Achilles Tendonitis

Achilles tendonitis is a common source of pain, particularly with regular running, athletics activities. Pain from Achilles tendonitis can even be generated during simple walking.

There are several types of injury that affect the Achilles tendon:
  • Paratendonitis: involving a crepitus (crackly) feeling in the tissues surrounding the tendon.
  • Proliferative Tendonitis: acute and reactive response to overload of the tendon structure (i.e. following a run on a hill) causing a fusiform thickening of the tendon.
  • Degenerative Tendonosis: slow onset chronic and recurrent response where inevitably the tendon never regains its former structure and therefore is always sensitive to a load.
  • Enthesis: inflammation of the insertion to the heel - associated with children during their growth spurts.

Achilles Tendonitis:

The Achilles tendon is the single strongest tendon in the human body. The primary function of the Achilles tendon is to transmit the power of the calf to the foot resulting in the ability to move us forward, allow us to jump, dance; you name it. If it has to do with motion, the Achilles tendon is a part of that activity. Occasionally the Achilles tendon looses the ability to keep up with us and the tendon becomes inflamed resulting in Achilles tendonitis.



Acute Achilles tendonitis

Acute Achilles tendonitis typically has an abrupt onset with moderate pain along the tendon about 2-3 centimeters from the tendons' insertion on the back of the heel. Most individuals with acute Achilles tendonitis can describe an injury or single event that initiated the pain. Symptoms of acute Achilles tendonitis occur at the beginning of an activity and are typically described as a sharp pain. As the activity progresses, the pain decreases for a period of time. With excessive use, the tendon again becomes painful at the end of activity. For example, runners with Achilles tendonitis experience pain as they begin their run. The pain subsides during their run only to recur near the end of their normal running distance.

Chronic Achilles tendonitis

Chronic Achilles tendonitis exhibits the same type of pain as acute Achilles tendonitis but the location of the pain is usually at the insertion of the Achilles tendon into the heel. Chronic Achilles tendonitis can also cause hypertrophy (enlargement) of the posterior heel and in limited cases, enlargement of the tendon. This bony enlargement of the back of the heel goes by many names including retrocalcaneal bursitis, pump bump or Haglund's Deformity.

In cases of chronic Achilles tendonitis it's important to differentiate between pain specifically due to the Achilles tendon or from the enlargement of the heel rubbing against the shoe. The difference between Achilles tendonitis and a pump bump can easily be understood by evaluating the pain while barefoot (suggestive of Achilles tendonitis) compared to pain while wearing shoes with an enclosed heel (pump bump). It's not unusual to find both conditions simultaneously.

Treatment of acute and chronic Achilles tendonitis



Knowing that the single greatest contributor to acute and chronic Achilles tendonitis is equinus (see the biomechanics section below for more information on equinus), we know that we need to weaken the calf muscle to allow the Achilles tendon an opportunity to heal. This can be done by elevating the heel with heel lifts or by high heel shoes. Inflammation of the tendon can be calmed by ice, both before and after activities. Anti-inflammatory medications, casting or ultrasound treatment can also be used. Steroid injections are typically not used to treat Achilles tendonitis since injecting the tendon has a tendency to weaken the tendon resulting in a possible rupture.

Manipulation techniques are also helpful to increase the range of motion of the ankle. One new technique involves manipulation of the fibula (smaller outer bone of the ankle and leg) to allow greater excursion of the talus (foot bone of the ankle). This technique must be performed by someone other than the patient and is performed as follows;
  1. The patient is placed in a sitting position with the hip and knee flexed. Standing on the side of the chair opposite to the leg that will be manipulated, place the index and middle fingers of both hands over the head of the fibula (That's just below the knee on the outside of the leg). Using a firm and rapid motion, manipulate the head of the fibula anteriorly (towards the front of the leg). A slight shift or pop may or may not be noted.
  2. Next, with the patient sitting and the hip and knee extended (straight) place traction on the foot with the ankle slightly plantar flexed (toes pointing down and away from the leg). Continue traction for 30-45 seconds. Then dorsiflex the ankle (move the foot/toes towards the shin). Complete a series of range of motion of the ankle with the patient.
  3. Repeat as needed.
In cases of chronic Achilles tendonitis, patients who do not respond to heel lifts, manipulation and anti-inflammatory medications require a lengthening procedure of the Achilles tendon with or without a partial resection of the posterior heel. In cases with minimal hypertrophy of the heel, lengthening of the tendon will suffice. Lengthening of the Achilles tendon may be performed through three 0.5cm incisions but does require a period of casting. Full recovery may take 6-18 months.

Achilles Tendon Ruptures

Chronic Achilles tendonitis is not a symptom to be ignored based upon the knowledge that Achilles tendonitis is often a precursor to an Achilles tendon rupture. A rupture of the Achilles tendon can be a debilitating injury. The actual rupture of the tendon is described by most patients as feeling as if they were hit in the back of the leg. An audible pop is often described. Most ruptures occur 2-4cm proximal to the insertion of the tendon into the calcaneus (heel bone).

The repair of Achilles tendon ruptures may be conservative or surgical. Orthopedic and podiatric literature abounds with articles that compare the merits of conservative vs surgical care of Achilles tendon ruptures. Re-rupture of the tendon is not uncommon regardless of the method of correction although, statistically, re-rupture does seem to occur less in those patients that undergo surgical repair. These findings may also reflect the nature of patient that would be a surgical candidate. Typically we would assume that those patients that were in poor health (eg elderly, diabetic, immune compromised) would not become surgical candidates and therefore may contribute to the increased rate of re-rupture seen in those treated with conservative care.



Recent articles have advocated a surgical approach for repair of ruptured Achilles tendons that employs both an open and percutaneus technique of repair. The most popular method was described by M. Kakiuchi of The Osaka Police Hospital in 1995. This technique involves the use of an open procedure at the site of rupture to enable debridement of the ruptured tendon. Kakiuchi also employs a closed technique to suture the tendon to allow for proper healing.

Nomenclature:
  • Achilles - Greek warrior from Homer's Iliad. Hence the term Achilles is always capitalized
  • Calcaneal apophysitis - see Sever's Disease
  • Haglund's Deformity - See pump bump
  • Pump bump - term that originated in the 1950's when many women were wearing pump high heels. Pumps were considered a contributing factor to an enlargement of the back of the heel. Pump bumps are typically found postero-lateral where as true Achilles tendonitis is posterior and specific to the insertion of the Achilles tendon.
  • Sever's Disease - An inflammatory disease of the growth plate of the posterior heel found in young boys. Usually seen in boys between 10 to 13 years old and during increased activities such as starting football or soccer practice. Pain with side to side compression of the heel
  • Tendonitis - refers to a group of conditions that have to do with inflammation surrounding or within the structure of a tendon. May or may not exhibit swelling.
Anatomy:

The Achilles tendon is the distal extension of the two muscles of the calf, the gastrocnemius and the soleus. The gastrocnemius is the longer of the two muscles and originates on the proximal side of the knee (above the knee). The soleus, or shorter muscle of the calf, originates distal to the knee joint. Combined, these muscles make up the calf. As these two muscles continue to the distal 1/3 of the leg, they combine to form the Achilles tendon. Fibers of the Achilles tendon continue beyond the insertion to form the plantar fascia on the bottom of the heel.

Fibers of the Achilles tendon attach to the back of the heel below the mid-level of the body of the heel. As a result, a space is formed between the Achilles tendon and the calcaneus. This space, called the retrocalcaneal space, is a common site for a bursa to form. With chronic wear, the bursa may become inflamed resulting in retrocalcaneal bursitis.

Biomechanics:

Equinus is the most common contributing factor to Achilles tendonitis. Equinus, derived from the term equine or horse, refers to one who walks on their toes. Equinus can determined by measuring the range of motion of the ankle with the knee flexed and extended. When the knee is flexed, the amount of equinus of the soleus muscle is measured. With the knee extended, both the soleus and gastrocnemius muscles are measured. Imaginary lines are established on the long axis of the leg and the foot. By dorsiflexing the foot (toward the body) an angular measurement is established between these two lines. Normal range of motion of the ankle, to complete a normal gait cycle, is 10 to 15 degrees beyond 90 degrees. This means that the normal range requires the ankle to dorsiflex to 90 degrees plus an additional 10 to 15 degrees. An inability to complete this range of motion is termed equinus.

Other factors may contribute to an inability to reach 90 degrees, such as a bony block on the front of the ankle.

Acute Achilles Tendonitis Symptoms:

Acute Achilles tendonitis typically has an abrupt onset with achiness 2-3 cm proximal to it�s insertion on the back of the heel. Most individuals with Achilles tendonitis can describe an injury or single event that initiated the pain. Symptoms of acute Achilles tendonitis occur at the beginning of an activity and are typically described as a sharp pain. As the activity progresses, the pain decreases for a period of time. With excessive use, the tendon again becomes painful at the end of activity. For example, runners with Achilles tendonitis experience pain as they begin their run. The pain subsides during their run only to recur near the end of their normal running distance.

Chronic Achilles Tendonitis Symptoms:

Chronic Achilles tendonitis exhibits the same type of pain as acute Achilles tendonitis but the location of the pain is usually at the insertion of the Achilles tendon into the heel. Chronic Achilles tendonitis can also cause hypertrophy (enlargement) of the posterior heel. Pain may be from the tendon pulling away from the heel, or from the enlargement of the heel rubbing against the shoe. This bony enlargement of the back of the heel goes by many names including retrocalcaneal bursitis, pump bump or Haglund's Deformity. The difference between Achilles tendonitis and a pump bump can easily be understood by evaluating the pain while barefoot (Achilles tendonitis) compared to pain while wearing shoes with an enclosed heel (pump bump).



Differential Diagnosis:
  • When considering the diagnosis of Achilles tendonitis as a differential diagnosis consider;
  • Gout - deposition of monosodium urate crystals (hyperuricemia)
  • Retrocalcaneal bursitis (Albert's Disease) - this is the formation and inflammation of a bursa at the back of the heel between the heel bone and Achilles tendon
  • Rheumatoid arthritis
  • Rheumatic Fever
  • Septic Arthritis
  • Sero-negative arthropathies such as Reiter's Syndrome
  • Sever's Disease - and inflammatory condition typically found in young over weight boys age 10 to 15 years old
  • Stress fracture of the calcaneus - Achilles tendonitis pain is characteristically different from that of fractures of the calcaneus. Fracture pain begins with the onset of activity and remains painful through the activity. Tendonitis, on the other hand, hurts at the onset of activity, subsides during the activity only to recur at the end of activity. These symptoms may vary in every case and are only referenced in and effort to differentiate symptoms.


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