What Causes Achilles Tendon Pain

Overview
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).

Causes
Achilles tendinitis is caused by repetitive or intense strain on the Achilles tendon, the band of tissue that connects your calf muscles to your heel bone. This tendon is used when you walk, run, jump or push up on your toes. The structure of the Achilles tendon weakens with age, which can make it more susceptible to injury - particularly in people who may participate in sports only on the weekends or who have suddenly increased the intensity of their running programs.

Symptoms
Achilles tendinitis symptoms present as mild to severe pain or swelling near the ankle. The pain may lead to weakness and decreased mobility, symptoms that increase gradually while walking or running. Over time, the pain worsens, and stiffness in the tendon may be noted in the morning. Mild activity may provide relief. Physical exam may reveal an audible cracking sound when the Achilles tendon is palpated. The lower leg may exhibit weakness. A ruptured or torn Achilles tendon is severely painful and warrants immediate medical attention. The signs of a ruptured or torn Achilles tendon include. Acute, excruciating pain. Impaired mobility, unable to point the foot downward or walk on the toes. Weight bearing or walking on the affected side is not possible.

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
The best treatment for Achilles tendonitis is preventative, stretching and warming up properly before starting an activity. Proper rest, accompanied by stretching and icing to reduce swelling, can help to heal an overworked Achilles tendon. Placing an adequate heel lift in both shoes will allow the heel to have contact with the ground without placing stress on the Achilles tendon. Wear a tie shoe that is stiff soled and has a wide base, then add an over-the-counter or custom foot orthosis inside the shoe to prevent the twisting motion of the Achilles tendon due to over pronation. In the event that the tendon is unable to heal due to your life style or activity, you may have to be put in a walking cast for a short period to give it a chance to heal. You need to have the doctor, physical therapist, or come in to our facility to check for a leg length difference due to the walking cast being higher. This is to prevent any discomfort to the hips. After the tendon has healed and before the foot is taken out of the walking cast, range of motion at the ankle must be tested and if the foot is not allowed to properly bend upwards 15 degrees then the tightness in the calf will cause the foot to over pronate and reinjure. A stretching program will be needed to loosen up the calf muscle before much weight bearing is done without the cast. The stretching program can be found at the menu for feet hurt. If necessary a heel lift can be put in both shoes to help take the stress off the tendon. Should the tightness of the calves be the primary cause for the Achilles tendon damage and stretching has not loosen the Achilles tendon sufficiently, then discussion with your doctor for a calf release may have to be considered.



Surgical Treatment
Chronic Achilles tendon tears can be more complicated to repair. A tendon that has torn and retracted (pulled back) into the leg will scar in the shortened position over time. Restoring normal tendon length is usually not an issue when surgery is performed within a few weeks of the injury. However, when there has been a delay of months or longer, the treatment can be more complicated. Several procedures can be used to add length to a chronic Achilles tear. A turndown procedure uses tissue folded down from the top of the calf to add length to the Achilles tendon. Tendon transfers from other tendons of the ankle can also be performed to help restore function of the Achilles. The results of surgery in a chronic situation are seldom as good as an acute repair. However, in some patients, these procedures can help restore function of a chronically damaged Achilles.

Prevention
Regardless of whether the Achilles injury is insertional or non-insertional, a great method for lessening stress on the Achilles tendon is flexor digitorum longus exercises. This muscle, which originates along the back of the leg and attaches to the tips of the toes, lies deep to the Achilles. It works synergistically with the soleus muscle to decelerate the forward motion of the leg before the heel leaves the ground during propulsion. This significantly lessens strain on the Achilles tendon as it decelerates elongation of the tendon. Many foot surgeons are aware of the connection between flexor digitorum longus and the Achilles tendon-surgical lengthening of the Achilles (which is done to treat certain congenital problems) almost always results in developing hammer toes as flexor digitorum longus attempts to do the job of the recently lengthened tendon. Finally, avoid having cortisone injected into either the bursa or tendon-doing so weakens the tendon as it shifts production of collagen from type one to type three. In a recent study published in the Journal of Bone Joint Surgery(9), cortisone was shown to lower the stress necessary to rupture the Achilles tendon, and was particularly dangerous when done on both sides, as it produced a systemic effect that further weakened the tendon.