Achilles tendon is the largest tendon in the body. It connects the calf muscles to the heel and is active during almost all activities including walking, jumping, and swimming. This dense tendon can
withstand large forces, but can become inflamed and painful during periods of overuse. Pain results from inflammation (tendonitis) or a degenerating tendon (tendinosis). Achilles tendon pathologies
include rupture and tendonitis. Many experts now believe, however, that tendonitis is a misleading term that should no longer be used, because signs of true inflammation are almost never present on
histologic examination. Instead, the following histopathologically determined nomenclature has evolved. Paratenonitis: Characterized by paratenon inflammation and thickening, as well as fibrin
adhesions. Tendinosis: Characterized by intrasubstance disarray and degeneration of the tendon.
Over-pronation, injury and overstresses of the tendon are some of the most common causes. Risk factors include tight heel cords, poor foot alignment, and recent changes in activities or shoes. During
a normal gait cycle, the upper and lower leg rotate in unison (i.e. internally during pronation and externally during supination). However, when a person over-pronates, the lower leg is locked into
the foot and therefore continues to rotate internally past the end of the contact phase while the femur begins to rotate externally at the beginning of midstance. The Gastrocnemius muscle is attached
to the upper leg and rotates externally while the Soleus muscle is attached to the lower leg and rotates internally during pronation. The resulting counter rotation of the upper and lower leg causes
a shearing force to occur in the Achilles tendon. This counter rotation twists the tendon at its weakest area, namely the Achilles tendon itself, and causes the inflammation. Since the tendon is
avascular, once inflammation sets in, it tends to be chronic.
Common symptoms of Achilles tendinitis include, pain and stiffness along the Achilles tendon in the morning, pain along the tendon or back of the heel that worsens with activity, Severe pain the day
after exercising, thickening of the tendon, bone spur (insertional tendinitis) swelling that is present all the time and gets worse throughout the day with activity, If you have experienced a sudden
"pop" in the back of your calf or heel, you may have ruptured (torn) your Achilles tendon. See your doctor immediately if you think you may have torn your tendon.
Your physiotherapist or sports doctor can usually confirm the diagnosis of Achilles tendonitis in the clinic. They will base their diagnosis on your history, symptom behaviour and clinical tests.
Achilles tendons will often have a painful and prominent lump within the tendon. Further investigations include US scan or MRI. X-rays are of little use in the diagnosis.
Proper footwear with a strong and secure counter (the heel circumference) may help to encourage heeling of the tendon. A tendinitis will occasionally resolve on it?s own, with rest, ice, and gentle
stretching. If symptoms persist for more than 2 weeks, consult your physician. Your physician may suggest physiotherapy and custom orthotics. Physiotherapy can suggest appropriate exercises and
modalities to aid in the healing process. Custom orthotics can be very successful in treating the problem, as the original cause may be due to an improper alignment of the foot and heel. Re-aligning
the foot to a neutral position may provide an optimal, biomechanically sound environment for healing to occur.
Surgery is considered when non-operative measures fail. Patient compliance and postoperative management is an important aspect of the operative management to prevent ankle stiffness or recurrence of
the symptoms. Surgery usually requires a removal of the damaged tissue (debridement) and meticulous repair of the tendon. Post-operative immobilization is required, followed by gradual range of
motion and strengthening exercises start. It may require 6 months for the full recovery. Some known complication are recurrence, stiffness of the ankle and deep vein thrombosis.
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.