ACHILLES TENDONITIS

CONDITION

Tendonitis is irritation and inflammation of a tendon, a thick band of fibrous tissue that connects muscle to bone. When irritation and inflammation have been present for a while, the tendon may start to break down and the condition is then more accurately called tendinopathy.

The Achilles tendon, one of the larges tendons in the body, crosses the back of the ankle and connects the calf muscles to the heel bone (Figure 1 below).

You can see it and feel it at the back of your ankle. When your calf muscles contract, the Achilles tendon pulls your heel up and pushes your toes and foot down toward the floor, allowing you to push off your foot and toes when walking, jumping and running.

Achilles tendon problems can last from weeks to months, but most will respond to non-surgical treatment and rehabilitation.

Causes

Achilles tendonitis can be caused by:

very tight calf muscles and heel tendons
sudden changes in activity or training level (intensity, duration and/or frequency)
training on hard running surfaces such as concrete
poor quality athletic shoes
flat or high-arched feet
obesity
smoking
diseases that affect tendons such as diabetes, rheumatoid arthritis and gout.

Achilles tendonitis can occur in people of all ages, but is most common in adults over age 40.

Symptoms and Signs

Achilles tendon problems can start right after an injury, but it is more common for them to develop slowly over time.

You will have burning, aching or sharp pain over your Achilles tendon, usually an inch or so above your upper heel bone.
At first, pain may occur late in or after running and jumping, especially if activities involve pushing off your toes.
Pain usually gets progressively worse and begins to occur earlier during activities and after rest as the inflammation and breakdown of tissues progress.
You may notice general swelling along the tendon that will make it look bigger than the tendon in the other ankle.
With more chronic tendon problems, a thickened area of tendon or a nodule (lump) may develop.
You may feel tightness at the back of your ankle, especially in the morning after activities that aggravate your injury.
You may notice crunching, creaking, grinding and/or warmth around the inflamed tendon.
Wearing shoes with good support or a raised heel or getting off your feet may relieve pain.
If, right after symptoms have started or after an injury, you have significant weakness when you try to push off your toes, you may have ruptured or torn your tendon.
If you hear a pop and/or have a sensation of being kicked or cut in the heel with an injury, you may have ruptured or torn your tendon.
Redness, fever, numbness or night pain do not usually occur with Achilles tendonitis and imply that something more serious may be causing your symptoms.

WHEN TO CALL YOUR DOCTOR

Call your doctor right away (night or day) if:

You develop substantial pain and swelling in the main tendon over the back of your ankle after an injury or fall on your heel or foot.
You develop other significant ankle or heel pain and swelling after an injury or fall on your ankle or foot.
You have considerable weakness or inability to push off your toes after an injury to your ankle or foot, especially if you heard a pop or had a sensation of being kicked or cut in the heel when you were injured.
You have significant pain or difficulty putting weight on or moving your ankle or foot after a fall or injury.
There is redness and warmth in the back of your ankle with swelling and/or fever.
You develop pain in the back of your ankle that awakens you from sleep.
There is pain, redness, warmth and/or swelling in your calf muscles or over the back of your leg above your ankle.

Call your doctor during regular office hours if:

You have ankle or heel numbness, tingling or loss of sensation.
You have pain elsewhere in your ankle other than over the Achilles tendon that developed over time and that did not follow an injury.
You notice that more than three or four other joints in your body are painful and swollen.
You have had a recent puncture wound around the ankle or heel.
Your ankle pain has become more constant and is getting progressively worse with weight-bearing activities, especially walking and running.
You have symptoms that started slowly and fit the description of Achilles tendonitis above (in symptoms and signs) that do not start getting better over two to three weeks or that do not go away completely by four weeks with the self-care measures listed below.

If your symptoms started immediately or within a few days after an injury or fall, see your doctor before trying the self-care measures listed below.

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SELF-CARE AT HOME

Avoid any activities that worsen your symptoms until your Achilles pain has resolved. These activities may include sports or exercise that involves running and jumping.
Until your symptoms get much better or go away completely, stay active with no-impact or low-impact exercise such as swimming, rowing, bicycling or using an elliptical trainer or glider.
When you have very little or no Achilles pain and swelling, you may gradually return to impact activities such as running.
- Run or walk on soft surfaces such as tracks or trails.
- Use walk-run intervals to get back to your previous level of exercise. You may want to start intervals by walking for four minutes, jogging for one minute and repeating that three to four times.
- You can gradually decrease the amount of walking and increase the amount of jogging until you are jogging for your entire workout. Then gradually increase jogging time.
Exercises that stretch your heel tendons and the bottom of your foot should be done daily. Hold each for 30 seconds and repeat three times.
- Calf stretch: Take the position shown in Figure 2 below and lean forward toward the wall while keeping your back leg straight. Feel the stretch in your calf muscle.
- Heel tendon stretch: Take the position shown in Figure 3 below and lean forward toward the wall while keeping your back knee bent until you can feel the stretch over the back of your ankle
Strengthening exercises should be done daily.
- Heel raises: Stand with the balls of your feet on a stair or step and raise your heels by pushing up onto your toes (Figure 4 below) using mainly the calf muscles of your non-injured leg. Avoid using the muscles of your injured leg to push up. When you are up on your toes, lift your non-injured ankle up off the step and slowly lower the heel of your injured ankle below the step, using the calf muscles of your injured leg.
- Do three sets daily, repeat each “heel drop” 10 to15 times with each set, and rest briefly between sets. Mild discomfort during the exercise is acceptable.
Apply an ice pack or cold pack to the Achilles tendon three times daily, especially after weight-bearing activities. Hold the ice pack or cold pack in place with plastic wrap or an elastic wrap.
Ice massage can help. Freeze water in a paper cup and peel the top of the cup back so the ice is sticking out. Rub the ice over the painful area for a few minutes at a time. Let your tendon get warm between massages. You can use ice massage anytime you are having pain or after activities that will probably cause pain.
You may take ibuprofen (Advil® or Motrin®). (See labels for dose and risks).
An over-the-counter arch support or gel heel cushion can be placed in shoes to elevate your heel and reduce symptoms.
Avoid walking barefoot and wear good-quality athletic shoes with the added cushion or support until your symptoms resolve.
If you have severe pain or weakness after a fall or injury, use crutches to take the weight off your injured ankle or tendon until you see your doctor.

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FOR MORE INFORMATION

REFERENCES

Alfredson H, Cook J: A treatment algorithm for managing Achilles tendinopathy: new treatment options. British Journal of Sports Medicine 41(4):211-6, 2007.
Morelli V: Achilles tendonopathy and tendon rupture: conservative versus surgical management. Primary Care 31(4):1039-54, 2004.
Wilson JJ: Common overuse tendon problems: a review and recommendation for treatment. American Family Physician 72(5):811-18, 2005.

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Authored by Christopher Madden, M.D.

Favorably reviewed by The American Medical Society for Sports Medicine

http://amssm.org

Disclaimer: This content is reviewed periodically and is subject to change as new healthcare information becomes available. The information is intended to inform and educate and is not a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional.