All About Achilles Tendinitis

Overview
The Achilles is a large tendon that connects two major calf muscles to the back of the heel bone. If this tendon is overworked and tightens, the collagen fibres of the tendon may break, causing inflammation and pain. This can result in scar tissue formation, a type of tissue that does not have the flexibility of tendon tissue. Four types of Achilles injuries exist, 1) Paratendonitis - involves a crackly or crepitus feeling in the tissues surrounding the Achilles tendon. 2) Proliferative Tendinitis - the Achilles tendon thickens as a result of high tension placed on it. 3) Degenerative Tendinitis - a chronic condition where the Achilles tendon is permanently damaged and does not regain its structure. 4) Enthesis - an inflammation at the point where the Achilles tendon inserts into the heel bone.

Causes
Sometimes Achilles Tendinitis is a result of sudden trauma, as you might encounter from playing sports, but you can also have Achilles tendon pain as a result of small, unnoticed, day-to-day irritations that inflame the tendon over time by a cumulative effect. In those with no history of trauma, Achilles Tendonitis is sometimes associated simply with long periods of standing. There are several factors that can cause the gradual development of Achilles Tendinitis. Improper shoe selection, particularly using high heels over many years, increases your odds of developing the condition. This is because high-heeled shoes cause your calf muscles to contract, leaving the tendon with a lot less slack in it. Inadequate stretching before engaging in athletic or other physically-demanding activities also predisposes you to develop the problem. This is especially true in "weekend athletes", individuals who tend to partake in excessive physical activities on an intermittent basis. Biomechanical abnormalities like excessive pronation (too much flattening of the arch) also tends to cause this condition. And it is much more common individuals with equinus. It is more common in the middle-aged, the out-of-shape, smokers, and in those who use steroids. Men get the condition more frequently than women. Those involved in jumping and high-impact sports are particularly vulnerable.

Symptoms
The onset of the symptoms of Achilles tendonitis tend to be gradual, with symptoms usually developing over a period of several days, or even weeks. Symptoms may include, Pain, this may be mild at first and may only be noticeable after exercise. Over time the pain may become constant and severe. Stiffness, this is usually relieved by activity. Sluggishness in the leg. Tenderness, particularly in the morning and most commonly felt just above where the tendon attaches to the heel bone. Swelling.

Diagnosis
A podiatrist can usually make the diagnosis by clinical history and physical examination alone. Pain with touching or stretching the tendon is typical. There may also be a visible swelling to the tendon. The patient frequently has difficulty plantarflexing (pushing down the ball of the foot and toes, like one would press on a gas pedal), particularly against resistance. In most cases X-rays don't show much, as they tend to show bone more than soft tissues. But X-rays may show associated degeneration of the heel bone that is common with Achilles Tendon problems. For example, heel spurs, calcification within the tendon, avulsion fractures, periostitis (a bruising of the outer covering of the bone) may all be seen on X-ray. In cases where we are uncertain as to the extent of the damage to the tendon, though, an MRI scan may be necessary, which images the soft tissues better than X-rays. When the tendon is simply inflamed and not severely damaged, the problem may or may not be visible on MRI. It depends upon the severity of the condition.

Nonsurgical Treatment
Achilles tendonitis will often respond to rest or changes in activity, stretching, or ice after activity. Non-steroidal anti- inflammatory drugs (NSAIDs), such as ibuprofen or naproxen may also help. Physical therapy focusing on stretching and strengthening, massage, alternating hot and cold baths, and ultrasound or sound waves can also help with healing and comfort. The temporary use of a heel lift or the insertion of an arch support, called an orthotic, into the shoe or sneaker can also help. Although seldom necessary, the ankle may be kept in a short leg cast or splint. Surgery is rarely needed but can remove bone spurs or the bony prominence of the heel bone. The injection of corticosteroids such as cortisone into the area of the Achilles tendon is usually avoided because it may cause the tendon to rupture.


Surgical Treatment
Occasionally, conservative management of Achilles tendon conditions fails. This failure is more common in older male patients and those with longstanding symptoms, those who persist in full training despite symptoms or those who have uncorrected predisposing factors. In these cases, surgery may be indicated. It should be remembered, however, that the rehabilitation program, particularly for severe Achilles tendon injuries, is a slow, lengthy program. Surgery is only indicated when there is failure to progress in the rehabilitation program. Surgery should not be considered unless at least six months of appropriate conservative management has failed to lead to improvement.

Prevention
The following measures can significantly reduce the risk of developing Achilles tendonitis. Adequately stretch and warm up prior to exercise. Warm down and stretch after exercise. Choose footwear carefully and use footwear appropriate to the sport being undertaken. Use orthotic devices in footwear to correctly support the foot. Exercise within fitness levels and follow a sensible exercise programme. Develop strong, flexible calf muscles.