Achilles Tendon Problems

Achilles Tendon Rupture

The Achilles tendon is the large cord like structure on the back of the leg just above the heel. It is the largest tendon in the body and has a tremendous amount of force transmitted through it during walking, running and jumping activities. The Achilles tendon is prone to injury, including rupture during periods of increased stress and activity. Common activities causing injury include running, basketball, baseball, football, soccer, volleyball and tennis. These activities require jumping and pushing forces that are possible due to the strength of the calf musculature and the ability of the Achilles tendon to endure this stress. Men from the ages of 30-50 are the most commonly injured during weekend athletic activities.

Anatomy

The Achilles tendon is the extension from the two large muscles in the calf region, the gastrocnemius and the soleus. These two muscles combine to form the Achilles tendon. The tendon forms in the lower one third of the leg and extends to the back of the heel bone (calcaneus). When the muscles of the calf contract this produces tension on the Achilles tendon pulling on the back of heel causing the heel to rise and the foot to point downward. It is during this motion that high-tension force is transmitted through the Achilles tendon during pushing and jumping activity. This high tension force can cause the Achilles tendon to tear or rupture. This happens in 3 common locations. The most common location for a tendon tear is within the tendon substance just above the heel. The second and third most common locations are where the Achilles tendon attaches into the heel bone and higher in the leg, where the tendon begins.

Symptoms and Diagnosis

Patients often describe a feeling of being kicked or hit with a baseball bat in the back of the heel during athletic activity. They are unable to continue the activity and have an extreme loss of strength with the inability to effectively walk. On physical examination there is often a defect that can be felt in the tendon just above the heel. A diagnosis of an Achilles tendon rupture is commonly made on physical exam. A MRI may be ordered to confirm the suspicion of a tear or to determine the extent of the tear.

Treatment

Early treatment is imperative for the best long-term outcome. Surgical repair is the most common treatment producing the greatest return to function and activity level. The goal of surgery is to realign the two ends of the ruptured tendon to allow healing. There are multiple techniques to accomplish this goal that will vary from surgeon to surgeon. Recovery from this injury is usually very successful with return to full function in approximately 6 months. Post operatively casting is required with the use of crutches or other means to remain non-weightbearing for 4-8 weeks. This is followed by a course of physical therapy. Partial rupture may or may not require surgical intervention depending on the extent of injury but cast immobilization is a common requirement.

Achilles Tendonitis

The Achilles tendon is the largest tendon in the human body. It is located at the back of the ankle joint and can be felt as a large, cord-like structure attaching to the back of the foot. Since tendons serve to attach muscles to bone, the Achilles tendon also attaches the large calf muscles, the gastrocnemius and soleus, to the back of the heel bone, the calcaneus.

The muscle mass and strength of the gastrocnemius and soleus muscles are greater than all of the other muscles of the lower leg combined. Therefore, the pull of these muscles on the Achilles tendon is very large since these muscles help balance the body while standing, push the body forward during walking, spring the body forward during running, and spring the body upward during jumping. Because of the large amount of stress which the Achilles tendon is subjected to during running and jumping activities, the Achilles tendon is prone to injury.

The most common form of injury to the Achilles tendon is called Achilles tendonitis, which is an inflammatory condition causing pain in the Achilles tendon. Achilles tendonitis generally occurs in people who are active in sports activities. Types of sports that commonly are associated with Achilles tendonitis are basketball, tennis, running, football, soccer, volleyball and other running and jumping sports.

Achilles tendonitis tends to occur more frequently in older athletes than in younger athletes. As a person ages into their thirties and especially into their forties and fifties, the ligaments and tendons of the body tend to lose some of their stretchiness and are not as strong as before. This predisposes older individuals who are active in running and jumping activities, to tendon injuries such as Achilles tendonitis. However, Achilles tendonitis can also occur in teenagers who are very active in running and jumping sports.

Diagnosis

Achilles tendonitis is diagnosed by a history and physical examination of the patient who describes pain at the back of the ankle with walking and/or running activities. The pain generally will be associated with an increase in running or jumping intensity or frequency. It is also often associated with a change from running in a thick heeled shoe to a thin heeled shoe, such as going from training shoes to racing flats and/or racing spikes in cross-country and/or track. The pain from Achilles tendonitis is often so severe that running is impossible and even walking is uncomfortable.

During the physical examination, the podiatrist will feel and push lightly around the Achilles tendon to see if it is tender or has any irregularities in its surface. Achilles tendonitis may cause the tendon to be thickened in areas, may cause swelling of the area around the tendon, and can even feel like the tendon has a painful bump on it. In addition, the person with Achilles tendonitis will limp while barefoot, but walk more normally with heeled shoes on. X-rays are not helpful in diagnosing Achilles tendonitis but may be taken to rule-out other pathology. MRIscans are only indicated if a partial or complete rupture of the Achilles tendon is suspected by the podiatrist.

Treatment

Achilles tendonitis generally responds very well to conservative treatment as long as it is diagnosed and treated early. Surgery is rarely indicated unless the Achilles tendonitis is particularly severe and chronic, or if the tendon has ruptured completely.

Initially, the podiatrist may treat the Achilles tendonitis by putting heel lifts into the patient’s shoes. In addition, the patient may be asked to avoid barefoot walking or walking in low-heeled shoes. Non-steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen (Motrin, Advil) and naproxen (Naprosyn, Aleve) may also be prescribed to calm the inflammatory process in the tendon. Icing may be suggested to help decrease the inflammation and pain in the tendon. Stretching exercises for the calf muscles may also be given to the patient to help loosen the calf muscle and Achilles tendon so that the tendon is not under as much stress during normal daily walking activities. The stretching should not be done however if it causes pain in the Achilles tendon.

Initially, the patient with Achilles tendonitis will be asked to modify their activities to decrease their running and jumping activities and do alternative physical activities, such as swimming, which don’t put as much stress on the Achilles tendon. As the tendon starts to feel better, the podiatrist will allow a gradual return to normal running and jumping activities. If normal return to activities is not possible within a few weeks, then many times the podiatrist may additionally prescribe physical therapy and/or functional foot orthotics to help the tendon heal more rapidly. The foot orthotics generally are used during both the sports activities and walking activities to allow for more normal foot and Achilles tendon function. If the physician is concerned about a partial tear of the tendon the patient may be placed in a below the knee cast. It can take several weeks or even months for the tendon to heal depending upon the severity of the injury to the tendon. It is not uncommon for a patient to return to activities too quickly and re-injure the tendon. Careful monitoring of a return to full activity is important and the patient must have patience during this period of time.

Xanthomas of the Achilles Tendon

An uncommon cause of small lumps in the Achilles tendon is an excessively high cholesterol level in the blood stream. This is a hereditary disorder that results in the deposition of cholesterol in the Achilles tendon. Frequently people will also have yellowish plagues on the lower eye lids, This is a serious condition and requires aggressive treatment by a physician to lower the cholesterol levels. Left untreated the high cholesterol levels can lead to premature heart attack and death.

Diagnosis

Diagnosis is made by clinical exam. Palpation of the Achilles tendon will reveal multiple small nodular masses. Noting excessively high blood cholesterol levels on routine lab tests provides conformation of the condition. A biopsy of the lesion will also make the diagnosis.

Treatment

The nodules in the Achilles tendon should be left alone. There is no value in removing them unless they are painful. Initial treatment should be directed at lowering the blood cholesterol levels.