Achilles Tendonitis

The Achilles tendon is the largest and strongest tendon in the body. It connects the calf muscles to the heel bone and is used when you walk, run, climb stairs, jump, and stand on your tip toes. Although the Achilles tendon can withstand great stresses from running and jumping, it is also prone to tendonitis, a condition associated with overuse.

Achilles tendonitis is inflammation of the Achilles tendon, the tissue connecting your calf muscle to your heel. This inflammation, a common response to injury, often arises from overuse, particularly in runners due to the repetitive calf muscle engagement during toe raises.

Insufficient rest after such activity can lead to painful inflammation.

Achilles tendonitis is a form of tendonitis typically caused by overuse and repetitive strain on the Achilles tendon, leading to micro-injuries that accumulate over time and cause damage. This overuse can stem from increased training intensity, new exercise routines, or even everyday activities. While athletes, especially runners, are often at higher risk of developing this type of disorder, individuals with less active lifestyles can also experience Achilles tendonitis.

Achilles tendonitis often arises from repetitive strain on the Achilles tendon, often due to activities like running or jumping, or from sudden increases in exercise intensity. Jobs that require prolonged standing or physically demanding work, along with inadequate warm-ups, can also contribute to its development. Exercising in cold weather or on inclines, especially when paired with unsuitable footwear, can further exacerbate the condition.

Chronic conditions like obesity, diabetes, hypertension, rheumatoid arthritis, and osteoarthritis can also affect tendon health and increase the likelihood of tendonitis.

Several anatomical foot conditions and muscle imbalances can contribute to increased stress on the Achilles tendon, potentially leading to tendonitis. These include flat feet (pes planus), high arches (pes cavus), excessive pronation (flattening of the foot arch), and the presence of a bony protrusion at the back of the heel (Haglund’s deformity). At the same time, tight or short calf muscles or a stiff Achilles tendon can also exacerbate this risk.

Some of the most common symptoms of Achilles tendonitis are the following:

• Pain and stiffness along the Achilles tendon in the morning
• Pain along the tendon or back of the heel that worsens with activity
• Severe pain the day after exercising
• Thickening of the tendon
• Bone spur formation (insertional tendonitis)
• Swelling that is present all the time and gets worse throughout the day or with activity
• Pain on the back of the heel when you wear shoes

There are two types of Achilles tendonitis, based on which part of the tendon is inflamed. The two types can occur separately or at the same time.

Noninsertional Achilles tendonitis

• In noninsertional Achilles tendonitis, fibers in the middle portion of the tendon (above where it attaches to the heel) are affected. Over time, the fibers may begin to break down and develop tiny tears. This can lead to tendon swelling and thickening.
• Noninsertional tendonitis more commonly affects younger, active people, especially runners.

Insertional Achilles tendonitis

• Insertional Achilles tendonitis involves the lower portion of the tendon, where it attaches (inserts) to the heel bone (also known as the calcaneus). It can occur at any time or activity level, although it is still most common in runners. It is frequently caused by calf muscle tightness, which places increased stress on the Achilles tendon insertion.
• This form of tendonitis is associated with the presence of a bony prominence on the heel (Haglund deformity).

In both noninsertional and insertional Achilles tendonitis, damaged tendon fibers may calcify (harden) over time. Bone spurs often form on the heel with insertional Achilles tendonitis.

When the Achilles tendon degenerates, it can thicken and develop nodules due to tissue damage. In rare cases, this degeneration, with or without pain, can lead to a rupture of the Achilles tendon, a serious injury requiring immediate medical attention.

During the physical exam, your orthopedic surgeon will press gently on the area to find where the pain, tenderness or swelling is and watch how the foot and ankle look moving and at rest.

One or more of these imaging tests can help diagnose Achilles tendinitis:

• X-rays: X-rays do not show soft tissues such as tendons. But they may show some signs of Achilles tendonitis and can help rule out other conditions that can cause some of the same symptoms.
• This device uses sound waves to look at soft tissues such as tendons. Ultrasound also can make real-time images of the Achilles tendon to show how it moves. A color-Doppler ultrasound can look at blood flow around the tendon.
• Using radio waves and a strong magnet, MRI scans can show the Achilles tendon in detail.

Therapeutic approaches for Achilles tendonitis depend on the condition’s duration and the extent of tendon damage. Early treatment focuses on reducing activity, immobilization, ice therapy, and NSAIDs. Physical therapy, including strengthening exercises, soft tissue mobilization, stretching, and potentially ultrasound or shockwave therapy, is also crucial. Appropriate footwear with heel lifts and soft-backed shoes can reduce pressure on the tendon.

Choosing the appropriate footwear with a 2-4 centimeter heel, heel lifts, and soft/open-backed shoes can help reduce pressure on the Achilles tendon. Heel lifts elevate the heel, shortening the tendon and reducing its stretch during walking, while shoes with a soft or open back allow for more natural movement and reduce pressure points. Custom or off-the-shelf orthotics may be recommended for individuals with flat feet or other biomechanical issues.

If conservative treatment for Achilles tendon issues (like tendonitis or Haglund’s deformity) fails, surgical intervention may be necessary. Surgical options vary depending on the specific condition. For tendonitis, procedures may involve removing inflamed or scarred tissue or addressing calcific deposits. In Haglund’s deformity, the bony prominence is removed. For Achilles tendon ruptures, surgery involves suturing and reattaching the tendon.