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 inflammed resulting in Achilles tendonitis. This article discusses the onset, symptoms and treatment of Achilles tendonitis. Achilles tendon ruptures are also discussed.
Anatomy of the Achilles Tendon
The Achilles tendon is the distal extension of the two muscles of the calf, the gastrocnemius and the soleus. The gastrocnemius is the shorter of the two muscles and originates on the proximal side of the knee (above the knee). The soleus, or longer 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 an retrocalcaneal bursitis.
Acute Achilles tendonitis
Acute Achilles tendonitis typically has a abrupt onset with moderate pain 2-3 cm proximal to 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 strictly 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 (equinus refers to a tight calf and Achilles tendon), 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 3-12 months.
Dr. Jeffrey A. Oster, DPM, is a board-certified Podiatrist and Pedorthist and is Medical Director of Myfootshop.com. He practices in Granville, Ohio. If you have any questions that you would like addressed in this column, please e-mail Dr. Oster at info@myfootshop.com and request that he cover the problem in Dancer.