Achilles Tendinosis

Anatomy

Three muscles including the medial gastrocnemius muscle, the lateral gastrocnemius muscle, and the soleus muscle join at the back of the ankle to form the Achilles tendon. The Achilles tendon, which is the strongest and largest tendon in the body, inserts on the heel bone (calcaneus) and is responsible for plantarflexing the foot at the ankle. The Achilles tendon is frequently referred to as the heel cord.

Condition

Achilles tendinosis occurs when there is degeneration of the Achilles tendon and is the result of chronic small tears in the tendon.

Symptoms

1. Although pain can be felt along the entire course of the tendon, it is generally encountered at the insertion of the tendon into the heel bone (calcaneus) or approximately 2-3 cm above the insertion
2. Pain is usually worse 1st thing in the morning or when walking after a period of rest (post-static dyskinesia). Pain is also felt when walking up and down stairs or up and down an incline
3. Swelling
4. Thickening of the tendon
5. Tenderness along the tendon
6. Prominent bone at the insertion of the tendon into the calcaneus

Diagnosis

Diagnosis is made by a comprehensive foot and ankle exam by Dr. Stewart along with x-rays of the foot. Imagining studies such as ultrasound and MRI are sometimes required to determine the extent of tendon injury.

Common causes

1. Overuse, which means there is too much physical activity. This commonly occurs in runners and/or walkers and in such sports as soccer, lacrosse, basketball, tennis, and football
2. Although less common, the condition can occur acutely in weekend warriors
3. Overweight or obesity
4. Inappropriate shoe gear including flats, flip-flops, or backless shoes
5. Barefoot walking
6. Genetic predisposition due to a flatfoot deformity
7. Tightness in the Achilles or gastrocnemius also known as equinus

Treatment

Achilles tendinosis generally takes 6-8 weeks to improve and early activity on a healing tendon can result in a set back in recovery. Non-compliance can double the recovery time and can be very frustrating for patients.

Early and aggressive conservative treatment is recommended to prevent further tendon injury. Dr. Stewart terms Achilles tendinosis a pro-active condition. Although we can never offer a 100% guarantee, the majority of Dr. Stewart’s patients improve with conservative (non-surgical care).

Conservative treatment for Achilles tendinosis includes:

1. Immobilization of the foot and/or ankle. Depending on the severity of the condition, this may require cast immobilization with crutches, a walking boot, a hinged ankle foot orthosis with supportive shoe gear, a multi-ligamentous ankle brace with supportive shoe gear, or custom foot orthotics with supportive shoe gear
2. Modification of physical activity including avoidance of walking, jogging, running, and the elliptical for exercise; recommended exercises include circuit training, swimming, and bicycling
3. Stretching and strengthening exercises with a Theraband
4. Compression therapy generally with prescription compression stockings
5. Physical therapy
6. Weight loss and dieting
7. Medications including anti-inflammatory medications (NSAIDs), Tylenol, oral steroids, and in some cases narcotic pain medication
8. Ice along the tendon 2-3 times per day for 20 minutes at the area of maximum tenderness. Elevation is recommended while icing
9. Avoidance of flip-flops, flats, and barefoot walking
10. Supportive shoe gear including a motion control running shoe such as Brooks, Asics, New Balance, or Saucony. Keen and Merrell style shoes are also recommended
11. Custom foot orthotics
12. Night splint to help stretch the tendon

If all conservative intervention fails, then surgical intervention maybe required. Dr. Stewart will determine which procedure is best for you.

Surgical treatment for Achilles tendinosis includes:

1. Tendon debridement and repair
2. Tendon grafting
3. Debridement of tendon and bone with reattachment of tendon to bone with bone anchors
4. Tendon lengthening