Figure 28

Figure 29

Figure 30

Figure 31

Problems that affect the Achilles tendon are common among active middle-aged people. The problems cause pain at the back of the calf and can result in a rupture of the Achilles tendon in severe cases.

Anatomy

The Achilles tendon is a strong, fibrous band that connects the calf muscle to the heel. The calf is actually formed by two muscles, the underlying soleus and the thick outer gastrocnemius. Together, they form the gastroc-soleus muscle group. When they contract, they pull on the Achilles tendon causing your foot to point down and helping you raise up on your toes. This powerful muscle group helps when you sprint, jump, or climb. Several different problems can affect the Achilles tendon — some rather minor and some quite severe.

Tendocalcaneal Bursitis: A bursa is a fluid-filled sac designed to limit friction between rubbing parts. These sacs, or bursa, are found in many places in the body. When a bursa becomes inflamed, bursitis results. Tendocalcaneal bursitis is an inflammation in the bursa behind the heel bone. This bursa limits friction where the thick fibrous Achilles tendon that runs down the back of the calf glides up and down behind the heel. (Figure 28: picture of enlarged Achilles tendon)

Achilles Tendinitis: A violent strain can cause injury to the calf muscles or the Achilles tendon. This can happen during a strong contraction of the muscle, as when running or sprinting. Landing on the ground after a jump can force the foot upward, also causing injury. The strain can affect different portions of the muscles or tendon. For instance, the strain may occur in the belly of the muscle. Or it may happen where the muscles join the Achilles tendon (called the musculotendinous junction).

Achilles Tendon Rupture: In severe cases, the force may even rupture the tendon. The classic example is the middle aged tennis player or “weekend warrior” who places too much stress on the tendon and experiences a rupture of the tendon. In some instances, the rupture may be proceded by a period of tendinitis, which renders the tendon weaker than normal. (Figure 29: picture of rupture)

Symptoms

Tendocalcaneal bursitis begins with pain and irritation at the back of the heel. There may be visible redness and swelling in the area. The back of the shoe can further irritate the condition, making it difficult to tolerate shoes. Achilles tendinitis usually occurs farther up the leg, just above the heel bone itself. The Achilles tendon in this area can be noticeably thickened and tender to the touch. Pain is present with walking, especially when pushing off on the toes.

Finally, Achilles tendon rupture is usually an unmistakable event. Some bystanders may report actually hearing a snap, and the victim of a rupture usually describes a sensation like “someone kicked me in the calf.” Following rupture there can be swelling in the calf and usually the patient cannot raise up on the toes.

Diagnosis

Diagnosis is almost always made based on clinical history and physical examination. In cases which there is an Achilles tendon rupture in question, an MRI scan may be necessary to confirm the diagnosis (but this is seldom the case).

Medical Treatment

Medical treatment for tendocalcaneal bursitis and Achilles tendinitis usually consists of a combination of rest, anti-inflammatory medication, and physical therapy (below). A cortisone injection for this condition is NOT indicated, due to increased risk of rupture of the tendon following the injection. Frequently, a cast will be recommended if the pain has been longstanding and is severe.

Non-operative treatment for an Achilles tendon rupture is somewhat controversial. It is clear that treatment with a cast will allow the vast majority of the tendon ruptures to heal but the incidence of re-rupture is increased in those patients treated with casting for 8 weeks when compared with those undergoing surgery. In addition, the strength of the healed tendon is significantly less in patients who elect cast treatments. For these reasons, many orthopedists and podiatric surgeons feel that Achilles tendon ruptures in younger active patients should be repaired surgically.

Surgery

In severe cases of Achilles tendinitis, surgery can be necessary. Surgery involves removing any inflammatory tissue around the tendon and heel bone. If the tendon is enlarged, it is debulked or made smaller. Some of the heel bone, which may have enlarged, is then removed. The injured tendon is then repaired with suture. Often, if a large amount of the tendon is removed off the heel bone, a small metal anchor is inserted into the heel bone to help anchor or reattach the Achilles tendon to its original position. (Figure 30: picture of enlarged tendon with calcaneal excision)

For tendons that have ruptured or actually torn completely through, surgery is used to assess the damage and to bring the ends of the ruptured tendon together. The ends of the tendon are usually frayed and the surgeon will meticulously repair the ends with suture. (Figure 31: picture of repaired rupture)

Rehabilitation

Early Healing Phase

Several treatment choices are available in the early stages of Achilles tendinitis or tendocalcaneal bursitis. The rehabilitation following rupture of the tendon is quite different.

Ice: Ice can be used in the first moments after this type of injury to calm inflamed bursae. A bag of crushed or cubed ice secured with an elastic wrap works well. Initially, this should be used for periods of 15 minutes hourly. Treatment in a cold-temperature whirlpool may be chosen for your condition. The cold water helps reduce swelling and pain and the turbulence of the whirlpool provides a massage action. In supervised therapy, you may continue to be treated with either an ice bag, cold pack, or ice massage.

Rest: An injury like this needs to be rested. This can be done by limiting activities like walking on the sore leg. A small (1/8″ – 1/4″) heel lift placed in your shoe can minimize stress by putting slack in the calf muscle and Achilles tendon. Be sure to place a similar lift sized in the other shoe to keep everything aligned.

Late Healing Phase

To continue addressing pain and swelling, a progressive treatment can be used to assist in overall healing.

Modalities: Your physical therapist has several techniques or modalities to help ease pain and to promote early healing. Examples can include a contrast bath, ultrasound, or friction massage.

Contrast Bath: Switching between a heat and cold source is an effective way to remove bruising and promote healing. This can be done with hot or cold packs or by placing the limb alternately in two whirlpools, one hot and one cold.

Ultrasound: The high-frequency sound waves from the ultrasound assist in healing by promoting blood flow, removing painful waste products from the injured area, and preparing the area to be stretched.

Friction Massage: Your physical therapist may begin applying friction massage by rubbing across the sore area. This can stimulate an increase in blood flow and assist in strengthening the underlying tissues.

Range of Motion: Gently bringing the toes and foot upward places a mild stretch on the calf muscles and Achilles tendon. This helps keep the tissue mobile and adds to overall healing. Do not pull the foot up so hard that you increase the pain.

Stretching: Low-level stretching may be used at this time. Your therapist can perform this manually and you may be shown a calf stretch. Stand in front of a wall with the sore foot placed slightly behind. Supported with your arms against the wall and keeping your heel on the ground, lean forward slowly and carefully until a mild stretch is felt in the calf. Hold 15 to 30 seconds, repeating 3 to 5 times.

Early Strengthening: Several exercises can be used safely at this point to begin stimulating healthy blood flow to the sore area and preparing for more advanced strengthening. (Could include therapeutic band plantarflexion; assisted heel raises).

Treadmill walking: Use of a treadmill with a slight and progressive elevation requires full movement of the foot in an upward direction. This assists with overall motion while providing endurance and conditioning. Taping: If you must be up and active, a special taping technique can be used along with your heel lift. This approach reinforces the sore area and prevents over-stressing the calf muscles.

Orthotics: Following an evaluation of foot structure and function, a shoe inset or orthotic could be needed. In most instances, a soft, accommodating orthotic will be used to reduce shock absorption for a supinated or rigid foot. This ultimately takes stress off of the foot and Achilles tendon.