The Achilles tendon is the largest tendon in the human body. It is located at the back of the ankle joint and can be felt as a large, cord-like structure attaching to the back of the foot. Since tendons serve to attach muscles to bone, the Achilles tendon also attaches the large calf muscles, the gastrocnemius and soleus, to the back of the heel bone, the calcaneus.
The muscle mass and strength of the gastrocnemius and soleus muscles are greater than all of the other muscles of the lower leg combined. Therefore, the pull of these muscles on the Achilles tendon is very large since these muscles help balance the body while standing, push the body forward during walking, spring the body forward during running, and spring the body upward during jumping. Because of the large amount of stress which the Achilles tendon is subjected to during running and jumping activities, the Achilles tendon is prone to injury.
The most common form of injury to the Achilles tendon is called Achilles tendinitis, which is an inflammatory condition causing pain in the Achilles tendon. Achilles tendinitis generally occurs in people who are active in sports activities. Types of sports that commonly are associated with Achilles tendinitis are basketball, tennis, running, football, soccer, volleyball and other running and jumping sports.
Achilles tendinitis tends to occur more frequently in older athletes than in younger athletes. As a person ages into their thirties and especially into their forties and fifties, the ligaments and tendons of the body tend to lose some of their stretchiness and are not as strong as before. This predisposes older individuals who are active in running and jumping activities, to tendon injuries such as Achilles tendinitis. However, Achilles tendinitis can also occur in teenagers who are very active in running and jumping sports.
Achilles tendinitis is diagnosed by a history and physical examination of the patient who describes pain at the back of the ankle with walking and/or running activities. The pain generally will be associated with an increase in running or jumping intensity or frequency. It is also often associated with a change from running in a thick heeled shoe to a thin heeled shoe, such as going from training shoes to racing flats and/or racing spikes in cross-country and/or track. The pain from Achilles tendinitis is often so severe that running is impossible and even walking is uncomfortable.
During the physical examination, the podiatrist will feel and push lightly around the Achilles tendon to see if it is tender or has any irregularities in its surface. Achilles tendinitis may cause the tendon to be thickened in areas, may cause swelling of the area around the tendon, and can even feel like the tendon has a painful bump on it. In addition, the person with Achilles tendinitis will limp while barefoot, but walk more normally with heeled shoes on. X-rays are not helpful in diagnosing Achilles tendinitis but may be taken to rule-out other pathology. MRI scans are only indicated if a partial or complete rupture of the Achilles tendon is suspected by the podiatrist.
Achilles tendinitis generally responds very well to conservative treatment as long as it is diagnosed and treated early. Surgery is rarely indicated unless the Achilles tendinitis is particularly severe and chronic, or if the tendon has ruptured completely.
Initially, the podiatrist may treat the Achilles tendinitis by putting heel lifts into the patient’s shoes. In addition, the patient may be asked to avoid barefoot walking or walking in low-heeled shoes. Non-steroidal anti-inflammatory drugs (NSAID’s) such as Ibuprofen (Motrin, Advil) and Naproxen (Naprosyn, Aleve) may also be prescribed to calm the inflammatory process in the tendon. Icing may be suggested to help decrease the inflammation and pain in the tendon. Stretching exercises for the calf muscles may also be given to the patient to help loosen the calf muscle and Achilles tendon so that the tendon is not under as much stress during normal daily walking activities. The stretching should not be done however if it causes pain in the Achilles tendon.
Initially, the patient with Achilles tendinitis will be asked to modify their activities to decrease their running and jumping activities and do alternative physical activities, such as swimming, which don’t put as much stress on the Achilles tendon. As the tendon starts to feel better, the podiatrist will allow a gradual return to normal running and jumping activities. If normal return to activities is not possible within a few weeks, then many times the podiatrist may additionally prescribe physical therapy and/or functional foot orthotics to help the tendon heal more rapidly. The foot orthotics generally are used during both the sports activities and walking activities to allow for more normal foot and Achilles tendon function. If the physician is concerned about a partial tear of the tendon the patient may be placed in a below the knee cast. It can take several weeks or even months for the tendon to heal depending upon the severity of the injury to the tendon. It is not uncommon for a patient to return to activities too quickly and re-injure the tendon. Careful monitoring of a return to full activity is important and the patient must have patience during this period of time.
Neglected Tendo-Achilles rupture is one that Dr. Parker devised a new combination for the repair of a tendon that was not treated properly or felt by the initial doctor that surgery was not necessary. It is quite a procedure and requires three months of recovery. Dr. Parker warns that the innocent neglect of Achilles tendinitis predisposes to potential rupture, usually four weeks after the inflamed tendon and usually in the “weekend warrior” athlete.
In this case, simple end to end coaptation is not possible in the neglected ruptures and the modified Strayer’s or Baker “tongue in groove” gastrocnemius recession that was first used for short “heel cords” was first modified by Dr. Parker in 1976 to develop a clean sliding flap to accomplish reapposition and repair of the tendinous ends as seen below.
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