What is it?
The Achilles tendon is the largest and strongest tendon in the body. It can support up to 12x your body weight! It is made up of two muscles: the Gastrocnemius and the Soleus. The Gastrocnemius muscle inserts above the knee and the Soleus muscle below the knee. Tightness in the Achilles tendon (called Equinus) can lead to pathology usually manifesting as pain in the tendon about 2-6cm above its insertion into the back of the heel (Non-insertional Achilles Tendonitis) or at the insertion itself (Insertional Achilles Tendonitis). Sudden increases in the intensity or amount of exercises can also lead to pain in the Achilles tendon.
Common symptoms of Achilles tendinitis include:
- Pain in the Achilles tendon with the first few steps in the morning
- Pain with increased activity
- Thickening of the tendon which you can feel approx. 2-6 cm above the insertion
- Bone spur on the back of the heel which you can sometimes feel if it is large
- Swelling and pain which worsen throughout the day
Diagnosing Achilles Tendonitis
The following are usually required for the physician to make an accurate diagnosis: a complete history of the complaint; a lower extremity physical exam including: assessing the Achilles range of motion (specifically a decrease in ankle joint dorsiflexion), palpation for signs of thickening of the Achilles and bone spurs, finding the point of maximum tenderness etc …
X-rays are helpful to assess for heel spurs and to rule out other causes of heel pain including stress fracture. Ultrasound examination can give the physician a dynamic view of the Achilles tendon. The thickness of the tendon, any possible tearing, or the existence of an inflamed bursa can be assessed with the ultrasound. MRI is also sometimes useful and can give a full picture of the tendon and the degenerative changes that may exist.
Treating Achilles Tendonitis
Treatment depends on severity. Most of my patients have already tried some kind of home therapy including anti-inflammatory medications, ice, rest, stretching etc… In some mild cases of Achilles tendonitis these treatments may be sufficient, but in many cases they are not. A physician may treat Achilles tendonitis with heel lifts, orthotics, adaptive shoe gear, a below knee cast or walker, NSAIDs, Medrol Dose Pak, Physical Therapy, etc… The average recovery time is 3-6 months.
If conservative care fails then surgical treatment may be an option. For insertional Achilles tendonitis this usually involves removal of the heel spur, debridement of the Achilles (removal of diseased portions), with or without lengthening of the Achilles (Gastrocnemius recession). To remove the heel spurs, the Achilles must be partially or completely released from its insertion into the calcaneus (heel bone). Following this release, strong anchors are placed in the bone to reattach the Achilles. Following surgery, a period of non-weight bearing is required which is usually anywhere from 4-8 weeks. Sometimes physical therapy is required as part of the recovery process. Statistically, Achilles tendon repairs have a high success rate and are a good alternative to living in pain.