The Achilles tendon connects the calf muscles in the lower leg to the heel bone. It is the largest yet most exposed tendon in the body. Achilles tendonitis is where the Achilles tendon, and sometimes the protective sheath through which it moves, becomes inflamed, causing pain and swelling symptoms.
Achilles tendonitis (also known as Achilles tendinopathy or tendonosis) is classified as an overuse injury. If left untreated it can become chronic (long-term), requiring more intensive treatment. Achilles tendonitis can also increase the risk of sustaining an Achilles tendon rupture (tear).
Signs and symptoms
The onset of the symptoms of Achilles tendonitis tend to be gradual, with symptoms usually developing over a period of several days, or even weeks. Symptoms may include:
- Pain - this may be mild at first and may only be noticeable after exercise. Over time the pain may become constant and severe
- Stiffness - this is usually relieved by activity
- Sluggishness in the leg
- Tenderness - particularly in the morning and most commonly felt just above where the tendon attaches to the heel bone
- Swelling.
Causes
The Achilles tendon is a strong band of connective tissue that attaches the calf muscle to the heel bone. When the muscle contracts, the tendon transmits the power of this contraction to the heel, producing movement. The Achilles tendon moves through a protective sheath and is made up of thousands of tiny fibres. It is thought that Achilles tendonitis develops when overuse of the tendon causes the tiny fibres that make up the tendon to tear. This causes inflammation, pain and swelling. As the tendon swells it can begin to rub against the sheath surrounding it, irritating the sheath and causing it too to become inflamed and swollen.
It has a poor blood supply, which can make it susceptible to injury and can make recovery from injury slow.
Physiotherapy
Physiotherapy plays an important role in the treatment of Achilles tendonitis. This generally focuses on two main areas – treatment and rehabilitation. Treatment may involve such techniques as massage, ultrasound, acupuncture and gentle stretching. Rehabilitation involves the development of an individualised recovery programme, the most important aspect of which is strengthening. Strengthening of the muscles surrounding the Achilles tendon helps to promote healing in the tendon itself. Strengthening is achieved through the use of specific exercises, which will be taught by the physiotherapist. One such exercise is eccentric loading, which involves contracting the calf muscle while it is being stretched. It is common for the rehabilitation programme to take up to three months. Podiatry
Podiatry, including gait analysis and the fitting of orthotic devices to support the foot and reduce stress on the tendon, may be recommended.
Casting/Splinting
For cases of Achilles tendonitis that do not respond to initial treatment, casting or splinting of the affected foot may be recommended to allow it to rest completely.
Surgery In cases of severe, long-term Achilles tendonitis the sheath may become thick and fibrous. In these cases surgery may be recommended. Surgery aims to remove the fibrous tissue and repair any tears in the tendon. A cast or splint will be required after the operation and a recovery program including physiotherapy, specific exercises and a gradual return to activity will be planned.
Factors that can lead to the development of Achilles tendonitis include:
- Tight or weak calf muscles
- Rapidly increasing the amount or intensity of exercise
- Hill climbing or stair climbing exercises
- Changes in footwear - particularly changing from wearing high-heeled shoes to wearing flat shoes
- Wearing inadequate or inappropriate shoes for the sporting activity being undertaken
- Not adequately warming up and stretching prior to exercise
- A sudden sharp movement that causes the calf muscles to contract and the stress on the Achilles tendon to be increased. This can cause the tendon fibres to tear.
Diagnosis
If Achilles tendonitis is suspected, avoid any exercise or activity that causes the pain. It is advisable to see a doctor promptly so that an accurate diagnosis can be made and appropriate treatment recommended.
The doctor will take a full medical history and will ask about the nature and duration of the symptoms. They will perform a physical examination of the affected area. Ultrasound scanning may be used to assess damage to the tendon or surrounding structures. Occasionally MRI (magnetic resonance imaging) may be recommended.
The symptoms of Achilles tendonitis are often similar to symptoms of other conditions such as partial Achilles tendon rupture and heel bursitis. This can make diagnosis difficult and a referral to an orthopaedic specialist may be required in order for an accurate diagnosis to be made.
Treatment
Treatment will depend on the severity of the injury. In general terms, the longer the symptoms are present before treatment begins, the longer the timeframe until complete recovery is achieved. Complete recovery can take between three and nine months.
Initial treatment of Achilles tendonitis includes:
- Rest - to avoid further injury to the area
- Ice - to reduce inflammation
- Elevation - to reduce swelling
- Bandaging/strapping - to support the area and restrict movement of the tendon
- Anti-inflammatory medications to reduce pain and inflammation. (Cortisone (steroid) injections to reduce inflammation are not usually recommended as they may weaken the tendon and increase the risk of rupture).
Other treatments include:
Physiotherapy plays an important role in the treatment of Achilles tendonitis. This generally focuses on two main areas – treatment and rehabilitation. Treatment may involve such techniques as massage, ultrasound, acupuncture and gentle stretching. Rehabilitation involves the development of an individualised recovery programme, the most important aspect of which is strengthening. Strengthening of the muscles surrounding the Achilles tendon helps to promote healing in the tendon itself. Strengthening is achieved through the use of specific exercises, which will be taught by the physiotherapist. One such exercise is eccentric loading, which involves contracting the calf muscle while it is being stretched. It is common for the rehabilitation programme to take up to three months. Podiatry
Podiatry, including gait analysis and the fitting of orthotic devices to support the foot and reduce stress on the tendon, may be recommended.
Casting/Splinting
For cases of Achilles tendonitis that do not respond to initial treatment, casting or splinting of the affected foot may be recommended to allow it to rest completely.
Surgery In cases of severe, long-term Achilles tendonitis the sheath may become thick and fibrous. In these cases surgery may be recommended. Surgery aims to remove the fibrous tissue and repair any tears in the tendon. A cast or splint will be required after the operation and a recovery program including physiotherapy, specific exercises and a gradual return to activity will be planned.
Prevention
The following measures can significantly reduce the risk of developing Achilles tendonitis:
- Adequately stretch and warm up prior to exercise
- Warm down and stretch after exercise
- Choose footwear carefully and use footwear appropriate to the sport being undertaken
- Use orthotic devices in footwear to correctly support the foot
- Exercise within fitness levels and follow a sensible exercise programme
- Develop strong, flexible calf muscles.
References
American Academy of Orthopaedic Surgeons (2010). Orthoinfo: Achilles tendinitis. Illinois: American Academy of Orthopaedic Surgeons. http://orthoinfo.aaos.org/topic.cfm?topic=A00147
Campbell, R (2005) Modern management of tendon problems. NZFP Continuing Medical Education. In, Royal New Zealand College of General Practitioners. Wellington. www.rnzcgp.org.nz/volume-32-number-1-february-2005
Saglimbeni, A.J., (2012) Achilles tendon injuries and tendonitis. Medscape Reference: Drugs, Diseases & Procedures. WEbMD, LLC http://emedicine.medscape.com/article/309393
Last reviewed – 20 April 2013