What is it?
Achilles Tendonitis is an inflammation of the tendon, usually resulting from overuse associated with a change in playing surface, footwear or intensity of an activity.
The Achilles Tendon is surrounded by a connective tissue sheath (paratenon or paratendon), rather than a true synovial sheath. The paratenon stretches with movement, allowing maximum gliding action. Near the insertion of the tendon are 2 bursae, the subcutaneous calcaneal and the retrocalcaneal bursae.
Achilles Tendonitis occurs in sports such as running, jumping, dancing and tennis. Other risk factors include participation in a new sporting activity or increasing the intensity of participation. Poor running technique, excessive pronation of the foot and poorly fitting footwear may contribute.
In cyclists, the problem may be a low saddle, which causes extra dorsiflexion of the ankle when pedalling. Quinolone antibiotics (e.g. ciprofloxacin, ofloxacin) can cause inflammation of tendons and predispose them to rupture.
- Gradual onset of pain and stiffness over the tendon, which may improve with heat or walking and worsen with strenuous activity.
- Tenderness of the tendon on palpation. There may also be crepitus and swelling. Pain on active movement of the ankle joint.
Ultrasound or MRI may be necessary to differentiate tendonitis from a partial tendon rupture.
Recovery usually takes weeks to months.
Achilles tendon rupture
- Rupture can occur at any age, but most often occurs in 30-50 year old recreational athletes. It is commonly seen in football, running, basketball, diving, tennis, and other sports that require a forceful push off with the foot.
Injury such as a fall, where there is forced dorsiflexion of the foot (producing a sudden stretch on the tendon) Deep lacerations over the site of the tendon.
Risk factors include:
- Increasing age
- Chronic/recurrent Achilles Tendonitis
- Steroids: Systemic corticosteroids (prolonged or high doses) or Cushing's syndrome. Previous steroid injections into or around the Achilles tendon
- Systemic conditions, e.g. Gout, Rheumatoid Arthritis, SLE
- Quinolone antibiotics (mainly if over 60 and/or also taking steroids)
- Acute onset of pain in tendon, felt as a sudden, sharp pain initially. Sometimes a 'snap' is heard as the tendon ruptures.
- The pain then settles into a dull ache.There may also be a history of less intense pain for several days before rupture.
- Patients may notice inability to stand on tiptoe, and altered gait (unable to 'push off' with the affected foot).
Ultrasound or MRI may help if the diagnosis is unclear (for example, to distinguish partial rupture from tendonitis).
Achilles tendon injury has a good prognosis, but the slight loss of function may be very significant for the competitive athlete. Surgical treatment of acute Achilles tendon ruptures significantly reduces the risk of re-rupture compared to non-operative treatment, but has a higher risk of other complications, including wound infection. Athletes may be unable to resume full activities for one year.
Treatments and drugs
Tendinitis is usually treated with relatively simple interventions, but successful treatment requires patience and careful adherence to treatment guidelines. Your doctor is likely to recommend a combination of interventions for Achilles tendinitis:
- Self-care strategies
- Pain medications
- Stretching and exercises
Self-care includes the following steps, often known by the acronym R.I.C.E.:
- Rest. Rest is essential for tissue healing. Depending on the severity of your symptoms, resting may mean not exercising for several days; reducing the duration and intensity of your routine; or switching to an activity that doesn't strain the Achilles tendon, such as swimming. You may need to wear a walking boot and use crutches if you have significant pain when putting weight on your foot.
- Ice. To decrease pain or swelling, apply an ice pack to the tendon for about 15 minutes after exercising or when you experience pain.
- Compression. Wraps or compressive elastic bandages can help reduce swelling and reduce movement of the tendon.
- Elevation. Raise the affected foot above the level of your heart to reduce swelling. Sleep with your affected foot elevated at night.
Your doctor is likely to recommend a prescription-strength or over-the-counter nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen (Nurofen) or naproxen (Naprosyn) to reduce inflammation and relieve pain.
Long-term use of NSAIDs can cause stomach pain, stomach bleeding, ulcers and other side effects. Talk to your doctor about how long you should take your medication and how he or she will monitor you for side effects.
Stretching and exercise
Appropriate stretching and exercise can promote healing and prevent recurring problems. Your doctor can refer you to a physical therapist or specialist in sports medicine. These techniques include:
- Stretching with knees straight. Lean against a wall with your knees straight and heels on the floor to stretch the upper portion of calf muscles.
- Stretching with knees bent. Place the foot forward and flex the knee and ankle with the heel flat on the floor to stretch the lower portion of calf muscles.
- Exercising calf muscles. Toe raises or the use of a calf-strengthening machine can help make the tendon stronger and treat Achilles tendon problems. A special type of strengthening called "eccentric" strengthening has been shown to be especially effective in treating chronic tendon problems. An example of this type of exercise to strengthen the calf muscle is slowly descending to the ground after rising on your toes.
Additional treatments may include the following:
- Orthotic devices protect or change the position of the foot and ankle in order to promote healing.
- Corticosteroid injections may be used with caution to reduce inflammation around a tendon that has been chronically inflamed.
- Surgery to repair damaged tissue and improve function of the tendon is considered only when several months of more conservative treatments don't work or if ongoing inflammation results in partial or complete rupture of the tendon.
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, start slowly and gradually increase the duration and intensity of the training.
- Take it easy. Avoid activities that place excessive stress on your tendons, such as hill running. 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. Strong calf muscles enable the calf and Achilles tendon to better handle the stresses they encounter with activity and exercise.
- Cross-train. Alternate high-impact activities, such as running and jumping, with low-impact activities, such as cycling and swimming
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.
- Ice. To decrease pain, muscle spasm and swelling, apply ice to the injured area for up to 20 minutes, several times a day.
- Compression. Because swelling can result in loss of motion in an injured joint, compress the area until the swelling has ceased.
- Elevation. Raise the affected ankle above the level of your heart to reduce swelling. It's especially important to use this position at night.
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.