Achilles tendonitis is when the achilles tendon becomes inflamed or irritated. This inflammation is often the result of a lot of stress on your calf muscles and achilles tendon from either a sudden increase in intensity or frequency of exercise. Chronic overuse can contribute to micro-tears in the achilles tendon, leading to wear and tear over time that weakens the tendon and thickening of the tendon from scar tissue.
When treated promptly, achilles tendonitis is often short-lived. Left untreated, Achilles tendonitis can cause persistent pain or cause your tendon to rupture. The healing process causes scar tissue to form. Because scar tissue is not as elastic as the tendon, the scar tissue doesn’t allow the tendon to stretch normally, which can lead to a rupture of the tendon.
Fortunately, rest and over-the-counter medications to reduce your pain and inflammation may be all the treatment you need for Achilles tendonitis. In some cases, physical therapy may be needed. If you ignore symptoms, the result can be a rupture or tear of the tendon and surgery may be needed.
Before you read any further, it might help to brush up on Foot and Ankle Anatomy.
Where is the Achilles Tendon and What Does it Do?
Tendons are strong, fibrous tissues that attach muscles to bones. When muscles contract, the muscle pulls on the tendon that moves the bone. The achilles tendon attaches the two calf muscles (the outer gastrocnemius and the underlying soleus) that share the achilles tendon to the heel bone (calcaneus).
When contracted, the calf muscles pull on the achilles tendon causing the foot to point downward helping you to rise up onto the ball of your foot. As the calf muscles relax, they allow you to lower your heel to the ground. This powerful muscle group in your calf helps you sprint, jump, or climb and provides the push-off phase in walking and running.
What Causes Achilles Tendonitis?
The achilles tendon is one of the strongest in the body but is prone to injury because of the tremendous pressure that is put on it with every step we take.Achilles tendonitis is often an overuse injury—doing too much too soon.
Problems with the Achilles tendon affect athletes most often; especially runners, basketball players, and sports that require jumping—like volleyball and tennis. Problems are also common in middle-aged adults. Tendonitis can also be caused by calf muscles that are too tight. Some injuries to the Achilles tendon are minor and some—ruptures—are rather severe.
Achilles tendonitis can be either acute which occurs over a period of a few days following and increase in training, or chronic which occurs over a longer time. In athletes, problems are often acute following a sudden increase in training—either distance, speed or hills. Risk factors for non-athletes include diabetes, age, obesity, steroids, certain antibiotics or a “weekend warrior” injury.
What do Achilles Tendon Problems Feel Like?
- Gradual onset of pain over a period of days
- Pain when exercise begins that gets better as the exercise progresses
- Pain gets better with rest
- Tenderness to pressure in the area
Chronic Achilles tendonitis can follow acute tendonitis if untreated. Chronic tendonitis is more difficult to treat.
- Gradual onset of pain over a period of weeks or months
- Pain with exercise that is constant throughout exercise
- Pain when walking uphill or up stairs
- Pain and stiffness in the tendon after rest and especially early in the morning
- Nodules or lumps in the tendon
- Tenderness with pressure
- Swelling or thickening of the tendon
- May have skin redness over the area
- May feel creaking when moving the ankle or pressing the tendon with your fingers
You can have pain either where the Achilles tendon attaches to the calf muscle—tendonitis—or where it attaches to the heel bone (calcaneus)—bursitis. There is a fluid-filled sac between the tendon and the bone, called a bursa that limits friction when the tendon glides up and down at the back of the heel bone. Bursitis usually starts as pain and irritation at the back of the heel. You may see redness or swelling there. Shoes can aggravate the condition making it hard to wear shoes but some are better than others for tendonitis.
Tendonitis occurs just above the heel. Tendonitis is caused by a violent strain to the calf muscles or the tendon during a strong contraction of the muscle as when running or sprinting. This strain can occur where the muscles join the Achilles tendon. You will have pain when pressing on the Achilles tendon and with walking, especially when pushing off your toes or putting weight on your toes as when going down stairs or stepping off a curb. (See xray image left.)
How are Achilles tendon problems identified?
Diagnosis is done by your doctor taking a history—“what were you doing when the pain started?”—and a physical exam to see where your calf and/or foot hurt. You will likely have xrays to rule out fracture and show bone spurs or other problems.
What Are My Treatment Options?
Your treatment will depend on the severity of our injury and how long it has been since your injury. You will likely be started on rest, ice and anti-inflammatory medicines such as aspirin or NSAIDs.
- Resting the painful Achilles tendon allows the inflammation to subside and allow for healing. A period of rest—stopping the activity that is causing the pain—after the onset of symptoms is important in controlling Achilles tendonitis.
- In patients who have more significant symptoms, a period of immobilization can help. Either a removable walking boot, or sometimes even a cast, can allow the inflamed tissue to cool down quickly. Wearing a walking boot keeps the calf muscle from pulling on the Achilles tendon.
- The boot prevents you from pushing off with the ball of your foot or pointing your toes downward. The walking boot should be worn when walking. However, there is some benefit to wearing the boot even when you’re at rest as the boot keeps a slight stretch on the tendon and prevents further shortening.
- Night Splint:
- A night splint keeps the foot in a similar position as the walking boot, with a gentle stretch on the Achilles tendon. However, a night splint is not sturdy enough to allow walking.
- Daily use of a night splint while sedentary, from minutes to several hours, can help physical therapy and continues the rehabilitation while at home. After recovery, a night splint can help prevent recurrent strains and maintains lower extremity flexibility, especially in athletes.
Physical Therapy for Achilles Tendonitis
For some injuries, physical therapy is recommended to help remove or stretch scar tissue and to control pain and swelling. Patients with mild symptoms of bursitis or tendonitis often do well with two to four weeks of physical therapy.
The physical therapist’s goal is to keep your pain and swelling under control, improve your range of motion and strength, and make sure you regain a normal walking pattern. Treatments such as ultrasound, moist heat, and massage are used to control pain and inflammation. As pain eases, treatment progresses to include stretching and strengthening exercise.
Physical therapy can also include shock waves, ultrasound, and ice. The key to proper ice and heat therapy is knowing when to ice and heat an injury. Your physical therapist knows when and how to apply treatment to reduce swelling and pain while still allowing the healing inflammatory process. Your therapist will teach you a home-care program to go along with the office therapy to help speed healing.
One purpose of the treatment is to break up scar tissue that has formed and to stretch out the scar tissue allowing the tendon to stretch normally without pain or tearing. The order of treatment is important. You don’t want to stretch a “cold” tendon. Injured tendons shorten and need to be stretched.
Also, be careful not to overdo stretching. Only gentle stretches for the calf muscles and Achilles tendon are used at first. As the tendon heals and pain eases, more aggressive stretches are done. Ask your therapist, “On a scale of 1-10, how much should I be stretching the tendon.” To prevent further scar tissue from forming, ice is applied after stretching, massage, or treatments. Don’t overdo therapy as this can slow down the healing process by adding further injury to the tendon.
- Ultrasound—high or low frequency sound waves—can help increase the blood flow to the area to reduce swelling and speed healing. The vibrating sound waves can travel deep into the tissue (muscles) creating gentle heat. The heat increases the blood flow to the area to deliver oxygen and nutrients and remove cell wastes. The deep heat also helps relieve pain, inflammation and muscle spasms. Ultrasound is painless. You may feel tingling; often, you won’t feel anything at all.
- Electrical Stimulation
- Low-energy shock wave therapy has been used successfully for chronic tendonitis. This therapy does not need anesthesia and can take several treatment sessions. The vibrations produced by the energy waves are applied to the painful areas. Shock wave therapy stimulates soft-tissue healing by increasing blood supply to the treated area.
- Small electrode pads are placed on the painful area. Then you control the degree of “shock” to the area. The therapy can last as long as 20 minutes. During the treatment, you can increase the intensity as you adjust to each level. During treatment you should feel a tingling sensation, but not pain.
Electrical stimulation can also be used in iontophoresis. This treatment involves the application of a topical anti-inflammatory to the area. The stimulation forces the medication into the tissues reducing inflammation.
- Steroid Injections
- Steroid injections are rarely used because it is believed they can weaken the tendon increasing the risk of total rupture.
What to Expect After Treatment
If you have mild symptoms, you should do well with 2-4 weeks of physical therapy; more severe injuries can take as long as 2-3 months. As your condition improves, you can begin doing exercises to strengthen your calf muscles. Strengthening starts gradually using exercises that work the calf muscles but protect the healing area.
Eventually, you can do specialized strengthening exercises that work the calf muscle while it lengthens. For example, standing on your tiptoes and then carefully lowering your heels back to the ground.
When your healing is well under way, regular visits to the therapist’s office will end. Your therapist will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program. You should be able to get back to normal activities. If you are an athlete, you will be guided through rehab specific to your sport.
It is important to properly rehab the tendon after you recover from the injury or the injury will return.
Questions About Achilles Tendonitis
• Q. How long do you have to wear walking boot?
A. How long you have to wear a walking boot will depend on how bad your injury is. Your first follow-up visit will likely be in 2 weeks after wearing the boot. If you still have problems, then you will likely wear the boot for a month and then follow-up with your doctor. If you still need the boot after two weeks, you may also be started on physical therapy which includes massage, and stretching exercises. The purpose of the boot is to rest the tendon.
The downside is you can lose muscle tone in your foot and calf from lack of use. You should wear the boot except to sleep at night. Achilles tendonitis can be caused by calf muscle inflexibility. Even when you’re sitting, wearing the boot will position your foot to keep your calf muscles in a slight stretch. Your doctor or PT may also prescribe a night boot for you to sleep in. The night boot is softer than the walking boot and is designed to keep a constant, slight stretch on your calf muscles. Because of the poor blood supply in this area, Achilles tendonitis can heal very slowly.
Without following proper treatment, you can injure the Achilles even more possibly requiring surgery, a cast and crutches.