The Achilles tendon is located in the back of the heel, connecting the calf muscle to the heel bone. It is the largest and strongest tendon in the body because it sees the largest forces in the body. Its role is to push down the ball of the foot such as pressing on a gas pedal or standing on tiptoes. You use it daily to walk, run, climb stairs and jump. Achilles Tendonitis is a condition in which the tendon is inflamed or irritated.
Achilles tendonitis like most other tendonitis usually occurs from an injury process that is going faster than the body's reparative process. Many patients report pain occurring after “overdoing it” with prolonged walking, hiking, running, or jumping. Runners often experience this especially after a sudden increase in the intensity or duration of their runs such as when trying to train for a marathon. Athletes who neglect a good pre and post activity routines may also lead to increased incidence of tendonitis.
Some people may also have bone spurs near the tendon and can cause additional irritation. Sometimes the small fibers of the tendon may become damaged over time from inflammation, leading to degeneration, partial tears, and eventually possible complete tear. See more information on: Achilles Tendon Ruptures.
Patients often complain of pain or discomfort at the back of the calf, above the heel, or ankle area. There may be accompanying stiffness in the ankle, swelling around the tendon, or tenderness to the touch. It sometimes is worse especially first thing in the morning, and also with extended walking or running activities.
Initial diagnostic workup will include a history and physical exam. An x-ray may be obtained in order to evaluate the anatomy of the foot and assess for any bone spurs as well as to rule out other diagnoses. Additional workup such as MRI imaging may be ordered if other pathology such as tear or rupture is suspected.
The treatment of Achilles tendonitis usually involves decreasing the injury process and trying to increase the reparative process. Reducing the injury process includes activity modification, meaning significantly decreasing or stopping all together running and jumping activities. Even prolonged walking should be modified if possible.
Increasing the reparative process includes a course of physical therapy focused on stretching to reduce tension, modalities to decrease inflammation, and then gentle progressive eccentric strengthening exercises to increase strength of the calf muscles and thereby relieve stress on the tendon. A use of a night splint to keep the Achilles tendon in a stretched position while sleeping can also help out.
Before the physical therapy exercises, warmth is usually applied in the form of heating pads or Ultrasound to increase the flexibility of the tendon, and after therapy, ice is usually applied to help decrease inflammation. This routine is important to follow when progressively returning back to sports activities, and when engaging in any running activities in general. If tolerated and not contraindicated, NSAIDs such as Ibuprofen, Advil, Aleve, can also be used to relieve pain.
If the above treatment is not successful, injections may be useful prior to considering surgery. In general, however, Dr. Steven Lee will not use Cortisone injections as this may increase the risk for tendon rupture since it tends to degrade collagen. Dr. Lee is a proponent of Platelet Rich Plasma (PRP) for most tendon issues that do not respond to standard treatment protocols. Read more about PRP here.
Treatment is often successful with these nonoperative measures and patients are usually able to return to normal activity after pain is relieved. Activity level should be increased gradually and stretching should also be done daily to prevent recurrence of the condition.
If the symptoms are persistent or there is a tear/rupture, surgical options may be discussed. The procedure typically involves making a small incision near the tendon at the ankle, debriding (removing) the degenerated and inflamed tissue, and then repairing the tendon with very strong sutures. The surgery usually takes less than 15 minutes to perform and is usually done as an outpatient. Learn more about scheduling surgery.
Dr. Steven Lee is one of the most experienced orthopedic surgeons with respect to the Achilles Tendon. He has written 5 research papers on the Achilles Tendon, and is one of the most experienced with respect to the use of PRP for tendon issues.
In general, patients will be placed into a splint immediately after surgery to protect the surgical area and repair. Patients are also advised to take aspirin to prevent formation of blood clots in the leg. The first post-op visit will occur 7-10 days after surgery in order to check the surgical site and change the splint into a cast or a cam walker (a boot that resembles the look of a ski boot).
During the first few weeks, it is extremely important to keep your foot and ankle elevated above the level of your heart to reduce swelling and therefore reduce wound/skin complications.
Depending on the procedure performed, patients are usually started on physical therapy after 2-3 weeks after surgery. Weight-bearing activities, mobility, and strength will gradually be restored with physical therapy. Patients can expect to improve steadily for up to a year after surgery, however, most can return to full activities anywhere from 3-6 months from the time of surgery
Learn more about post-operative care.
*It is important to note that all of the information above is not specific to anyone and is subject to change based on many different factors including but not limited to individual patient, diagnosis, and treatment specific variables. It is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopedic advice or assistance should consult Dr. Steven Lee or an orthopedic specialist of your choice.
*Dr. Steven Lee is a board certified orthopedic surgeon and is double fellowship trained in the areas of Hand and Upper Extremity Surgery, and Sports Medicine. He has offices in New York City, Scarsdale, and Westbury Long Island.