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The Achilles tendon joins the calf muscles to the heel bone and runs down the back of the lower leg. When this tendon is put under excess strain, it can become inflamed. This is Achilles tendinitis.
The Achilles tendon is the largest tendon in the body. It can endure great force, but it is still susceptible to injury.
Achilles tendinitis, or tendonitis, usually results from microtears that occur in the tendon during strenuous, high impact exercise, such as running.
Untreated, the tendon can become torn or ruptured. In mild cases, treatment may involve resting or changing an exercise routine, but more severe cases may need surgery.
Treatment aims to relieve pain and reduce swelling. The choice of treatment will depend on the severity of the condition and whether the patient is a professional athlete or not.
The doctor will probably suggest a combination of strategies.
Methods of treating Achilles tendinitis include:
- Ice packs: Applying these to the tendon, when in pain or after exercising, can alleviate pain and inflammation.
- Rest: This gives the tissue time to heal. The type of rest needed depends on the severity of the symptoms. In mild cases, it may mean reducing the intensity of a workout, but severe cases might require complete rest for days or weeks.
- Elevating the foot: Keeping the foot raised above the level of the heart can reduce swelling.
- Pain relief: Nonsteroidal anti-inflammatory drugs (NSAIDS), such as ibuprofen, can reduce pain and swelling. People with asthma, kidney disease, or liver disease should first check with a doctor.
- Steroid injections: Cortisone, for example, can reduce tendon swelling, but it has also been associated with a greater risk of tendon rupture. Giving the injection while scanning the area with ultrasound can reduce this risk.
- Compression bandages and orthotic devices: Ankle supports and shoe inserts can aid recovery as they take the stress off the tendon. Heel lifts, which move the foot away from the back of the shoe, may help patients with insertional Achilles tendinitis.
- Extracorporeal shockwave therapy (ESWT): High-energy shockwaves are used to stimulate the healing process. Results have not been consistent, but if other measures do not work, it might be worth trying before opting for surgery.
It usually takes between a few days and 6 weeks for tendinitis to heal.
Surgery can repair the damage sustained by the tendon as a result of Achilles tendinitis. The American Academy of Orthopedic Surgeons (AAOS) only recommends surgery if the pain continues for 6 months or more.
The most common procedure is gastrocnemius recession. This involves lengthening one of the two muscles that make up the calf, to give the ankle a wider range of motion.
A physical therapist can teach stretching exercises to improve flexibility and increase calf strength.
Here are two exercises, suggested by the AAOS.
- Lean forward with your hands against a wall.
- Have one foot on the ground, with the leg straight, and one foot in front of it, with the knee bent.
- Push your hips toward the wall and hold for 10 seconds.
- Relax and repeat 20 times for each foot.
Bilateral heel drop
- Stand with the front half of your foot on the stair and the heel off, holding a rail to make sure you are balanced and will not fall.
- Slowly lift your heels and lower them as far as you can.
- Repeat 20 times.
Both exercises must be done slowly and in a controlled manner. Doing them fast can increase the damage.
This may help the Achilles tendon to heal and prevent future injury. Physical therapy is normally more effective for noninsertional Achilles tendinitis.
The main symptom of Achilles tendinitis is a gradual buildup of pain that worsens with time.
The individual may also notice the following:
- The Achilles tendon feels sore a few centimeters above where it meets the heel bone.
- The lower leg feels stiff, slow, or weak.
- A slight pain appears in the back of the leg after running or exercising and becomes more severe.
- Pain in the Achilles tendon occurs while running or a couple of hours after.
- Pain is greater when running fast, for a long time, or when climbing stairs.
- The Achilles tendon swells or forms a bump.
- The Achilles tendon creaks when touched or moved
These and other similar symptoms feature in a number of conditions, so medical advice is needed for an accurate diagnosis.
A doctor will ask about symptoms and perform a physical examination. They will lightly touch the back of the ankle and tendon to locate the source of the pain or inflammation.
The doctor will also test the foot and ankle to see if the range of motion and flexibility is impaired.
An imaging test, for example, an x-ray, MRI or ultrasound scan, can help to eliminate other possible causes of pain and swelling and to assess any damage to the tendon.
Achilles tendinitis can lead to Achilles tendinosis, a degenerative condition in which the structure of the tendon changes and becomes susceptible to serious damage. The tendon can tear, causing great pain.
Tendinitis and tendinosis are different conditions. Tendinitis involves inflammation, while tendinosis is a degenerative process on a cellular level, and there is no inflammation. Tendinosis is often misdiagnosed as tendinitis. Getting the correct diagnosis will lead to more appropriate treatment.
Achilles tendinitis can develop in different ways. Some are easier to avoid than others, but being aware of them can aid earlier diagnosis and help prevent serious injury.
Noninsertional Achilles tendinitis is more common in younger, more active people. The fibers in the middle of the tendon start to break down, thicken, and swell.
Insertional Achilles tendinitis is not necessarily related to activity. It affects the lower portion of the tendon as it inserts into the heel bone.
Causes of Achilles tendinitis include:
- Using incorrect or worn out shoes when running or exercising
- Not warming up properly before exercise
- Increasing intensity of exercise too quickly, for example, running speed or distance covered
- Prematurely introducing hill running or stair climbing to an exercise routine
- Running on hard or uneven surfaces
- The calf muscle is injured or has little flexibility, putting more strain on the Achilles tendon
- Sudden intense physical activity such as sprinting for the finish line
Bone spurs are extra bone growths where the tendon joins the bone. These can rub against the Achilles tendon, causing damage and discomfort.
Patients taking fluoroquinolone antibiotics may have a higher risk of tendinitis and tendon rupture. In 2008, the FDA asked that a boxed warning be added to the prescribing information for Cipro, or ciprofloxacin, Factive, or gemifloxacin and others.
The risk of injury does not disappear when the dosage stops. People have reported tendon problems several months after they stopped using the drug.
Recovery depends on how severe the tendinitis is.
The AAOS says that it may take several months for the pain to go away, even with early treatment.
If the pain does not resolve within 6 months, surgery may be necessary. Those who have surgery may not be able to return to competitive sports or running for at least 12 months. Some cannot return to their sport.
Prevention and early treatment are the best way to prevent long-term problems.
Achilles tendinitis cannot be completely prevented, but the risk of developing it can be reduced by being aware of the possible causes and taking precautions.
- Varying exercise: Alternating between high-impact exercises, such as running, and low-impact exercise, for example, swimming, can reduce stress on the Achilles tendon on some days.
- Limiting certain exercises: Too much hill running, for example, can put excessive strain on the Achilles tendon.
- Wearing the correct shoes and replacing them when worn: Shoes that support the arch and protect the heel create less tension in the tendon.
- Using arch supports inside the shoe: This can help if the shoe is in good condition but does not provide the required arch support.
- Gradually increasing the intensity of a workout: Achilles tendinitis can occur when the tendon is suddenly put under too much strain, so warming up and increasing the level of activity gradually gives the muscles time to loosen up, and this puts less pressure on the tendon.
It is important to stretch and warm up before and after exercising. Stretching helps to keep the Achilles tendon flexible, so there is less chance of tendinitis developing. Stretching every day, including rest days, will further improve flexibility.
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