What is the Achilles tendon?
The Achilles tendon is the largest tendon in your body. It stretches from the bones of your heel to your calf muscles. You can feel it — a springy band of tissue at the back of your ankle and above your heel. It lets you point your toes toward the floor and raise up on your tiptoes.
An Achilles tendon injury can happen to anyone, whether you’re an athlete or just going about your everyday life.
It’s common for this tendon to get injured. It can be mild or moderate and feel like a burning pain or stiffness in that part of your leg. If the pain is severe, your Achilles tendon may be partly torn or completely ruptured.
The Achilles tendon attaches your calf muscles to your heel bone, or calcaneus. You use this tendon to jump, walk, run, and stand on the balls of your feet. Continuous, intense physical activity, such as running and jumping, can cause painful inflammation of the Achilles tendon, known as Achilles tendonitis (or tendinitis).
There are two types of Achilles tendonitis: insertional Achilles tendinitis and noninsertional Achilles tendonitis. Insertional Achilles tendonitis affects the lower portion of your tendon where it attaches to your heel bone. Noninsertional Achilles tendonitis involves fibers in the middle portion of the tendon and tends to affect younger people who are active.
Simple home treatments can help Achilles tendonitis. However, if home treatment doesn’t work, it’s important to see a doctor. If your tendonitis gets worse, your tendon can tear. You may need medication or surgery to ease the pain.
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 tip toes. Although the Achilles tendon can withstand great stresses from running and jumping, it is also prone to tendinitis, a condition associated with overuse and degeneration.
How does it get injured?
Most Achilles tendon problems occur in middle-aged athletes and are basically overuse injuries. In a few cases, other medical conditions contribute to the weakening of the tendon. A high-arched or low-arched foot may increase the stresses on the Achilles tendon.
As we get older the tendon becomes less flexible and less able to absorb the repeated stresses of running. Eventually small “degenerative” tears develop in the fibres of the tendon. The body tries to repair these tears. Sometimes the repair process is successful. However, the blood supply of the lower part of the tendon is not very strong and the combination of this and the continued stresses of running mean that the tendon may not completely heal. Instead, the tendon and its lining become painful and swollen, and the tendon may feel weak. The combination of degenerative and repair processes in the tendon is called tendonosis (or sometimes tendonitis). Because the lining of the tendon is called its tenosynovium, inflammation of the lining is called tenosynovitis.
Sometimes the tendon becomes weakened by the degenerative process to the extent that it tears completely.
How would I know if I had an Achilles tendon problem?
If you had a complete tear, you would probably feel a sudden pain in your heel or calf. Some people say this feels as though they had been kicked in the calf, or hit them with a squash raquet. Usually the heel becomes painful, swollen and bruised, and it becomes difficult to walk.
Tendonosis and tenosynovitis develop more gradually. The Achilles tendon and the heel become painful and a swelling may develop in or around the tendon. At first the problem is present mainly on running or playing sport, but later it may become increasingly difficult to walk because of the painful tendon.
What are common Achilles tendon problems?
The two main problems are:
- Achilles tendinopathy. This refers to tiny tears (microtears) in the tissue in and around the tendon. These tears are caused by overuse. Achilles tendinopathy is also often called Achilles tendinitis.
- Achilles tendon tear or rupture. An Achilles tendon also can partially tear or completely tear (rupture) camera.gif. A partial tear may cause mild or no symptoms. But a complete rupture causes pain and sudden loss of strength and movement.
Problems with the Achilles tendon may seem to happen suddenly. But usually they are the result of many tiny tears in the tendon that have happened over time.
Achilles tendon injuries are common in people who do things where they quickly speed up, slow down, or pivot, such as:
These injuries tend to happen when you start moving suddenly as you push off and lift your foot rather than when you land. For instance, a sprinter might get one at the start of a race as he surges off the starting block. The abrupt action can be too much for the tendon to handle. Men over 30 are particularly prone to Achilles tendon injuries.
Excessive exercise or walking commonly causes Achilles tendonitis, especially for athletes. However, factors unrelated to exercise may also contribute to your risk. Rheumatoid arthritis and infection are both linked to tendonitis.
Any repeated activity that strains your Achilles tendon can potentially cause tendonitis. Some causes include:
- exercising without a proper warmup
- straining the calf muscles during repeated exercise or physical activity
- playing sports, such as tennis, that require quick stops and changes of direction
- sudden increase in physical activity without allowing your body to adjust to increased training
- wearing old or poorly fitting shoes
- wearing high heels daily or for prolonged durations
- having bone spurs in the back of your heels
- being older, as the Achilles tendon weakens with age
These things also can make you more likely to have this kind of injury:
- You wear high heels, which can stress the tendon.
- You have “flat feet,” also called fallen arches. This means that when you take a step, the impact causes the arch of your foot to collapse, stretching the muscles and tendons.
- Your leg muscles or tendons are too tight.
- You take medicines called glucocorticoids or antibiotics called fluoroquinolones.
The most obvious sign is pain above your heel, especially when you stretch your ankle or stand on your toes. It may be mild and get better or worse over time. If the tendon ruptures, the pain is instant and severe. The area may also feel tender, swollen, and stiff.
If your Achilles tendon tears, you may hear a snapping or popping noise when it happens. You could have bruising and swelling, too. You also may have trouble pointing your toes and pushing off your toes when you take a step.
Pain—aching, stiffness, soreness or tenderness—within the tendon. This may occur anywhere along the tendon’s path, beginning with the tendon’s attachment directly above the heel upward to the region just below the calf muscle. Pain often appears upon arising in the morning or after periods of rest, then improves somewhat with motion but later worsens with increased activity.
Tenderness, or sometimes intense pain, when the sides of the tendon are squeezed. There is less tenderness, however, when pressing directly on the back of the tendon.
When the disorder progresses to degeneration, the tendon may become enlarged and may develop nodules in the area where the tissue is damaged.
Treatment approaches for Achilles tendonitis or tendonosis are selected on the basis of how long the injury has been present and the degree of damage to the tendon. In the early stage, when there is sudden (acute) inflammation, one or more of the following options may be recommended:
Immobilization. Immobilization may involve the use of a cast or removable walking boot to reduce forces through the Achilles tendon and promote healing. Ice. To reduce swelling due to inflammation, apply a bag of ice over a thin towel to the affected area for 20 minutes of each waking hour. Do not put ice directly against the skin.
Oral medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be helpful in reducing the pain and inflammation in the early stage of the condition. Orthotics. For those with overpronation or gait abnormalities, custom orthotic devices may be prescribed.
Night splints. Night splints help to maintain a stretch in the Achilles tendon during sleep.
Physical therapy. Physical therapy may include strengthening exercises, soft-tissue massage/mobilization, gait and running re-education, stretching and ultrasound therapy.
Treating Achilles tendonitis
Many treatments are available for Achilles tendonitis, ranging from home remedies, like rest and anti-inflammatory medication, to more invasive treatments, like steroid injections, platelet-rich plasma (PRP) injections, and surgery. Your doctor might suggest:
- reducing your physical activity
- very gently stretching and later strengthening your calf muscles
- switching to a different, less strenuous sport
- icing the area after exercise or when in pain
- elevating your foot to decrease any swelling
- wearing a brace or walking boot to prevent heel movement
- going to physical therapy
- taking anti-inflammatory medication, such as aspirin (Bufferin) or ibuprofen (Advil), for a limited time
- wearing a shoe with a built-up heel to take tension off your Achilles tendon
Diagnosing Achilles tendonitis
To diagnose Achilles tendonitis, your doctor will ask you a few questions about the pain and swelling in your heel or calf. Your doctor may ask you to stand on the balls of your feet while they observe your range of motion and flexibility. The doctor also feels around (palpates) the area directly to pinpoint where the pain and swelling are most severe.
Imaging tests may help confirm Achilles tendonitis, but you usually don’t need them. If ordered, the tests include:
X-rays, which provide images of foot and leg bones
MRI scans, which can detect ruptures and tissue degeneration
ultrasounds, which can show tendon movement, related damage, and inflammation
Complications of Achilles tendonitis
The most common complication of Achilles tendonitis is pain, having trouble walking or exercising, and your tendon or heel bone becoming deformed. You can also experience a complete tear (rupture) of your Achilles tendon. In this case, you’ll usually need surgery to fix the rupture.
One study found that complications such as hematomata (blood swelling and clotting inside tissue) and deep vein thrombosis (blood clot in a deep vein) are possible after a surgery for Achilles tendonitis. Complications can worsen if you don’t follow your doctor’s instructions after an operation. If you continue to put stress or wear on your Achilles tendon after a surgery, your tendon can rupture again.
Surgery can repair the damage sustained by the tendon as a result of Achilles tendinitis. The American Academy of Orthopedic Surgeons (AAOS) only recommends surgery if the pain continues for 6 months or more.
The most common procedure is gastrocnemius recession. This involves lengthening one of the two muscles that make up the calf, to give the ankle a wider range of motion.
Stretches and exercises
A physical therapist can teach stretching exercises to improve flexibility and increase calf strength.
Here are two exercises, suggested by the AAOS.
- Calf stretch
- Lean forward with your hands against a wall.
- Have one foot on the ground, with the leg straight, and one foot in front of it, with the knee bent.
- Push your hips toward the wall and hold for 10 seconds.
- Relax and repeat 20 times for each foot.
- Bilateral heel drop
- Stand with the front half of your foot on the stair and the heel off, holding a rail to make sure you are balanced and will not fall.
- Slowly lift your heels and lower them as far as you can.
- Repeat 20 times.
Both exercises must be done slowly and in a controlled manner. Doing them fast can increase the damage.
This may help the Achilles tendon to heal and prevent future injury. Physical therapy is normally more effective for noninsertional Achilles tendinitis.
Achilles tendinitis cannot be completely prevented, but the risk of developing it can be reduced by being aware of the possible causes and taking precautions.
Warming up before exercise can prevent injury.
- Varying exercise: Alternating between high-impact exercises, such as running, and low-impact exercise, for example, swimming, can reduce stress on the Achilles tendon on some days.
- Limiting certain exercises: Too much hill running, for example, can put excessive strain on the Achilles tendon.
- Wearing the correct shoes and replacing them when worn: Shoes that support the arch and protect the heel create less tension in the tendon.
- Using arch supports inside the shoe: This can help if the shoe is in good condition but does not provide the required arch support.
Gradually increasing the intensity of a workout: Achilles tendinitis can occur when the tendon is suddenly put under too much strain, so warming up and increasing the level of activity gradually gives the muscles time to loosen up, and this puts less pressure on the tendon.
It is important to stretch and warm up before and after exercising. Stretching helps to keep the Achilles tendon flexible, so there is less chance of tendinitis developing. Stretching every day, including rest days, will further improve flexibility.
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