Achilles Tendon Pain?

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Achilles Tendon Injuries & Problems

Problems that affect the Achilles tendon include tendonitis, tendinopathy, retrocalcaneal bursitis, and tendonosis. Each of these conditions will be described and explained. These problems affect athletes most often, especially runners, basketball players, and anyone engaged in jumping sports. They are also common among both active and sedentary (inactive) middle-aged adults. These problems cause pain at the back of the calf. Severe cases may result in a rupture of the Achilles tendon.

Anatomy of the Achilles Tendon

The Achilles tendon is a strong, fibrous band that connects the calf muscle to the heel. The calf is actually formed by two muscles, the underlying soleus and the thick outer gastrocnemius. Together, they form the gastroc-soleal muscle group. When they contract, they pull on the Achilles tendon, causing your foot to point down and helping you rise on your toes. This powerful muscle group helps when you sprint, jump, or climb. Several different problems can occur that affect the Achilles tendon, some rather minor and some quite severe.

Retrocalcaneal Bursitis

A bursa is a fluid-filled sac designed to limit friction between rubbing parts. It acts like a pillow between the heel bone or calcaneus and the achilles tendon. These sacs are found in many places in the body. When a bursa becomes inflamed, the condition is called bursitis. Retrocalcaneal bursitis is an inflammation in the bursa behind the heel bone. This bursa normally limits friction where the thick fibrous Achilles tendon that runs down the back of the calf glides up and down behind the heel.

Achilles Tendinitis

A violent strain can cause trauma to the calf muscles or the Achilles tendon. Sometimes this is referred to as tendonitis. This injury can happen during a strong contraction of the muscle, as when running or sprinting. Landing on the ground after a jump can force the foot upward, also causing injury. The strain can affect different portions of the muscles or tendon. For instance, the strain may occur in the center of the muscle. Or it may happen where the muscles join the Achilles tendon.

Achilles Tendinopathy/Tendinosis

Chronic overuse may contribute to changes in the Achilles tendon as well, leading to degeneration and thickening of the tendon. Studies show there is no sign of inflammation with overuse injuries of tendons. Most experts now refer to this condition as tendinopathy or tendonosis instead of tendonitis.

Achilles Tendon Rupture

In severe cases, the force of a violent strain may even rupture the tendon. The classic example is a middle-aged weekend warrior who places too much stress on the tendon and experiences a tearing or pop of the tendon. In some instances, the rupture may be preceded by a period of tendonitis, which renders the tendon weaker than normal.
Problems with the Achilles tendon seem to occur in different ways. Initially, irritation of the outer covering of the tendon, called the paratenon, causes paratendonitis. Paratendonitis is simply inflammation around the tendon. Inflammation of the retrocalcaneal bursa may also be present with paratendonitis. Either of these conditions may be due to repeated overuse or ill-fitting shoes that rub on the tendon or bursa.
As we age, our tendons can degenerate. Degeneration means that wear and tear occurs in the tendon over time and leads to a situation where the tendon is weaker than normal. Degeneration in a tendon usually shows up as a loss of the normal arrangement of the fibers of the tendon. Tendons are made up of strands of a material called collagen. (Think of a tendon as similar to a nylon rope and the strands of collagen as the nylon strands.) Some of the individual strands of the tendon become jumbled due to the degeneration, other fibers break, and the tendon loses strength.
The healing process in the tendon causes the tendon to become thickened as scar tissue tries to repair the tendon. This process can continue to the extent that a nodule forms within the tendon. This degenerative condition without inflammation is called tendonosis. The area of tendonosis in the tendon is weaker than normal tendon. Tiny tears in the tissue around the tendon occur with overuse. The weakened, degenerative tendon sets the stage for the possibility of actual rupture of the Achilles tendon.
Retrocalcaneal bursitis usually begins with pain and irritation at the back of the heel. There may be visible redness and swelling in the area. The back of the shoe may further irritate the condition, making it difficult to tolerate shoe wear.
Achilles tendonitis usually occurs further up the leg, just above the heel bone itself. The Achilles tendon in this area may be noticeably thickened and tender to the touch. Pain is present with walking, especially when pushing off on the toes.
An Achilles tendon rupture is usually an unmistakable event. Some bystanders may report actually hearing the snap, and the victim of a rupture usually describes a sensation similar to being violently kicked in the calf. Following rupture the calf may swell, and the injured person usually can't rise on his toes.

Diagnosis

Diagnosis is almost always by clinical history and physical examination. The physical examination is used to determine where your leg hurts. We will probably move your ankle in different positions and ask you to hold your foot against the our hand pressure. By stretching the calf muscles and feeling where these muscles attach on the Achilles tendon, we can begin to locate the problem area.
We may run some simple tests if a rupture is suspected. One test involves simply feeling for a gap in the tendon where the rupture has occurred. However, swelling in the area can make it hard to feel a gap.
Another test is done with your leg positioned off the edge of the treatment table. We will squeeze your calf muscle to see if your foot bends downward. If your foot doesn't bend downward, it's highly likely that you have a ruptured Achilles tendon.
When we are unsure whether the Achilles tendon has been ruptured, an MRI scan may be necessary to confirm the diagnosis. This is seldom the case. The MRI creates images that look like slices and shows the tendons and ligaments very clearly. This test does not require any needles or special dye and is painless.
We may order an ultrasound test. An ultrasound uses high-frequency sound waves to create an image of the body's organs and structures. The image can show if an Achilles tendon has partially or completely torn. This test can also be repeated over time to see if a tear has gotten worse.
By using the MRI and ultrasound tests, we can determine if surgery is needed. For example, a small tear may mean that a patient might only need physical therapy and not surgery.

Treatment

Nonsurgical Treatment

Tendonitis/Tendinopathy

In the past, nonsurgical treatment for retrocalcaneal bursitis and Achilles tendonitis started with a combination of rest, ice, and anti-inflammatory medications such as aspirin or ibuprofen.
If there is an inflammatory process, then the condition should respond fairly quickly to drug and antiinflammatory interventions. Limiting, but not eliminating, inflammation is the new goal.
Physical therapy may be recommended for any of these tendon problems. Treatment will depend on what type of problem (tendonitis or tendinopathy/tendonosis) is present.
Your therapist will know when and how to apply cold modalities to reduce swelling and pain but still allow the healing inflammatory process. Physical therapy for chronic tendon problems may also include a special program of stretching and eccentric strengthening exercises. Your therapist will instruct you in a home care program.
Low-energy shock wave therapy has been used successfully for chronic tendinopathy. The procedure does not require anesthesia but it may take several treatment sessions. The vibration produced by the energy waves is applied to areas of tenderness while the affected foot and ankle are gently moved in all directions. Shock wave therapy works by turning off nerves responsible for pain without affecting motor function. It also stimulates soft-tissue healing by increasing blood supply to the area treated.

Tendinosis
If the problem is one of tendon tissue degeneration, healing and recovery may take longer. The injury will not respond to treatment designed to reduce inflammation. Correct treatment of tendinosis involves allowing new tendon tissue growth and improving the strength of the tendon. Rehabilitation following rupture of the tendon is quite different and is described later.
An acute injury needs rest. This can be done by limiting activities like walking on the sore leg. A small ¼ or ½ inch heel lift placed in your shoe can minimize stress by putting slack in the calf muscle and Achilles tendon. Be sure to place a similar sized lift in the other shoe to keep everything aligned. A cortisone injection is not advised for this condition, due to the increased risk of rupture of the tendon following injection.

Tendon Rupture

Nonsurgical treatment for an Achilles tendon rupture is somewhat controversial. It is clear that treatment with a cast will allow the vast majority of tendon ruptures to heal, but the incidence of rerupture is increased in those patients treated with casting for eight weeks when compared with those undergoing surgery. In addition, the strength of the healed tendon is significantly less in patients who choose cast treatment. For these reasons, we feel that Achilles tendon ruptures in nearly all patients should be surgically repaired.

Surgery

Surgical treatment for Achilles tendonitis is not usually necessary for most patients. Surgery options range from a release of the tendon to a more involved, open approach of repair.
In some cases of persistent tendonitis and tendinosis a procedure called debridement of the Achilles tendon may be suggested to help treat the problem.
This procedure is usually done through an incision on the back of the ankle near the Achilles tendon. The tendon is identified, and any inflamed tissue is removed. The tendon is then split, and the degenerative portion of the tendon is removed. The split tendon is then repaired and allowed to heal. It is unclear why, but removing the degenerative portion of the tendon seems to stimulate repair of the tendon to a more normal state.
Surgery may also be suggested if you have a ruptured Achilles tendon. Reattaching the two ends of the tendon repairs the torn Achilles tendon. This procedure is usually done through an incision on the back of the ankle near the Achilles tendon. Numerous procedures have been developed to repair the tendon, but most involve sewing the two ends of the tendon together in some fashion.

After Surgery

Traditionally, patients would be placed in a cast or brace for six to eight weeks after surgery to protect the repair and the skin incision. Crutches would be needed at first to keep from putting weight onto the foot. Complications can occur such as delayed healing, infection, and scarring. More serious problems such as tendon rupture and nerve damage can also occur.
Passive range of motion exercises during this period help patients maintain good general muscle strength and aerobic fitness. Upon removing the cast, a shoe with a fairly high heel is recommended for up to eight more weeks, at which time physical therapy begins.
Immobilizing the leg in a cast can cause joint stiffness, muscle wasting, and blood clots. To avoid these problems, surgeons may have their patients start doing motion exercises very soon after surgery. Patients wear a splint that can easily be removed to do the exercises throughout the day. A crutch or cane may be used at first to help you avoid limping.

Dr. Silvers and Dr. Williams of Advanced Foot and Ankle Center in McKinney and Prosper, Texas have 5 years combined postgraduate training in foot and ankle conditions including managing achilles tendon problems. They also have over 12 years combined private practice experience in treating all conditions of the foot and ankle.The physicians at Advanced Foot and Ankle Center in McKinney and Prosper, Texas are the providers to seek out for treatment not only for achilles tendon problems, but for all of your foot and ankle needs.Advanced Foot and Ankle Services the residents of McKinney, Allen, Plano, Frisco, Prosper, Pilot Point, Little Elm, Melissa, Anna, Celina and surrounding communities. We strive for compassionate and uncompromised foot and ankle care. Our doctors and staff will treat you like family and we respect your busy schedule. Your foot and ankle care is our top priority and we strive to deliver excellent care for all of your podiatric needs. To schedule an appointment to see Dr. Eric Silvers or Dr. Kory Williams of Advanced Foot and Ankle Center , please call us at 972-542-2155 or visit our website at http://www.advancedfoottexas.com/ . We often have same day appointments along with lunchtime, evening and early morning hours.Eric M. Silvers, DPM , PABoard Certified Foot and Ankle SpecialistAdvanced Foot and Ankle CenterMcKinney , TexasProsper, Texashttp://www.advancedfoottexas.com

Eric M. Silvers, DPM, PA
Board Certified Foot and Ankle Specialist
Advanced Foot and Ankle Center
McKinney, Texas
Prosper, Texas
http://www.advancedfoottexas.com
972-542-2155