THE ACHILLES TENDON
The Achilles tendon is the strongest and largest tendon in the human body. It is the
soft tissue structure that connects your calf muscles (gastrocnemius and soleus) to
your heel bone. It functions during the gait cycle to help you propel forward and to lift
your heel off the ground.
ACHILLES TENDINITIS & TENDINOSIS
When the Achilles tendon is overused or traumatized, it becomes inflamed, causing
pain, swelling, and inflammation. This is known as Achilles tendinitis.
Causes of Achilles Tendinitis:
Prolonged or repetitive activity
Tight calf muscles
Use of high heeled shoes for an extended amount of time and then switching to flatter shoes or barefoot walking
When the tendinitis becomes chronic, it is termed tendinosis. Achilles tendinosis refers to the degeneration, and sometimes calcification, of the tendon.
Symptoms may vary, depending on the timing and extent of the injury/damage to the
tendon, but may include increased warmth, swelling, and pain.
The pain associated with Achilles tendinitis and tendinosis usually happens in one of
two places. The first is along the back of the heel bone. This is known as insertional
Achilles tendinitis and is more commonly found in older patients. Sometimes, there
is also a palpable bump along the back of the heel, near the insertion of the Achilles
tendon. This is known as a Haglund’s deformity (aka a pump bump). Having the bump
may cause additional irritation while wearing certain shoes as a result of the rubbing.
The second area of pain is just proximal (about 2-6 cm) to the Achilles tendon insertion
point and is known as noninsertional Achilles tendinitis. This area of the tendon
has less blood supply, which makes it more susceptible to injury; therefore, this is
usually the site of pain for the younger population. It is also where the tendon is most
likely to rupture.
Achilles tendinitis and tendinosis pain often occurs with activities, especially higher impact ones (e.g. running, jumping), or while walking uphill (or with an incline), when the tendon is being stretched. Women may notice the pain as they switch from wearing high heels to flatter shoes or being barefoot.
1. Rest, Modification of activities, & Immobilization
Sometimes it takes a temporary modification of activities to help give the Achilles tendon a rest. This means, avoiding higher impact activities (e.g. walking, running, jumping) and switching to lower impact activities (e.g. swimming, biking) until the symptoms improve or resolve. If the pain persists, though, continued participation will only prolong, or inhibit, the healing process. Therefore, depending on the severity of the pain and when it occurs, helps determine how aggressive one needs to be with resting and/or immobilizing of the extremity. If modification of activities is not enough, sometimes a walking boot is required for a period of time.
Icing one to two times daily (especially after exercise) can help decrease inflammation. Ice should be avoided in persons with neuropathy/numbness or poor circulation.
3. Anti-inflammatory medications
Anti-inflammatory medications can also help with inflammation and swelling, which, in turn, helps with pain; however, pain medications should not be used long-term.
To my knowledge, there is no real good injection therapy for acute Achilles tendinitis. Steroid injections are not recommended in the Achilles tendon as they can cause weakness, and potential rupture, of the tendon.
Most injections are saved for the more chronic tendinosis. For Achilles tendinosis, two injection therapy options are PRP injectionsand Prolotherapy. While PRP and prolotherapy differ in their composition, both aim to stimulate, and use, the body’s own healing process to help speed up recovery.
Blood is made up of plasma, red and white blood cells, and platelets. Platelets function to help with clotting of
blood, but they also contain growth factors that aid in the healing process. Platelet-rich plasma, or PRP, is
plasma that contains a higher concentration of platelets than normal. The purpose of PRP injections is to
increase the number of growth factors into and around an area of soft tissue damage, thus stimulating and
speeding up the healing process. The ultimate goal is decreased pain, improved function, and return to sports
Prolotherapy (aka proliferation therapy) is a nonsurgical, serial injection of a dextrose solution that is injected
into the affected area to stimulate an acute low-grade traumatic process, allowing the body to use its own
inflammatory markers to aid in the body’s healing process naturally, thus regenerating and repairing damaged
tissues, restoring joint stability, and improving pain.
The studies regarding PRP & Prolotherapy injections are limited. Check out my blog to learn more about their
uses and research results in treating chronic musculoskeletal pain.
Wearing proper shoe gear is always an important concept to think about when treating lower extremity pathologies. For Achilles tendon pain, it is important to wear good, supportive tennis or walking shoes (e.g. New Balance, Brooks, ASICS, Saucony) as much as possible and avoid barefoot walking and the use of flat shoes and flip-flops. Wearing a shoe with a slight heel (temporarily) may also help because it will take tension off the tendon, allowing it to rest.
These are devices that go into many different types of shoes to help cushion, support, and control
abnormal motions of your feet. They can also help with the realignment of the lower extremity more
proximally, including your knees, hips, and back. They can be purchased off-the-shelf or be
custom-made to fit your feet.
Over-the-counter (OTC) orthotics (top picture at right)
These are pre-constructed devices that can be purchased off the shelf. There are several brands
and variations to these shoe inserts. The benefit of OTC orthotics is that they are cheaper (will likely
not cost you more than $65-70) and they are ready to wear immediately. The downfall of OTC
orthotics is that they are not made for your specific foot so they have limitations as far as how much
they may help with your foot pain or other lower extremity-related issues.
Custom-molded orthotics (CMOs) (bottom picture at right)
These are specially-made devices that are made specific for your feet, foot deformities, and related
biomechanical issues. Scans, impressions, or molds of your feet are taken and then sent to a lab for
manufacturing. Within a couple weeks, the custom orthotics are returned and fitted for your shoes.
They are more expensive, starting at around $400; however, they should last significantly longer than
OTC orthotics. Whereas, OTC orthotics may wear out in about a year, you may get 5 or more years out
of one pair of custom orthotics.
Check out my blog to learn more about the differences between OTC and custom orthotics.
Heel lifts are devices that get placed along the inside-back part of your shoe. They work like heeled shoes in that they elevate your heel, thus taking tension off the Achilles tendon. They should only be used temporarily, though, because over time, the Achilles tendon can accommodate to this new shortened length, which may cause shortening of the tendon over time. Heel cushions can add extra padding or cushion along the bottom or the back of the heel, which may be helpful in the presence of a Haglund’s deformity.
Stretching is important because many people that develop Achilles tendinitis and tendinosis already have tight calf muscles. Also, as people age, their soft tissues (e.g. tendons, ligaments) become less elastic and often tighten. This puts them at increased risk for developing injuries. Therefore, routine stretching can help regain flexibility and length back in these structures, as well as help prevent injuries from occurring.
When to stretch:
In my patients that experience post-static dyskinesia (pain with first steps after periods of rest, such after sleeping or sitting at a desk for a
long period of time), I usually recommend moving their feet and ankles around first, as well as massaging each calf muscle, and then
carefully try doing the exercises. For those that are still exercising, or are involved in sports/athletics, it is also important to stretch after your
The timing of the exercises is crucial for proper rehabilitation, so it is important to get clearance from your doctor before starting any exercise
program, especially if you are injured. The stretching exercises can either be done on your own or under the guidance of a trained physical
Wall stretches: These are done while leaning against a wall. Place one foot in front of the other, keeping your heels on the ground and your feet pointing straight ahead. For the first exercise, bend your front knee and keep your back leg and knee straight (see Wall Stretch #1 below). Lean into the wall by bringing your hips forward. You should feel a mild pulling (not painful) sensation along the back of the back leg. Hold this for 30 sec. Repeat 3 times and then switch legs. For the second exercise, keeping the same position (feet straight ahead, heels down, and front knee bent), now bend the back knee (see Wall Stretch #2 below). Lean forward and hold this position for 30 sec. Repeat 3 times and then switch legs.
Step Stretches: Find a staircase or small step, where you can hold onto a railing forbalance. Using both feet, place your heels off the step and slowly lower them, keeping your knees straight, until you feel a mild pulling (not painful) sensation along the back of the legs. Hold this for 30 sec. Repeat 3 times. Then, like the above exercise, you can bend your knees slightly and hold this position on the step for 30 sec, repeating 3 times. Once you are comfortable with the above exercise, you can try doing single heel drops (see Stair Stretch below)
Towel Stretches: These exercises are done while seated on the ground (or while in bed). For the first exercise, place a towel around your forefoot and while keeping your knee straight (see Towel Stretch below), slowly pull the towel towards your body until you feel a mild pulling (not painful sensation) along the back of your leg. Hold this for 30 sec. Repeat 3 times and switch legs to stretch the opposite calf muscles. For the second exercise, bend the involved knee slightly (like you did with the wall & step stretches), then pull the towel towards you again and hold for 30 sec. Repeat 3 times and switch legs to stretch the opposite calf muscles.
Check out my blog on “Why Stretching Your Calf Muscles Daily Is Important” to learn more about the importance of stretching daily.
This is a device that is worn on the lower extremity while you sleep. It holds the foot in a position that keeps the plantar fascia and the Achilles tendon out to length and prevents them from shortening while you sleep. This is often helpful for those that get “first steps of the morning” pain along the Achilles tendon. The night splints can be easily purchased online. From my patients that have used them, their biggest complaint is that they can be uncomfortable to sleep with.
This is considered if the patient has failed conservative care for at least 6 months. Treatment options vary depending on several factors, including the type of tendinitis (insertional or noninsertional), the presence of calcified deposits within the tendon and/or a pump bump, and the tightness of the calf muscles. The recovery can range from weeks to several months, so it should be saved as a last resort. Your doctor can discuss the details further with you should you need surgical intervention.
ACHILLES TENDON RUPTURES
Achilles tendon ruptures used to be a “weekend warrior” injury. It was often a middle-aged man playing
basketball, or another sport, for the first time in years, and the sudden movement and force placed on
the Achilles tendon caused it to tear or rupture. Nowadays, Achilles tendon ruptures are being seen in
the younger athletic population. The youngest Achilles tendon full rupture I have seen was in a man in
his early 20s!
Causes of Achilles Tendon Rupture:
Achilles tendon ruptures are mostly sports-related and like Achilles tendinitis and tendinosis, occur
within the tendon, just proximal to the insertion point, in the “watershed area”.
In the elderly population, because of their weakened bone density, the Achilles tendon can rupture
at the insertion point and actually take some of the heel bone with it (aka calcaneal avulsion fracture).
The use of floroquinolone antibiotics and intratendinous steroid injections may also put persons at
increased risk of Achilles tendon ruptures.
The symptoms may vary, depending on the extent of the rupture (partial vs complete), but usually involve
an altered gait and/or limp and difficulties walking on the affected limb.
There are a number of different examinations that can be performed by a healthcare professional to help diagnosis the rupture. Usually an MRI is not necessary.
Ecchymosis: Because the Achilles tendon is the largest tendon in the body, when it is
ruptured, it will cause significant bruising in the lower leg/calf region.
Palpable gap: When the tendon is completely ruptured, the proximal end may start to roll up into the back of the leg, so there may be a bulge felt higher up; however, in the distal part of the lower leg, just proximal to the heel bone, there will be a palpable dell, or gap, in where the tendon used to be.
Thompson Test: With the patient lying flat on their stomach, the calf muscle is squeezed and if the Achilles tendon is intact, the foot will flex. If the tendon is ruptured, no movement of the foot will occur.
Non-operative vs surgical treatment of Achilles Tendon ruptures has been controversial for many years. There are benefits and risks associated with each. Many studies have looked at the differences in outcomes between the two, including complication rates, time to return to activity, and re-rupture rates; however, the decision to operate or not, should be made on a case by case basis, taking into consideration the health status of the patient, current and projected future activity level and
Wall Stretch #1
Wall Stretch #2
Disclaimer: The above information is meant for educational purposes only and should not be construed as medical advice. Should you feel that you are suffering from an Achilles tendon problem, or another foot-related issue, please schedule an appointment to see the doctor.