symptoms. Failing which the treatment becomes very tough and impossible in many cases. This could lead only to surgical treatment.
- Rest is the basic need for healing the damage. Rest could be needed for days and even weeks for healing.
- Reducing physical activity
- Switching to less strenuous exercises and sports
- Keeping the feet elevated to decrease swelling
- Icing the swelling and paining part for 20 minutes several times a day
Gentle stretching exercises to strengthen the calf muscles along with it the tendons and surrounding structures.
A special type of strengthening exercise called ‘eccentric’ could be done. This involves a small weight to be slowly raised and lowered by the leg. Also lifting the body slowly up and down standing only on the affected leg. This could also be done with hyperextension of the affected heel. This could be done with the help of a book or on steps so that the tip of the heel is inches below the forefeet. This is done to further strengthen the tendon in the following ways:
- Eccentric increases the tensile strength of the tendon.
- Lengthen the muscle-tendon junction
- Ankle joint movement strain reduced
- Decreases the degeneration of the collagen fibers
For chronic pain and severe cases, a physical therapist may be consulted for the treatment. Depending on the severity and the condition the therapist may recommend the following methods:
- To wear a walking boot or brace to reduce heel movement
- To wear an elastic bandage around the ankle and lower leg to compress it. This reduces the swelling and pain.
- To wear Ankle supports, Crutches, Shoe insert or wedge to elevate the heel thus balancing the feet
Medications for treatment:
Nitroglycerine applied on the affected area could produce some relief.
Some over the counter medications can give some relief. They are some NSAIDs or Nonsteroidal anti-inflammatory agents like
Ibuprofens like Motrin IB, Advil and others
Naproxen like Aleve
Patients who are suffering from liver, kidney, and asthma should consult the doctor before taking NSAIDs.
Some injections give relief to Achilles Tendon and reduce swelling and pain. Some are found not so effective in the treatment.
Anesthetic injections between the tendon and the surroundings are called Brisement. This heals to a large extent but should be repeated more than once.
- Steroid Injections
- Platelet-rich plasma or PRP injections
- Corticosteroid injection
- Autologous blood injections
Extracorporeal Shock Wave Therapy or ESWT is the last option before surgery. This is done by high energy shock waves to stimulate the healing process. If this treatment is not healing within 6 weeks then the last resort is only to conduct surgery.
Surgical treatment can be done only after complete rest for more than 3 months. MRI scans are thoroughly checked before conducting the surgery.
- Surgery involves removal of the calcification deposits in the tendon
- Cutting out the surrounding thickened and scarred sheath
- Any tear within the tendon is repaired
- Abnormal scar tissues of the tendon are removed
- For older people, nearly 50 percent of the tendon is removed
- A tendon from the back of the ankle is transferred to the heel bone
As soon as the surgery is over rest and permitted motions are done immediately to prevent repeat scarring of the tendon. The normal activity could resume only after three to six months. Complete recovery may take up to one or two years.
Surgical treatment heals more than 75 % of patients completely. Care and concern should be followed after the surgery. This could avoid complications like Hematomata which is blood clotting and swell inside the tissue, and Vein Thrombosis or blood clot in the vein.
Prevention Of Achilles Tendinitis:
Prevention is better than cure. This old adage is still the mantra of healthy living. Lifestyle includes exercises daily. But the exercises done should not lead to an ailment. Hence the following preventions should be taken to prevent Achilles Tendinitis:
- Warm up before any exercise
- Stretching the muscles at the beginning of each day to improve agility
- To stretch the Achilles tendon you should stand with a straight leg and lean forward as you keep the heel on the ground
- Intensify the exercise routine gradually without any sudden spurt of activities
- Vary exercises according to their high and low impacts on the body
- Do not push too hard and take a break whenever possible during physical activity.
- Shoes are the saviors of the feet. Use proper shoes not only during exercising but also all the time.
- Replace the worn-out shoes regularly.
- Exercise according to the body condition and importantly as per the age and its limitations
- Avoid uphill running, hard, slanting and uneven surfaces.
- Stop any physical activity if it accompanies with the pain in the leg
- Avoid high heel shoes even if the pain is felt wearing them. This should be followed even if it is good for your appearance.
- Eat collagen and omega 3 rich food.
- Maintain good body posture and neutral walking.
Achilles tendinitis is a clinical syndrome characterized by the combination of pain, swelling, and impaired performance. For many patients, the control of the symptoms is a more realistic aim than a complete cure.
If the symptoms are not treated within 6 months, surgery is the only option. It involves a lot of suffering and financial burden. Hence all preventive ways should be taken to avoid Achilles Tendinitis.
The risk of Achilles tendon rupture is small but present. So living a healthy lifestyle and with good habits can save hospital bills and time in hospital beds.