6/25/2018

Achilles Tendonitis

Achilles Tendonitis

The Achilles tendon is the single strongest tendon in the human body. The primary function from the Achilles muscle is to transmit the power of the calf to the foot resulting in the ability to move us ahead, allow us to jump, dance; you name it. When it has to do with motion, the Achilles tendon is a part of that activity. From time to time the Achilles tendon looses the ability to keep up with us all and the tendon will become inflammed resulting inAchilles tendonitis. This article discusses the onset, symptoms and also treatment of Achilles tendonitis. Achilles tendon ruptures are also discussed.

Acute Achilles Tendonitis

Acute Achilles tendonitis typically has a unexpected onset with moderate pain 2-3 cm proximal to the tendons' insertion on the back of the heel. The majority of individuals with severe Achilles tendonitis can describe an injury or single event that initiated the pain. Symptoms of acute Achilles tendonitis occur at the beginning of the activity and are typically described as a sharp pain. As the exercise progresses, this decreases for a period of time. With excessive use, the tendons again becomes painful at the end of activity. For example, runners withAchilles tendonitis experience pain as they begin their run. The pain goes away throughout their run only to recur close to the end of their normal running range.

Chronic Achilles tendonitis exhibits the same type of pain as acute Achilles tendonitis but the location of the pain is usually at the installation of the Achilles tendon into the heel. Chronic Achilles tendonitis can also trigger hypertrophy enlargement) of the posterior heel and in limited cases, enlargement of the tendon. This bony enhancement of the back of the heel goes by many names including retrocalcaneal bursitis, pump bump or Haglund's Deformity.

Cases of chronic Achilles tendonitis it is critical to identify between discomfort just due to the Achilles muscle or from the enlargement of the heel rubbing against the shoe. The difference between Achilles tendonitis and a pump bump can easily be understood by evaluating the pain while barefoot effective of Achilles tendonitis) compared to pain while wearing shoes with an enclosed heel (pump bump). It's not unusual to find both conditions concurrently.

Knowing that the single greatest cause of serious and chronic Achilles tendonitis is equinus (see the biomechanics section below for more information on equinus), we know that we need to weaken the calf muscle to be able to allow the Achilles tendon an opportunity to cure. This can be achieved by increasing the heel with heel lifts or by high heel shoes. Inflammation of the tendon can be calmed by ice, both before and after activities. Anti-inflammatory medications, casting or ultrasound treatment can also be used. Steroid injections are typically not used to deal with Achilles tendonitis since injecting the tendon has a tendency to weaken the tendon resulting in a possible rupture.

Manipulation techniques will also be helpful to increase the range of motion of the ankle. One new technique involves manipulation of the fibula (smaller outside bone of the ankle and leg) to allow greater excursion of the talus (foot bone of the ankle). This technique must be performed by someone other than the patient and is performed as follows;

The patient is placed in a sitting position with the hip and knee flexed. Standing on the side of the chair opposite to the leg that will be manipulated, put the index and middle fingers of both hands over the head of the fibula (That's just below the knee on the outside of the leg). Using a firm and rapid motion, change the head of the fibula anteriorly (towards the front of the leg). A slight shift or pop may or may not be noted.

Next, with the patient sitting and the hip and knee extended straight) place traction on the foot with the ankle slightly plantar flexed (toes pointing down and away from the leg).Continue traction for 30-45 seconds. Then dorsiflex the ankle move the foot/toes for the shin). Complete a series of range of motion of the ankle with the patient.

Repeat as Needed.

Cases of chronic Achilles tendonitis, patients who do not respond to heel lifts, manipulation and anti-inflammatory medications require a lengthening procedure of the Achilles tendon with or without a partial resection of the posterior heel. In cases with minimal hypertrophy of the heel, lengthening of the tendon will suffice. Lengthening of the Achilles tendon may be performed through three 0.5cm incisions however does require a time period of casting. Full recovery may take 6-18 months.

Achilles Tendon Ruptures

Chronic Achilles tendonitis is not a symptom to be overlooked based upon the knowledge that Achilles tendonitis is often a precursor to an Achilles tendons rupture. A rupture of the Achilles tendon can be a debilitating injury. The actual rupture of the tendon is described by the majority of patients as feeling as if they were hit in the back of the leg. An audible pop is often described. The majority of ruptures occur 2-4cm proximal for the attachment of the tendon into the calcaneus (heel bone).

The repair of Achilles tendon ruptures may be conservative or surgical. Orthopedic and podiatric literature abounds with content articles that compare the merits of conservative vs surgical good care of Achilles tendon ruptures. Re-rupture of the muscle is not uncommon regardless of the method of correction although, statistically, re-rupture does seem to occur less in those patients that undergo operative repair. These findings may also reflect the nature of patient that would be a operative candidate. Typically we would assume that those patients that were in poor health (eg elderly, diabetic, immune compromised)would not become surgical applicants and for that reason may contribute to the increased rate of re-rupture seen in those treated with conservative attention.

Recent articles have advocated a surgical approach for repair of ruptured Achilles tendons that employs both an open and percutaneus technique of repair. The most popular method was described by M. Kakiuchi of The Osaka Police Clinic in 1995.This method involves the use of an empty procedure at the site of rupture to enable debridement of the ruptured tendon. Kakiuchi additionally employs a closed technique to suture the tendon to allow for proper healing.

Nomenclature:

Achilles - Greek warrior from Homer's Iliad. Hence the termAchilles is always capitalized.

Haglund's Deformity - See pump bump

  • Pump bump - term that originated in the 1950's when many women were wearing pump high heels.
  • Pumps were considered a contributing factor to an enlargement of the back of the heel.
  • Pump bumps are typically found postero-lateral where as trueAchilles tendonitis is posterior and specific to the insertion of the Achilles tendon.

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Sever's Disease

An inflammatory disease of the growth plate of the posterior heel found in young boys. Usually seen in boys age to 13 years old and in the course of increased activities such as commencing football or even soccer practice. Pain with side to side compression of the heel.

  • Tendonitis - refers to a group of problems that have to do with inflammation surrounding or within the structure of a tendon.
  • May or may not exhibit swelling.

Anatomy:

The Achilles tendon is the distal extension of the two muscles of the calf, the gastrocnemius and the soleus. The gastrocnemius is the longer of the two muscles and stems on the proximal side of the leg (above the knee). The soleus, or shorter muscle of the calf, originates distal to the knee joint. Combined, these muscles make up the calf. As both of these muscle groups continue to the distal 1/3 of the leg, they combine to form the Achilles tendon. Fibers of the Achilles tendon continue beyond the installation to make up the plantar fascia on the bottom of the heel.

  • Fibers of the Achilles tendon attach to the back of the heel below the mid-level of the body with the heel.
  • As a result, a space is formed between the Achilles tendon as well as the calcaneus.
  • This space, called the retrocalcaneal room, is a common site for a bursa to form.
  • With chronic put on, the actual bursa may become inflamed resulting an retrocalcaneal bursitis.

Biomechanics:

Equinus is actually the most common contributing factor to Achilles tendonitis. Equinus, produced from the term equine or horse, refers to one who walks on their foot. Equinus can determined by measuring the range of motion of the ankle with the knee flexed and extended. When the knee is flexed, the amount of equinus of the soleus muscle is measured. With the knee extended, both soleus and gastrocnemius muscles are measured. Imaginary lines are proven on the long axis of the leg and the foot. By dorsiflexing the foot (toward the body) an angular measurement is actually established between these two lines. Normal range of motion of the ankle, to accomplish a normal gait cycle, is 10 to 15degrees past 90 degrees. This means that the normal range calls for the ankle in order to dorsiflex to 90 degrees plus an additional to 15 degrees. An inability to complete this range of motion is called equinus.

Other factors may give rise to an inability to reach 90degrees, such as a bony block on the front of the ankle.

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  • Symptoms:

    Acute Achilles tendonitis.

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    • Acute Achilles tendonitis typically has a unexpected onset with achiness 2-3 cm proximal to its' attachment on the back of the heel.
    • Many individuals with Achilles tendonitis can explain an injury or single event that initiated the pain.
    • Symptoms of acute Achilles tendonitis occur at the beginning of an exercise and are usually described as a sharp pain.
    • As the activity progresses, this decreases for a period of time.
    • With excessive use, the tendon again becomes painful at the conclusion of activity.
    • For example, runners with Achilles tendonitis experience pain as they begin their run.
    • The pain subsides during their run only to recur near the end of their normal running range.

    Chronic Achilles tendonitis exhibits exactly the same form of pain as acute Achilles tendonitis but the location of the pain is usually at the insertion of the Achilles tendon into the heel. Chronic Achilles tendonitis can also cause hypertrophy enlargement) of the posterior heel. Pain may be from the tendon pulling away from the back heel, or from the enlargement of the heel rubbing against the shoe. This bony enlargement of the back of the heel goes by many names including retrocalcaneal bursitis, pump bump or Haglund's Deformity. The difference betweenAchilles tendonitis and a pump bump can easily be understood by analyzing the pain whilst barefoot (Achilles tendonitis)compared in order to pain while wearing shoes with an enclosed heel (pump bump).

    Differential Diagnosis:

    When considering the diagnosis of Achilles tendonitis as a differential diagnosis consider;

    Gout - deposition of monosodium urate deposits (hyperuricemia)

    Retrocalcaneal bursitis (Albert's Disease) - this is the development and inflammation of a bursa behind the heel between the heel bone and Achilles tendon

    Rheumatoid Arthritis

    Rheumatic Fever.

    Septic Arthritis

    Sero-negative arthropathies such as Reiter's Syndrome.

    Sever's Condition - as well as inflammatory condition typically found in youthful over weight boys age 10 to 15 years old

    Stress crack with the calcaneus - Achilles tendonitis pain is characteristically different from that of fractures of the calcaneus. Fracture pain begins with the onset of action and remains painful through the activity. Tendonitis, on the other hand, damages at the onset of activity, subsides during the activity simply to recur at the conclusion of exercise. These symptoms may vary in every case and are only referenced in and effort to differentiate symptoms.

    • Tarsal Tunnel Syndrome - also known as posterior tibial nerve neuralgia.
    • Tarsal Tunnel Syn. characteristically has pain that does not decrease with rest.
    • Also has numbness or 'tingling' of the toes
    • Hattrup, S., Johnson, K.A., A review of ruptures of theAchilles tendon.
    • Foot and Ankle 6:34, 1985

    Fierro, N., Sallis, R., Achilles tendon break, is casting enough?. Post. Grad. Mediterranean sea. 98:145, 1995

    • O'Brien, T. the needle test for complete rupture of theAchilles tendon.
    • J. of Bone and Joint Surg. 66-A(7):1099-1101,

    Bradley, J., Tibone, J., Percutaneus and also open surgical repairs of Achilles tendon ruptures, a comparative study. Am. J.Sports Mediterranean sea. 18:188, 1990

    Wills, C., Washburn, S., Caiozzo, V., Prietto, C. Achilles tendon rupture; a review of the literature comparing medical vs. non-surgical treament. Clin. Orthop. 207:156. 1986

    • Dananberg HJ, Shearstone J, Guiliano M: Manipulation method for the treatment of ankle equinus.
    • JAPMA 90:8 2000
    • Rebeccato A, Santini S, Salmaso G, Nogarin L: Repair of theAchilles Tendon Rupture: A Functional Comparisonof ThreeSurgical Techniques.
    • JFS 40:4 2001
    • Kakiuchi M.
    • A combined open and percutaneus technique for repair of tendon Achilles.
    • JBJS. 77-B:60-63, 1995

    About the author:Jeffrey A. Oster, DPM, C.Ped is a aboard certified foot and ankle surgeon. Dr. Oster is also board certified in pedorthics. Medical professional. Oster is medical director of Myfootshop.comand is in active practice in Granville, Ohio.