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, climb stairs, jump, and stand on your toes. Although the Achilles tendon can withstand the stress from running and jumping, it is prone to tendinitis, which is a condition associated with overuse and degeneration.
What is Tendinitis?
To put it simply, tendinitis is the inflammation of a tendon. Inflammation is the body's natural response to injury or illness and often leads to swelling, pain, or irritation.
There are two types of Achilles tendinitis depending on which part of the tendon is inflamed.
Non-insertional Achilles Tendinitis
In non-insertional Achilles tendinitis, the fibers in the middle of the tendon have started to break down (degenerate), swell, and thicken from small tears.
Tendinitis in the middle of the tendon affects more young and active individuals.
Insertional Achilles Tendinitis
Insertional Achilles tendinitis involves the end of the tendon where it attaches to the heel bone.
Both non-insertional and insertional Achilles tendinitis can result in calcification (hardening) of damaged tendon fibers. Bone spurs (extra bone growth) often occur with insertional Achilles tendinitis.
Tendinitis affecting the area where the tendon attaches to the heel bone can occur at any time, even in inactive patients. However, it most often results from years of overuse (long-distance runners, sprinters).
Causes of Achilles Tendinitis
Achilles tendinitis is typically not associated with a specific injury. The problem results from repeated stress on the tendon. This often occurs when we push our bodies beyond our capacity without being ready. However, other factors, including the following, can increase the likelihood of developing tendinitis:
Sudden increase in the amount or intensity of exercise activity - For example, increasing the distance you run every day without giving your body a chance to adapt to a new distance, doing interval training without being ready, or running on an unfamiliar surface.
Tight calf muscles - Having tight calf muscles and suddenly starting an aggressive exercise program can create extra stress on the Achilles tendon.
Bone spur - An extra bone growth that can cause pain by rubbing against the Achilles tendon when it is attached to the heel bone.
Doctor Examination Findings
Swelling along the Achilles tendon or at the back of your heel
Thickening or enlargement of the Achilles tendon
Bony protuberances at the lower part of the tendon at the back of your heel (insertional tendinitis)
Maximum point of sensitivity
Pain in the middle of the tendon (unsettled tendinitis)
Pain at the lower part of the tendon at the back of your heel (insertional tendinitis)
Limited range of motion in your wrist - especially, a decrease in your ability to stretch your foot
Imaging Methods
Your doctor may request imaging tests to make sure that your symptoms are caused by Achilles tendinitis.
X-Ray
X-rays provide clear images of the bones. X-rays can reveal whether or not the lower part of the Achilles tendon has calcified or hardened. This calcification indicates insertional Achilles tendinitis. In cases of severe Achilles tendinitis that is not insertional, calcification may also occur in the middle part of the tendon.
Magnetic Resonance Imaging (MRI)
While magnetic resonance imaging (MRI) is not necessary to diagnose Achilles tendinitis, it is important for planning surgery. The MRI scan can show how severe the damage to the tendon is. If surgery is necessary, your doctor will choose the procedure based on the amount of tendon damage.
Treatment
Non-Surgical Treatment
In most cases, non-surgical treatment options relieve pain, but it may take several months for symptoms to fully disappear. Even with early treatment, pain may last for more than 3 months. If you have pain for several months before starting treatment, the continuity of the treatment methods may require 6 months.
Rest
The first step in reducing pain is to reduce or even stop activities that worsen the pain. If you regularly engage in high-impact exercises (such as running), transitioning to low-impact activities will create less stress on the Achilles tendon. Cross-training activities such as cycling, elliptical exercise, and swimming are low-impact options that can help you stay active.
Ice
Placing ice on the most painful area of the Achilles tendon can be beneficial and can be done throughout the day as needed. This can be done for up to 20 minutes and should be stopped earlier if the skin becomes numb.
Use of Painkillers
Non-steroid anti-inflammatory drugs reduce pain and swelling. However, they do not reduce thickening of the degenerated tendon. I highly recommend that you consult your doctor before using these types of drugs for long periods.
Exercise
The following exercises strengthen the calf muscles and help reduce stress on the Achilles tendon and increase blood flow to aid in healing.
Calf stretching exercise
Lean one of your legs against the wall so that it's flat and the heel is touching the ground. Place the other leg forward with the knee bent. Contract your calf muscles and the Achilles tendon by pushing your heels towards the wall in a controlled manner. Hold the position for 10 seconds and relax. Repeat this exercise 20 times for each leg. A strong stretching sensation should be felt in the calf during the stretching.
Eccentric Strengthening Protocol
Eccentric strengthening is defined as the lengthening of a muscle while contracting (tightening). Eccentric strengthening exercises can cause damage to the Achilles tendon if not done properly. I recommend doing these exercises under the supervision of a physiotherapist first. After working with a therapist, the exercises can be done at home. These exercises may cause some discomfort, but it should not be unbearable.
Bilateral Heel Drop
Stand on the edge of a stair or a balanced elevated platform with only the front half of your foot on it. This position will allow your heel to move up and down without hitting the stair. Make sure you're balanced correctly to prevent falling and injury. You can hold onto a railing to help with your balance.
Lift your heels off the ground and then slowly lower your heels to the lowest point possible. Repeat this step 20 times. This exercise should be performed slowly and controlled. Quick movements can increase the risk of injuring the tendon. As the pain improves, you can increase the difficulty level of the exercise by holding small weights in each hand.
Single Leg Heel Drop
This exercise is performed similarly to the bilateral heel drop, except that all of your weight is focused on one leg. This should only be done after you've mastered the bilateral heel drop.
Tendon Injections
Cortisone Injection
Cortisone, a type of steroid, is a strong anti-inflammatory medication. Cortisone injections into the Achilles tendon are rarely recommended because they can cause the tendon to tear. If there is an accompanying bursitis in front of the Achilles tendon, especially in insertional Achilles tendinitis, it may be advisable to have a cortisone injection.
PRP (Platelet Rich Plasma) and PRGF (Plasma Rich in Growth Factors) injections
PRP refers to serum obtained by separating platelets from a person's own blood. PRGF is prepared by removing growth factors from the platelets in this serum and freeing them from the cells using another method. The most important difference between PRP and PRGF is the high concentration of growth factors and proteins necessary for tissue repair. For the treatment of Achilles tendinitis, one of these two methods is chosen based on the patient.
Supportive shoes and orthotics
Some shoes and orthotic devices can help alleviate pain caused by insertional Achilles tendinitis. For example, shoes with a softer heel can reduce irritation to the tendon. Additionally, lifting the heel with a sole helps reduce stress and tension on the tendon.
Lifting the heels, is also very helpful for patients with insertional tendinitis because they can move the heel away from the back of the shoe, where rubbing can occur.
Just like heel lifts, silicone achilles sleeves can also reduce irritation at the back of the shoe.
If your pain is severe, your doctor may suggest a walking boot for a short period of time. This gives the tendon a chance to rest before starting any treatment. Long-term use of a boot is not recommended, as it can weaken the calf muscle.
Surgical treatment
Surgery should only be considered to relieve Achilles tendinitis if pain does not improve after 6 months of non-surgical treatment. The specific type of surgery depends on the location of the tendinitis and the amount of damage to the tendon.
Gastrocnemius relaxation
This is the surgical lengthening of the calf (gastrocnemius) muscles. Tight calf muscles apply increased pressure to the Achilles tendon, so this procedure is useful for patients who still have difficulty flexing their feet despite the constant tension.
In a gastrocnemius release surgery, one of the two muscles forming the calf is lengthened to increase the movement of the ankle. The procedure can be performed through a traditional open incision or a smaller incision with a small camera-containing endoscope.
The complication rates for gastrocnemius release are low.
Gastrocnemius release can be performed with or without debridement, which means removal of the damaged tissue.
Debridement and repair
If the tendon has less than 50% damage, this procedure is performed. The aim of this operation is to remove the damaged part of the Achilles tendon. After the unhealthy part of the tendon is removed, the remaining tendon is repaired with stitches.
In cases of insertional tendinitis, bone spurs are also removed. In these cases, the repair of the tendon may require the use of metal or resorbable screws to help secure the Achilles tendon to the heel bone.
After debridement and repair, most patients are allowed to walk or transition to a removable cast within 2 weeks, but this time period depends on the amount of damage to the tendon.
Debridement with Tendon Transfer
If the tendon has more than 50% damage, this surgery is performed. In cases where more than 50% of the Achilles tendon is unhealthy and needs to be removed, the remaining tendon is not strong enough to function on its own to prevent the remaining tendon from breaking. To prevent this, an Achilles tendon transfer is performed. The tendon that helps the big toe move down is transferred to the heel bone to add strength to the damaged tendon.
Although this procedure may seem like a big operation, the big toe will still be able to move and most patients will not notice a change in their walking or running form.
Depending on the extent of the tendon damage, some patients may not be able to return to competitive sports or running.
Healing
Most patients have a good outcome from the surgery. The main factor in surgical healing is the amount of tendon damage. The more damaged the tendon, the longer the recovery time and the lower the probability of a patient returning to sports activities.
Physical therapy is an important part of the healing process. Many patients need a 12-month rehabilitation before they are pain-free.
