Achilles Tendonitis

Achilles was a Greek warrior who fought in the Trojan War. According to legend, as an infant his mother could make him invulnerable to injury by dipping him in the waters of the River Styx. Unfortunately, she held him upside down in the water by his heel, leaving that area unprotected. As fate (or the Gods) would have it, he was struck in that same heel with an arrow during the battle, and was killed. The term “Achilles heel” has become a synonym for weakness.

Anatomy
The Achilles' tendon is the largest tendon in the body. It connects the muscles in the back of the calf to the back of the heel. It is the major plantar flexor of the ankle. However, it is not the only one. There are other muscles in the leg that can also plantar flex the ankle.

The tendon itself is a thick structure made of long fibers of collagen, a complex compound that makes up the “connective tissues” in our bodies. This tendon originates proximally off the posterior calf muscles, the gastrocnemius and the soleus. It then runs down to the back of the heel bone, the calcaneus, where it inserts, or attaches into the bone. All tendons have a surrounding structure, the tendon sheath, that provides nourishment for the tendon, and lubrication so that the tendon can glide back and forth.

Like any tendon the Achilles tendon can become irritated. Sometimes this will occur if there has been a change in activities, a change in shoewear, or a significant change in the surface that you are walking on or running on. Sometimes it seems to develop without any preceding clause.

Achilles tendonitis can occur in a variety of ways. There may be irritation in the substance of the tendon itself, or in the tendon sheath. In some cases the irritation can progress to a partial tear in the tendon. If the irritation occurs where the tendon is attaching to the calcaneus it is considered “insertional tendonitis”.

With irritation of the tendon there may be a growth of bone at the insertion, called a “bone spur”. If the bone forms in the tendon itself above the insertion it is called “calcific tendonitis”.

The physical examination can help to differentiate between these different types of tendonitis. There may be a "bump" that is visible or can be felt through the skin.  The bump may be off of the heel bone, or part of the Achilles tendon. 

Plain XRays also are important in the evaluation. They should be obtained in the evaluation of all patients with this problem.

In some instances it may be helpful to obtain an MRI study to assess for a partial tendon tear.

Treatment
The treatment for Achilles tendonitis is primarily non-surgical. Changing activities and shoewear, rest, oral anti-inflammatory medications, immobilization in a CAM Walker and physical therapy are all useful in treating this problem. Most commonly some combination of these modalities will give relief and full return to function.

Surgical treatment is reserved for patients who do not improve with conservative treatments. Types of surgical treatments include excision of partial tears, excision of bone spurs, and excision of areas of calcification in the tendon.

For a discussion of Surgical Treatment Go Here.

The Achilles tendon is one area where cortisone injections should be avoided. Cortisone has a significant chance of causing the Achilles tendon to rupture.