achilles tendonitisAlthough I have a discussion on tendonitis elsewhere on this site, I thought I would devote a whole discussion to Achilles tendonitis as it is probably the most common tendonitis occurring on the foot and one of the most common tendon diseases occurring in the body in general. It is estimated that Achilles tendonitis accounts for upwards of 20 percent of all athletic injuries. Typical of most athletic injuries the range of severity is wide, but there is always the chance that a minor injury will transform into a major injury if adequate measures are not taken or the patient tries to “run” through the injury. Men, over the age of 40, are more prone to damage to the Achilles tendon, even rupture of the tendon due to the fact that as we age the structure of the tendon becomes more rigid and therefore more prone to tearing. Achilles tendonitis can occur in one of three places, either the uppermost portion of the tendon where it originates from the gastrocnemius muscle, or the portion of tendon just behind the ankle and lastly at the attachment of the tendon into the heel bone. Note the diagram below of the Achilles tendon; the yellow arrows note the most common sites of pain.
The anatomical make-up of the Achilles tendon is somewhat different than most tendons in that instead of having a “synovial sheath” which is a covering surrounding the tendon, the Achilles tendon is surrounded by a loose fatty layer of tissue known as the paratenon. Two problems with this type of anatomical arrangement is that the paratenon supplies the Achilles tendon with most of its blood supply, so healing of the Achilles tendon is very much dependant on the integrity of the paratenon and secondly, the paratenon itself is subject to injury. Many people will sustain injury to both the paratenon and the Achilles tendon resulting in adhesions (scarring) between the two structures that will lead to further reduction of motion and an increase in pain. The most common causes of Achilles tendonitis are poor training techniques particularly by older athletes. Inadequate warm-up, a rapid increase in mileage, or rapid increase in intensity of other sports will put excessive tension on the tendon. For runners the type of surface used for running can have a negative impact on the Achilles tendon. Concrete surfaces do not allow for any shock absorption on impact and thus the shock of the foot hitting the ground results in damage to the posterior musculature including the Achilles tendon. Running on uneven surfaces such as sand or a “banked” road results in more expenditure of energy by the lower leg muscles making the Achilles tendon more prone to injury. Running uphill applies more strain to the Achilles tendon increasing the possibility of injury. Poor athletic shoe selection can also create Achilles tendonitis. A shoe that constantly rubs and irritates the back of the heel may eventually lead to irritation of the tendon. A poor shock absorbing athletic shoe will put more strain on the Achilles tendon. An athletic shoe that does not adequately hold the heel bone (calcaneus) in place may also put unnecessary strain on the Achilles tendon. Foot structure will also play a role in the development of Achilles tendonitis. A foot that over pronates causes the Achilles tendon to overwork and may lead to injury. A foot that over supinates is a poor shock absorbing foot and this too may lead to inflammation of the tendon. The main complaint by patients is pain in the back of the heel. This pain needs to be distinguished from retrocalcaneal bursitis (see bursitis) or retrocalcaneal bone spur, along with some less common causes such as gout or Rheumatoid arthritis. The pain is most pronounced after periods of inactivity such as sleeping or sitting for a long period. Walking around will generally decrease but not eliminate the amount of pain. When exercising the pain is most prevalent when jumping or pushing off. Most cases of Achilles tendonitis is diagnosed by proper history and physical examination. On occasion an MRI may be necessary primarily to evaluate for tears within the tendon. In determining treatment for Achilles tendonitis it is important to first determine the cause. Elimination of factors that are exacerbating the problem such as poor athletic shoes, lack of adequate warm up or poor running surfaces all need to be addressed. If it is determined that a particular foot structure is the causative agent then an orthotic may be necessary to remove excessive pronation or supination. {see my recommended orthotic}
Looking for an effective, safe means to reduce or eliminate your foot pain, consider BLU-MJK. Use it in place of oral anti-inflammatory medication. Click the picture below  In situations where these simple procedures have not helped then physical therapy may be necessary. This consists of a program where the physical therapist works on reducing the inflammation while at the same time tries to increase the flexibility of the Achilles tendon. We generally do not give cortisone injections for Achilles tendonitis particularly at the insertion of the heel because this has been shown to increase the chance of Achilles tendon rupture. If injectable cortisone is to be used it should be injected underneath the skin and not directly into the tendon. In cases of rupture of the Achilles tendon surgery is generally the indicated treatment. The exception would be in those individuals who lead a very sedentary life style or are not good surgical candidates. In these cases the patients are usually put in a cast for upwards of several months. Symptoms of an Achilles rupture is described as a sudden sharp pain behind the ankle. Patients will describe hearing a “pop” and say they feel like someone kicked them in the heel even though there was no actually trauma. As stated earlier these types of injury are most common in men over the age of 40. A small percent of these cases will have reported having some tendon discomfort prior to the rupture but for most, there is no prior history of pain.
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