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Achilles Tendon Injuries

What is the Achilles tendon?

A tendon is a band of tissue that connects a muscle to a bone. The Achilles tendon or the calf tendon is a band of tissue that connects the heel bone to the calf muscle of the leg. It is considered the largest tendons in the body. Also known as the “heel cord”, the Achilles tendon facilitates walking by helping to raise the heel off the ground. Our calf comprises of 2 major muscles, the gastrocnemius which is a more superficial muscle that originates from above the knee joint and the other, soleus which is of the deeper layer and originates from below the knee joint.

What sorts of injury can happen to the Achilles tendon?

As the Achilles tendon plays significant roles in human mobility and can withstand great stresses from running and jumping, there are quite a number of injuries that can potentially occur to the tendon, these include:

  • Non-insertional Achilles tendinopathy

  • Insertional Achilles tendinitis

  • Haglund deformity

  • Retrocalcaneal bursitis

  • Peritendinitis, calf strain, calcified tendon, tearing or rupturing of tendon

  • Calf cramps, intermittent claudication, rest pain

  • Compartment syndrome

  • Condition-related to systemic cause such as rheumatoid or inflammatory arthritis, seronegative spondyloarthropathies, Reiter's syndrome

Out of the listed conditions, Achilles tendinopathy/tendonitis will be the most common condition occurred to a vast population. As such, this writing will be focusing more on this condition.

What is Achilles tendonitis/ Achilles tendinopathy?

It is first important for us to learn more about some of the terminology to avoid any confusion. The terms, tendonitis, tendonosis, and tendinopathy can sometimes be used interchangeably and causes misunderstanding. To keep it simple,

Tendonitis – inflammation of the tendon.

Tendonosis – degeneration of the tendon, where tendon loses its organized structure and is likely to develop microscopic tears.

Tendinopathy – impaired performance, swelling and tendon pain.

For the purpose of this writing, Achilles tendinopathy will be used.

Achilles tendinopathy is a painful condition characterised by tissue damage, swelling and pain in the Achilles region.

There are two types of Achilles tendinopathy, based upon which part of the tendon is damaged.

Non-insertional Achilles tendinopathy

In non-insertional Achilles tendinopathy, the fibers in the middle portion of the tendon have begun to break down with tiny tears, degenerated, swell and thicken. It commonly affects the younger and active population.

Insertional Achilles tendinopathy

Insertional Achilles tendinopathy involves the lower portion of the heel, where the tendon attaches or inserts to the heel bone. It can occur at any time, even in patients who are not active.

In both non-insertional and insertional Achilles tendinopathy, damaged tendon fibers may also calcify and become hardened. Bone spurs often form with insertional Achilles tendinopathy.

How does Achilles tendinopathy occur?

Achilles tendinopathy usually results from the following factors:

  • Overuse, repetitive stress to the tendon – a sudden increase of a repetitive activity or prolonged stress on ankles and feet.

  • Excessive pronation, a problem where your feet roll inward and flatten out more than normal when you walk or run.

  • Poor footwear.

  • Unfavorable surface conditions/training errors.

  • Poor muscle flexibility (tight or weak calf muscles).

  • Decreased joint range of motion (stiff ankle joint).

  • Trauma (falling or tripping).

What are the symptoms?

Common symptoms of Achilles tendinopathy include:

  • Pain and stiffness along the Achilles tendon in the morning, limited ankle range of motion.

  • Pain along the tendon or back of the heel that worsens with activity and when you stretch the tendon.

  • Severe pain the day after exercising.

  • Thickening of the tendon.

  • Bone spur.

  • Swelling that is present all the time and gets worse throughout the day with activity.

IMPORTANT: If you have experienced a sudden “pop” in the back of your calf or heel, you may have ruptured or torn your Achilles tendon. You will be unable to lift your heel off the ground or point your toes. It is best to visit your podiatrist immediately to prevent further complications.

How is it treated?

In most cases, conservative treatments will provide pain relief, although it may take a few months for symptoms to completely subside. Even with early treatment, the pain may persist. Common management options include:

Rest. The first step in reducing pain is to decrease or even stop the activities that make the pain worse. If you regularly perform high-impact activities such as running or netball, switching to low impact activities will put less stress on the Achilles tendon. Cross-training activities such as biking and swimming are some of the low-impact options you can perform temporarily to help you stay active.

  • Ice. Put ice packs on the Achilles tendon for 20-30 minutes every 3 to 4 hours for the first 2 or 3 days or until the pain goes away. Ice should be stopped earlier if the skin becomes numb. It is always a good idea to use a thin cloth between the ice and the skin.

  • Elevation. Raise your lower leg on a pillow when you are lying down to assist in the reduction of swelling.

  • Non-steroidal anti-inflammatory medication. Medications such as ibuprofen can reduce pain and swelling.

  • Stretching and strengthening exercises. Those exercises can be extremely helpful in addressing muscle stiffness, tightness and preventing further complications.

  • Dry needling. Dry needling is often indicated to complement the exercises prescribed to address muscle tightness, inflammation, and swelling.

  • Heel lift. Heel lift may be supplied to wear until your tendon heals and possibly longer. The lift prevents extra stretching of your Achilles tendon.

  • Use of supportive footwear and orthotic therapy. It is important to assess the biomechanics of the lower limb in the management of this condition. Orthotics may be recommended to address any relevant biomechanical problem.

How can I prevent Achilles tendinopathy?

The best way to prevent Achilles tendon injury is to stretch your calf muscles and Achilles tendon before exercise. If you have tight Achilles tendons or calf muscles, stretch them twice a day regardless if you are doing any sports activities that day. If you have a higher risk of Achilles tendinopathy, avoid running uphill a lot and wear supportive footwear.

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