A tendon is a band of tissue that connects a muscle to a bone. The Achilles tendon runs down the back of the lower leg and connects the calf muscle to the heel bone. This is also references as the heel cord. The Achilles tendon is the strongest tendon in the body and assists with walking/running to push off and move the foot in a downward (plantarflexion) position.
Achilles tendonitis is an acute inflammation of the Achilles tendon. This inflammation is typically short- lived and subsides with rest, ice, elevation, anti-inflammatories.
Over time, if the tendonitis is not resolved, the condition may progress to a degeneration of the tendon (Achilles tendonosis), in which the tendon loses its organized structure and develops microscopic tears at the insertion of the achilles tendon in the calcaneus (heel bone) and at times above the insertion of the achilles insertion point. In rare cases, chronic degeneration with or without pain may result in rupture of the tendon.
Achilles tendonitis and tendonosis can be caused by an increase of a repetitive activity involving the Achilles tendon (overuse disorder). This activity puts stress on the tendon too quickly, leading to micro-injury of the tendon fibers. Because of the ongoing stress on the tendon, the body is unable to repair the injured tissue. The structure of the tendon is then altered, resulting in continued pain to include:
- Athletes are at risk for developing disorders of the Achilles tendon due to repetitive stress.
- Laborers can develop Achilles tendonitis/tendonosis due to excessive stress placed on their foot/ankle.
- Weekend Warriors are at risk due to increasing stress to the achilles tendon because athletic events are participated only on weekends/infrequently and excessive strain is laced on the the achilles.
- –Excessive pronation (flattening of the arch) has a tendency to develop Achilles tendonitis/tendonosis due to the increasing demands placed on the tendon. The achilles moves towards the outside of the foot instead of it’s anatomical position on the inside during ambulation. Shoes without stability aggravates the achilles tendon as well as other portions of the foot/ankle.
Pain, stiffness, soreness, or tenderness within the tendon.
- This occurs anywhere along the tendons, starting with the tendon’s attachment directly above the heel upward to the region just below the calf muscle.
- Often pain appears when getting up in the morning or after periods of rest (post-static dyskinesia), and can improve somewhat with motion but then worsens towards the end of the day or with increased activity.
- Tenderness and/or intense pain is noted when the sides of the tendon are squeezed.
- At times there is less tenderness when pressing directly on the back of the tendon.
- When the disorder progresses to degeneration, the tendon may become enlarged and may develop nodules in the area where the tissue is damaged.
Haglund’s deformity is a bony enlargement on the back of the calcaneus (heel bone). The soft tissue adjacent to the Achilles tendon becomes irritated when the enlarged bone rubs against shoes. This leads to painful bursitis, which is an inflammation of the bursa (fluid-filled sac between the tendon and bone that normally protects these two structures from each other).
Haglund’s deformity is also refereed to the “pump bump” due to the rigid backs of pump-style shoes which can create pressure that aggravates the bone and the enlargement during ambulation. Other shoes with a rigid back can also cause this irritation. Some literature links Haglund’s deformity to a familial/hereditary cause. Foot structures that can make one prone to developing this condition include:
- high-arched foot
- tight Achilles tendon
- tendency to walk on the outside of the heel (supination)
- A bump on the back of the heel
- Pain in the area where the Achilles tendon attaches to the heel
- Swelling in the back of the heel
- Redness near the inflamed tissue
In diagnosing Achilles tendonitis, Achilles tendonosis and/or Haglund’s deformity; range of motion and the condition of the tendon will be evaluated as well as your surgeon gently pressing on areas of the tendon/calcaneus (heel bone) to determine the area of discomfort. The extent of the condition can be further assessed with x-rays or other imaging modalities.
X-rays will typically be ordered to rule out other injuries as well as evaluate the extent of the Haglund’s deformity. An MRI may be ordered to determine the extent of the pathology to the achilles tendon as well as determine surgical planning should surgery be warranted.
Non Surgical Treatment
Treatment approaches for Achilles tendonitis or Achilles tendonosis are based on how long the pathology has been present and the amount of damage to the tendon. Conservative treatment options are encouraged prior to surgical intervention.
Treatment of Haglund’s deformity is directed at reducing the inflammation of the bursa. While these approaches can resolve the pain and inflammation, the bony enlargement will not shrink or go away. Again conservative treatment options are encouraged prior to surgical intervention.
- Immobilization/Rest. Immobilization may involve the use of a short leg cast or removable walking boot to reduce the strain and forces going through the Achilles tendon as well as the irritation on the Haglund’s deformity.
- Ice. Apply an ice pack to the painful area as well as behind the knee placing a thin towel between the ice and the skin. Use ice for 20 minutes and then wait at least 40 minutes before icing again.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) may be helpful in reducing the pain and inflammation in the early stage of the conditions.
- At times a Nitroglycerin patch has been shown to reduce the inflammation and pain to the insertion point of the achilles as well as the inflamed bursa sac. It is recommended to cut the Nitroglycerin patches in stamp size portions and apply to the area once daily. If a headache occurs, please take Tylenol 600mg. Avoid taking Tylenol and NSAIDs at the same time.
- Orthotics. Custom orthotic devices may be prescribed for those with over-pronation or gait abnormalities to control the motion of the foot.
- Night splints. Night splints help to maintain a stretch in the Achilles tendon during sleep.
- Heel Lifts. Pads placed inside the shoe cushion and lift the heel and to reduce irritation and strain on the achilles during ambulation.
- Shoe modification. Backless or soft backed shoes help avoid or minimize irritation.
- Exercises. Stretching exercises help relieve tension from the Achilles tendon.
- Physical therapy. Physical therapy may include strengthening exercises, soft-tissue massage, mobilization, ambulation education, stretching, and ultrasound therapy to reduce inflammation.
If non-surgical approaches fail to restore the tendon to its normal condition, surgery may be necessary. Your surgeon will select the best procedure to repair the tendon and/or excise the bony enlargement, based upon the extent of the pain, the patient’s age and activity level, and other factors.
Surgery is typically an outpatient procedure (day surgery) and scheduled at your convenience.
A splint will be placed on your surgical foot/ankle after surgery. No weight to the surgical foot/ankle is advised until your surgeon encourages weight bearing (typically 6 weeks post surgery).