Achilles Tendon Injuries
Achilles tendon injury is a common condition that causes pain along the back of the leg near the heel (calcaneus) bone where it inserts. The Achilles tendon is the thickest and strongest tendon in the body and the forces from toeing off (up to 3 times your weight) are taken in by the Achilles. Uphill running and fore foot striking and jumping put extra stress on the tendon.
Overuse of the tendon can lead to tendon injury. A sudden increase in activity, tight calf muscles and presence of bone spurs can lead to tendon damage. Most overuse injuries are commonly called tendonitis by runners. Tendonitis is an inflammation of the tendon usually caused by a sudden force. Chronic use usually causes degeneration, which is accurately called tendinosis. Most overuse injuries to tendons caused by running are actually tendinosis rather than tendonitis. It can be important to distinguish because the treatment may be different if dealing with inflammation rather than degeneration. In the first few weeks of Achilles pain, there may be inflammation, but if pain is chronic there is a degenerative process.
The Achilles tendon has two areas where problems commonly occur. When the middle portion of the tendon is involved, it is termed noninsertional and this affects younger, active people and is more common. Pain at the junction of the tendon and calcaneus is insertional tendinitis/tendinosis and can be more difficult to treat. There can be calcification of the tendon in any area affected.
Common symptoms of Achilles pain include: pain and stiffness in the morning and worsening pain with exercise, thickening of the tendon and swelling. If there was an injury with a pop or sensation of a tear or there is a lot of sudden swelling, an Achilles rupture should be considered. An x-ray may be done to rule out bone spurs and calcification within the tendon. Usually MRI is not necessary. An ultrasound can be done in the office to see the fibers of the tendon.
Nonsurgical treatment is the mainstay of Achilles tendinitis and tendinosis. Conservative measures such as ice and rest are started. This may mean simply backing off on some mileage as opposed to stopping running, but cross training is encouraged. Physical therapy is very helpful and will concentrate on eccentric strengthening, which means strengthening the tendon and muscles as it lengthens (as opposed to concentric strengthening, which is strengthening as a muscles shortens--think bicep curls). Eccentric heel drops with both straight knee and bent knee are evidence based and a mainstay of treatment. Graston (soft tissue mobilization with an instrument) may be done at physical therapy as well. Cortisone injections are not recommended because they can lead to tendon rupture in the Achilles. Some patients find relief with heel lifts or orthotics or shoes with more drop. In severe cases, immobilization with a boot may be recommended. Ultrasound-guided percutaneous procedures may be done in the office for some cases unresponsive to the above therapy. PRP (platelet rich plasma) injections can be helpful and stem cells are still being investigated for use and may be found helpful. Surgery is very rarely done.
Return to running after an Achilles injury depends on the severity. A mild tendonitis may mean only a few days off from athletics and returning while working on heel drops. But a more chronic tendinosis or severe case may take longer to heal. Generally, when an athlete can run and jump with minimal pain and is not changing their gait due to the issue, they may return to a modified program.