What is Achilles Tendonitis?
The Achilles tendon is a strong, thick, and important structure that functions to bring the ankle and foot downwards and propel the body forward in gait. Thousands of fibrous bands of tissue bind together to form the dense Achilles. The calf muscle (gastrocnemius) becomes the Achilles tendon about midway in the lower leg. The tendon travels down the back of the leg, crosses the ankle, and attaches to the top and back of the heel bone (calcaneus). The Achilles tendon acts as a “rubber band” that stretches back and forth with each step.
When there is an acute or new injury to a portion of the tendon and it becomes inflamed, this is called Achilles tendonitis (-itis = inflammation). In this acute state of injury, the swelling of the tendon is not visible.
Left untreated, Achilles tendonitis can transition into a chronic state called Achilles Tendinosis where a thickening and swelling of the tendon is visible. This can eventually lead to partial tears and an Achilles Tendon Rupture.
What are the Symptoms of Achilles Tendonitis?
Patients will complain of a deep achy pain, and sometimes a sharp knife like pain. The pain is more pronounced with walking and activities. There is usually no pain at rest. There will be pain with any pressure on or squeezing of the tendon. Most patients will complain of significant pain when taking their first few steps out of bed or after sitting for some time, and then walking. This pain can ease when there is more walking, and then increase again towards the end of the day. Most find that being barefoot, using flat shoes and shoes without support lend to more pain because the tendon is used at its maximum. The pain usually will worsen gradually over time.
What Causes Achilles Tendonitis?
Achilles tendonitis is caused by a recurring repetitive injury to the area over time. Sudden movements from a stationary position or repetitive overuse of the tendon can lead to stress through the tendon. When there is an instance where the tendon is not able to stretch and be elastic during an activity (even walking) the tendon to suffer micro tears before its attachment to the heel. This is the weakest portion of the tendon because it has the least amount of blood flow. As the micro tears increase, there is an onset of inflammation and pain that will be felt within the tendon. When the foot is at rest or under bed sheets, the foot and ankle are in a downward position; the tendon is in a shortened, relaxed state. As soon as sudden weight is put through the foot, the already damaged tendon is asked to stretch too quickly, and more micro tears are created. This is the reason for the common increased pain in the mornings. As the tendon stretches out with more walking, it will tear less. It is seen in women and men, athletes and non-athletes.
Patients that are born with (toe walkers) or acquire over time, a muscle/tendon complex that is too short (equinus), have a higher chance of developing Achilles tendonitis. Examples of those that risk shortening their tendon are those that wear high heel shoes for extended periods of time and ballet dancers that go onto point.
How is Achilles Tendonitis diagnosed?
Diagnosis is achieved by the clinical examination, and a diagnostic ultrasound of the patient. Dr. Soomekh will listen to the patient’s complaints, symptoms, and goals. The examination involves a hands-on analysis of the patient’s foot and ankle and an evaluation of their gait. There will be special examination of the Achilles tendon and its muscle to determine any underlying cause and any shortening of the tendon. Digital radiographs (x-rays) of the ankle to may be obtained in the office and reviewed with the patient. The films evaluate the heel bone for any heel spurs (retrocalcaneal exostosis) and the tendon is examined for any calcifications within.
Dr. Soomekh may evaluate the tendon using a state-of-the-art diagnostic ultrasound. This examination will show the thickness and swelling and any amount of damage and tearing of the tendon. It is used as an important tool to examine the degree of injury and the effectiveness of treatment.
An MRI may be ordered in cases of severe tearing or rupture of the tendon. It may also be needed for those patients with chronic Achilles tendinosis.
How is Achilles Tendonitis Treated?
Dr. Soomekh educates that early diagnosis and treatment of Achilles Tendonitis are the keys to successful treatment, faster recovery and painless lifestyle.
Conservative Treatment for Achilles Tendonitis:
Conservative treatments rely on their ability decrease pain, reduce inflammation, stop the micro tearing of the tendon, and stretch the tendon. Dr. Soomekh will recommend a strict 2 to 4 week initial home therapy protocol. Reduction of the inflammation and pain can be achieved by treating the area with a daily regimen of ice therapy and the use of anti-inflammatory medications (NSAID’s). A period of rest will be needed in order to reduce the constant strain on the tendon while it is trying to heal. A discussion of appropriate shoes will be advised in order to support the tendon. Heel lifts can be placed in the shoes to place some slack on the Achilles. In some cases a walking boot may be recommended. The patient will be educated on a stretching regimen for the calf and the Achilles tendon. Stretching of the muscle/tendon complex is very important in order to elongate the complex allow the tendon to be more elastic and reduce the occurrence of the micro tears. These stretching exercises will be especially important in the mornings before getting out of bed or after a period of rest. Dr. Soomekh may recommend a course of visits to a Physical Therapist.
Custom Molded Orthotics:
Custom molded orthotics (insoles) are an integral part of healing and maintaining the integrity of the Achilles and redirecting the pull of the tendon. The pull of the tendon on the heel bone plays an important role in the support of the arch of the foot. When the tendon is damaged and irritated, the arch and the heel will need to be supported by a custom orthotic to reduce the forces placed on the tendon while walking and increased activity. The orthotics control the amount of motion through the heel during gait, and take off some of the strain the tendon would normally incur.
Cortisone (steroid) Injections:
Dr. Soomekh does NOT recommend cortisone injections for Achilles tendonitis. Steroid injections have many positive applications for treatment of foot and ankle problems. However, the Achilles tendon can weaken when injected with cortisone.
Surgical treatment for Achilles Tendonitis:
Surgery is not usually needed for cases of acute Achilles tendonitis.
Chronic Achilles Tendinosis:
With patients seek treatment late or those that fail conservative therapies the Achilles tendonitis may have evolved into a chronic state. This is then called Achilles tendinosis. Click here to be directed to our page on Achilles tendinosis.
Dr. Soomekh has perfected and reinvented these treatment techniques and is recognized by his peers as one of the top Achilles specialists in the Los Angeles area.