Coping With Achilles Tendon Pain

Overview
Achilles tendinitis is a common condition that causes pain along the back of the leg near the heel. The Achilles tendon is the largest tendon in the body. It connects your calf muscles to your heel bone and is used when you walk, run, and jump. Although the Achilles tendon can withstand great stresses from running and jumping, it is also prone to tendinitis, a condition associated with overuse and degeneration. Simply defined, tendinitis is inflammation of a tendon. Inflammation is the body's natural response to injury or disease, and often causes swelling, pain, or irritation. There are two types of Achilles tendinitis, based upon which part of the tendon is inflamed. Noninsertional Achilles tendinitis, Noninsertional Achilles Tendinitis. In noninsertional In both noninsertional and insertional Achilles tendinitis, damaged tendon fibers may also calcify (harden). Tendinitis that affects the insertion of the tendon can occur at any time, even in patients who are not active.

Causes
There are a number of ways a person can develop Achilles tendinitis. Some causes are easier to avoid than others, but being aware of them can aid earlier diagnosis and help prevent serious injury. 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 (e.g. running speed or distance covered). Prematurely introducing hill running or stair climbing to exercise routine. Running on hard or uneven surfaces. Calf muscle is injured or has little flexibility (this puts a lot of strain on the Achilles tendon). Sudden intense physical activity such as sprinting for the finish line. Achilles tendinitis can also be caused by differences in foot, leg or ankle anatomy. For example, some people can have flatness in their foot where there would normally be an arch; this puts more strain on the tendon. The FDA has asked that a boxed warning be added to the prescribing information for fluoroquinolone antibiotics. Patients taking these drugs may experience an increased risk of tendinitis and tendon rupture. Fluoroquinolones include Cipro (ciprofloxacin), Factive (gemifloxacin), Levaquin (levofloxacin), Avelox (moxifloxacin), Noroxin (norfloxacin), Floxin (ofloxacin) and Proquin (ciprofloxacin hydrochloride). It is important to remember that the risk for injury is not necessarily gone when the drug is stopped. Cases have been reported in which tendon problems occurred up to several months after the drug was discontinued.

Symptoms
Paratenonitis presents in younger people. Symptoms start gradually and spontaneously. Aching and burning pain is noted especially with morning activity. It may improve slightly with initial activity, but becomes worse with further activity. It is aggravated by exercise. Over time less exercise is required to cause the pain. The Achilles tendon is often enlarged, warm and tender approximately 1 to 4 inches above its heel insertion. Sometimes friction is noted with gentle palpation of the tendon during ankle motion. Tendinosis presents similarly but typically in middle-aged people. If severe pain and limited walking ability are present, it may indicate a partial tear of the tendon.

Diagnosis
A podiatrist can usually make the diagnosis by clinical history and physical examination alone. Pain with touching or stretching the tendon is typical. There may also be a visible swelling to the tendon. The patient frequently has difficulty plantarflexing (pushing down the ball of the foot and toes, like one would press on a gas pedal), particularly against resistance. In most cases X-rays don't show much, as they tend to show bone more than soft tissues. But X-rays may show associated degeneration of the heel bone that is common with Achilles Tendon problems. For example, heel spurs, calcification within the tendon, avulsion fractures, periostitis (a bruising of the outer covering of the bone) may all be seen on X-ray. In cases where we are uncertain as to the extent of the damage to the tendon, though, an MRI scan may be necessary, which images the soft tissues better than X-rays. When the tendon is simply inflamed and not severely damaged, the problem may or may not be visible on MRI. It depends upon the severity of the condition.

Nonsurgical Treatment
In order to treat achilles tendinitis effectively, it is important to complete a thorough examination of the entire lower extremity. Once the true cause is identified, a comprehensive treatment program can be initiated to reduce inflammation and improve any faulty lower extremity biomechanics. Treatment options may include biomechanical analysis of gait. Splinting/bracing to alleviate the strain on the tendon. Soft tissue mobilization/manual therapy to decrease inflammation and promote healing of the tendon. Strengthening/flexibility and proprioceptive exercises. Home exercise program. Modalities for pain and inflammation (i.e. ultrasound, iontophoresis, electrical stimulation, ice). Methods to alter faulty mechanics (i.e taping, orthotics). Education about lifestyle changes (i.e. proper shoes, activity modification).


Surgical Treatment
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
Warm up slowly by running at least one minute per mile slower than your usual pace for the first mile. Running backwards during your first mile is also a very effective way to warm up the Achilles, because doing so produces a gentle eccentric load that acts to strengthen the tendon. Runners should also avoid making sudden changes in mileage, and they should be particularly careful when wearing racing flats, as these shoes produce very rapid rates of pronation that increase the risk of Achilles tendon injury. If you have a tendency to be stiff, spend extra time stretching. If you?re overly flexible, perform eccentric load exercises preventively. Lastly, it is always important to control biomechanical alignment issues, either with proper running shoes and if necessary, stock or custom orthotics.