Achilles Tendon Injuries

Achilles Tendonitis and Achilles Tendon Rupture

Achilles tendinitis occurs when this large tendon becomes irritated and inflamed. The Achilles tendon is the connection of your calf muscles to the heel and is prone to overuse and wear and tear. Two type of tendinitis occur: Insertional and Non-insertional. Insertional Achilles tendinitis involves the area where tendon inserts to the heel bone (calcaneus), while non-insertional is related to the mid portion of the tendon swelling and thickening.

In both situations, the tendon fibers are thickened, inflamed and may calcify. Insertional Achilles tendinitis may also involve bone spurs of the calcaneus.

This injury typically occurs over time and is not likely due to a one-time event. Repetitive stress to the tendon and training errors are a more likely culprit.

Signs and Symptoms

Patients often report stiffness and pain that is worse in the AM, thickening of the tendon compared to the other side, swelling and pain that worsens with activity. A sudden “pop” in the back of the calf or heel is concerning for a rupture of the Achilles tendon, and urgent consultation is recommended.

Physical Examination and Work-up

On examination, range of motion may be limited, pain occurs with palpation of the tendon and the tendon is notably thickened. Weakness may or may not be present.  

In the case of a rupture, a palpable loss of tendon will be present. 

Thompson Test: while lying on your stomach with feet hanging over the end of the exam table, the examiner squeezes the calf muscle to see if the foot will automatically flex. If it doesn’t, this finding is consistent with a ruptured Achilles tendon.

Imaging

X-rays are utilized to rule out an avulsion fracture of the Achilles and will also demonstrate calcification of the tendon, if present. An MRI is most helpful in planning for a surgical intervention but is often not necessary to make a diagnosis of Achilles tendinitis.

Management of Achilles Tendinitis

Non-operative care includes rest, NSAIDs, physical therapy, and activity modification are the first line of treatment for Achilles tendinitis. Even with physical therapy, symptoms may persist longer than 3 months. Physical therapy includes both hands-on treatment (manual therapy), along with an eccentric strengthening protocol. Cortisone into the Achilles tendon are rarely recommended because they can cause the tendon to rupture.

In the setting of insertional Achilles tendinitis, shoe wear may exacerbate the symptoms and orthotics, alternate shoes or heel lifts may be recommended. 

Surgery for Achilles tendinitis, such as debridement, is rarely needed and may be considered in the setting of failed nonsurgical treatment. The specific type of surgery depends on the location of the tendinitis and the amount of damage to the tendon.

Management of Achilles Tendon Ruptures

Repair of the Achilles tendon involves creating an incision in the back of the lower leg and stitching the torn tendon together. Depending on the extent of injury, the repair might be reinforced with other tendons incorporated into the repair. Physical therapy is an essential component of the rehabilitation process, and a strict protocol is prescribed.