Achilles tendonitis is one
of the most common running injuries. The achilles tendon is the large tendon at the back of the ankle. It connects the calf muscles made up of the gastrocnemius and soleus to the heel bone or
calcaneus. It provides the power in the push off phase of walking and running where huge forces are transmitted through the achilles tendon. Achilles tendonitis is often now referred to as achilles
tendinopathy. This is because the term tendinopathy covers all types of overuse achilles tendon injury. Strictly speaking tendonitis suggests an inflammatory condition of the tendon but in reality
few achilles tendon injuries are actually down to pure inflammation. Soleus muscleThe main finding, particularly in older athletes is usually degeneration of the tissue with a loss of normal fibre
structure. Other very similar conditions may actually be due to inflammation or degeneration of the tendon sheath which surrounds the tendon rather than the achilles tendon itself. In addition to
being either chronic or acute, achilles tendonitis can also be at the attachment point to the heel called insertional achilles tendonitis or in the mid-portion of the tendon typically around 4cm
above the heel. Healing of the achilles tendon is often slow, due to its poor blood supply.
Achilles tendinitis may be caused by intensive hill running, sprinting, or stair climbing. Overuse resulting from the natural lack of flexibility in the calf muscles. Rapidly increasing intensity of
exercise, especially after a period of inactivity. Sudden and hard contraction of the calf muscles when exerting extra effort, like that in a final sprint or high jump.
Recurring localized pain, sometimes severe, along the tendon during or a few hours after running. Morning tenderness about an inch and a half above the point where the Achilles tendon is attached to
the heel bone. Sluggishness in your leg. Mild or severe swelling. Stiffness that generally diminishes as the tendon warms up with use.
To confirm the diagnosis and consider what might be causing the problem, it?s important to see your doctor or a physiotherapist. Methods used to make a diagnosis may include, medical history,
including your exercise habits and footwear, physical examination, especially examining for thickness and tenderness of the Achilles tendon, tests that may include an x-ray of the foot, ultrasound
and occasionally blood tests (to test for an inflammatory condition), and an MRI scan of the tendon.
Nonsurgical methods include rest and stop doing activities that cause stress to the tendon. Ice the area by applying ice to the tendon for 15 minutes after exercising. Compress the tendon by using an
athletic wrap or surgical tape. Elevate your injury. You can reduce swelling by lying down and raising your foot at a level that is above your heart. Stretch your ankles and calf muscles. Take
anti-inflammatory medication (e.g.: ibuprofen to reduce swelling). Wear orthotics and running shoes. Take part in physical therapy.
Surgery should be considered to relieve Achilles tendinitis only if the pain does not improve after 6 months of nonsurgical treatment. The specific type of surgery depends on the location of the
tendinitis and the amount of damage to the tendon. Gastrocnemius recession. This is a surgical lengthening of the calf (gastrocnemius) muscles. Because tight calf muscles place increased stress on
the Achilles tendon, this procedure is useful for patients who still have difficulty flexing their feet, despite consistent stretching. In gastrocnemius recession, one of the two muscles that make up
the calf is lengthened to increase the motion of the ankle. The procedure can be performed with a traditional, open incision or with a smaller incision and an endoscope-an instrument that contains a
small camera. Your doctor will discuss the procedure that best meets your needs. Complication rates for gastrocnemius recession are low, but can include nerve damage. Gastrocnemius recession can be
performed with or without d?bridement, which is removal of damaged tissue. D?bridement and repair (tendon has less than 50% damage). The goal of this operation is to remove the damaged part of the
Achilles tendon. Once the unhealthy portion of the tendon has been removed, the remaining tendon is repaired with sutures, or stitches to complete the repair. In insertional tendinitis, the bone spur
is also removed. Repair of the tendon in these instances may require the use of metal or plastic anchors to help hold the Achilles tendon to the heel bone, where it attaches. After d?bridement and
repair, most patients are allowed to walk in a removable boot or cast within 2 weeks, although this period depends upon the amount of damage to the tendon. D?bridement with tendon transfer (tendon
has greater than 50% damage). In cases where more than 50% of the Achilles tendon is not healthy and requires removal, the remaining portion of the tendon is not strong enough to function alone. To
prevent the remaining tendon from rupturing with activity, an Achilles tendon transfer is performed. The tendon that helps the big toe point down is moved to the heel bone to add strength to the
damaged tendon. Although this sounds severe, the big toe will still be able to move, and most patients will not notice a change in the way they walk or run. Depending on the extent of damage to the
tendon, some patients may not be able to return to competitive sports or running. Recovery. Most patients have good results from surgery. The main factor in surgical recovery is the amount of damage
to the tendon. The greater the amount of tendon involved, the longer the recovery period, and the less likely a patient will be able to return to sports activity. Physical therapy is an important
part of recovery. Many patients require 12 months of rehabilitation before they are pain-free.
Regardless of whether the Achilles injury is insertional or non-insertional, a great method for lessening stress on the Achilles tendon is flexor digitorum longus exercises. This muscle, which
originates along the back of the leg and attaches to the tips of the toes, lies deep to the Achilles. It works synergistically with the soleus muscle to decelerate the forward motion of the leg
before the heel leaves the ground during propulsion. This significantly lessens strain on the Achilles tendon as it decelerates elongation of the tendon. Many foot surgeons are aware of the
connection between flexor digitorum longus and the Achilles tendon-surgical lengthening of the Achilles (which is done to treat certain congenital problems) almost always results in developing hammer
toes as flexor digitorum longus attempts to do the job of the recently lengthened tendon. Finally, avoid having cortisone injected into either the bursa or tendon-doing so weakens the tendon as it
shifts production of collagen from type one to type three. In a recent study published in the Journal of Bone Joint Surgery(9), cortisone was shown to lower the stress necessary to rupture the
Achilles tendon, and was particularly dangerous when done on both sides, as it produced a systemic effect that further weakened the tendon.