What is an Achilles tendon injury?
An Achilles tendon injury may be diagnosed as either inflammation of the Achilles tendon (tendonitis), chronic degeneration of the Achilles tendon (tendinopathy) or a complete or partial tear of the Achilles tendon (rupture). These types of injuries usually occur during explosive foot motion during physical activity, or from impact, such as tripping or falling.
The Achilles tendon is the largest, thickest tendon in the body. It is best described as a strong, fibrous, cord-like band of tissue that runs down the lower part of the back of the leg. The Achilles tendon can easily be felt by feeling the back of your lower leg, right above the heel bone. It connects the lowermost of your calf muscles (specifically the plantaris, gastrocnemius and soleus) to the back of the heel bone (the calcaneus). The Achilles tendon’s function is to enable walking, by causing the heel to lift up and the toes to point downwards (known as plantar flexion) as the calf muscles contract, as well as facilitating knee flexion. In cases where an Achilles tendon injury has occurred, the patient will likely be having difficulty or pain walking, because this important function is inhibited.
What are the risk factors for an Achilles tendon injury?
There are certain factors that put a person at greater risk of suffering an Achilles tendon injury:
- Age: risk increases with age, particularly people over 30 years old
- Sex: males are at greater risk
- Bodyweight: those that carry excess body weight or are obese are at greater risk of Achilles tendon injury
- People that participate in sports that require the player to carry out explosive or forceful movements, such as jumping or quick pivoting, or sudden acceleration or stopping when running. Examples of such sports include soccer, basketball, tennis, volleyball and others.
- People that often wear high heels, placing extra stress on the Achilles tendon
- People with pes planus, or “flat feet”, because when the person takes a step, the foot arch flattens, which causes pulling on the muscles and tendons in the lower leg
- Those who have poor flexibility in the muscles and tendons of the lower leg and the foot
- Those who are taking particular medications, specifically corticosteroids or fluoroquinolone antibiotics, which are thought to weaken the tendon and lead to Achilles tendon injury.
What are the signs and symptoms of an Achilles tendon injury?
If you have suffered an Achilles tendon injury, you may experience pain in the area of the Achilles tendon either during or immediately following exercise. The pain is usually localized and may be dull and achy, or sharp and sudden, depending on the type of Achilles tendon injury you have. Some people describe feeling weakness or stiffness at the back of the heel. Symptoms will vary depending on the type of Achilles tendon injury, however difficulty walking, especially uphill, tends to be a common problem.
Signs of Achilles tendonitis
In addition to the signs and symptoms mentioned above, in an Achilles tendon injury that may be tendonitis, the patient would likely experience:
- Redness that is visible to the naked eye
- Tenderness and warmth in the sore area
- At a cellular level, there is an active inflammatory process occurring.
Signs of Achilles tendinopathy
With an Achilles tendon injury that may be tendinopathy, the patient may experience:
- Pain and stiffness in the Achilles tendon area, which is worse at night or first thing in the morning
- Loss of strength in the affected area
- Possible presence of a lump
- At a cellular level, there is no active inflammatory process, and eventually the cells become disorganized and weakened, which can lead to micro-tearing and eventually rupture of the Achilles tendon.
Signs of Achilles tendon rupture
If the nature of the Achilles tendon injury is a rupture, it is probable that the patient will experience a sudden pain that feels like a strike or snap at the back of the heel. The pain is usually sharp before subsiding to a dull throb.
If any of the symptoms stated above are experienced and an Achilles tendon injury is suspected, it is important to seek medical attention as soon as is practical. If the pain is due to Achilles tendonitis, with proper prompt treatment under a suitably qualified sports podiatrist, the patient will often return to exercise within a few short weeks. However, if the pain is ignored and inappropriately managed, Achilles tendinopathy may occur, and in severe degenerative cases Achilles rupture may result, which carry poorer recovery outcomes and significantly longer recovery times.
The RICE method is helpful in avoiding further Achilles tendon injury until a doctor can be seen:
- Rest – keep off the injured foot and ankle; use crutches if they are available
- Ice – a covered ice pack should be applied for 20 minutes at a time to reduce swelling at the site of the Achilles tendon injury
- Compression – an elastic bandage can be used to apply comfortable, firm pressure on the injured foot
- Elevation – lay down or sit with the injured foot propped up so that it is elevated above the level of the heart; this helps to reduce swelling.
How is an Achilles tendon injury diagnosed?
Your sports podiatrist will have a great deal of expertise in diagnosing the different types of Achilles tendon injury. The process is usually straightforward. Your sports podiatrist will conduct a detailed assessment, including making enquiries as to when and how the Achilles tendon injury occurred, whether or not you have injured the tendon before, or if you have ever experienced any similar symptoms. They will evaluate your muscle strength, flexibility and range of motion in the injured foot compared to the healthy one, and palpate the area around the tendon to feel for any abnormalities or characteristic lumps that commonly occur with an Achilles tendon injury. Your sports podiatrist will probably perform a Thompson Test to determine if there is an Achilles tendon rupture. If it is deemed beneficial, medical imaging, such as an ultrasound, x-ray or MRI may be ordered so that your sports podiatrist can accurately visually assess the structures in the injured foot and exclude any other problems.
How is an Achilles tendon injury treated?
The treatment chosen for an Achilles tendon injury very much depends on the diagnosis (whether it is tendonitis, tendinopathy, or a rupture that is causing the problem) and the patient’s individual circumstances. Depending on the complexity and of the injury, the patient’s return to physical activity may be in just a few weeks from the beginning of treatment, or in more complicated cases (such as with a complete severe rupture) around 6 months.
Non-surgical treatments may be used to treat an Achilles tendon injury in cases where it is not a complete rupture. Depending on the severity of your Achilles tendon injury, your sports podiatrist may recommend any one or a combination of the following treatments:
- Bio-mechanical assessment
- NSAIDs: non-steroidal anti-inflammatory drugs that are available over the counter can help to reduce pain and inflammation
- Heel lifts inside the shoe and footwear changes
- Corticosteroid injections: which are usually ultrasound-guided in order to reduce the risk of the tendon rupturing. The purpose of these is also to reduce inflammation and pain
- Extracorporeal shock wave therapy (ESWT): high-frequency sound waves are directed into the injured tendon. This stimulates the healing process by signaling the brain, and often provides almost immediate pain relief
- Controlled Motion Ankle (CAM) boot, brace or a cast: to limit movement at the ankle and allow the tendon to heal over a period of time.
Surgery can sometimes be an advantageous method of treating Achilles tendon injury in cases where the problem is a rupture. Surgical intervention is beneficial because it is thought to decrease the likelihood of the Achilles tendon re-rupturing. Surgical repair is also associated with increased push-off strength in the foot and enhanced range of motion in the ankle. There are a number of surgical techniques employed by surgeons to repair the ruptured tendon. The surgeon will elect the best technique for the patient’s individual circumstances and Achilles tendon injury. Following surgery, the affected foot will be immobilized using a CAM boot, cast, or brace. This restraint allows the tendon some healing time before the patient is allowed to weight-bear on the foot again. All surgeries carry some risks, which the surgeon will discuss in detail with the patient, relevant to their individual circumstances before the decision is made to undergo any surgical treatment.
Physical therapy is an important component of the treatment plan for an Achilles tendon injury, regardless of whether the patient is being treated via a surgical or non-surgical approach. The patient is prescribed a series of safe and appropriate exercises to facilitate the strengthening of the muscles in the lower leg and the foot, and to improve the range of motion in the foot and ankle. It is imperative that the healing Achilles tendon is not over-stressed. The patient must follow their physical therapy plan strictly for the best possible healing outcome when rehabilitating an Achilles tendon injury.
The information published in the above article is for informational purposes only and should not be taken as general advice. If you are experiencing foot or ankle pain and suspect that you may have suffered an Achilles tendon injury, you should consult with a suitably qualified sports podiatrist promptly to discuss your concerns. You can make an appointment by emailing email@example.com or by calling 82110600.
Karl Lockett– sports podiatrist.