Achilles Tendinosis

Achilles tendinosis occurs when the achilles tendon degenerates and becomes inflamed. The tendon can swell and may cause pain. This condition is common in athletes, runners and patients who have calf tightness. Achilles tendinosis may occur in the middle of the tendon. This is known as midsubstance achilles tendinosis. It may also occur at the point where the tendon connects to the heel bone. This is known as insertional achilles tendinosis.

What are the symptoms of achilles tendinosis?
Many changes can be seen when the achilles tendon becomes inflamed. Patients have pain and/or tightness in the tendon behind the ankle. Most of the time there is no trauma or injury, but rather a slow progression of pain. Patients may have difficulty climbing stairs or running. Patients may also have pain after sitting for long periods or after sleeping. Many patients will notice a bump either in the tendon (midsubstance achilles tendinosis) or right behind the heel bone (insertional Achilles tendinosis). Some may also get irritation from shoes rubbing against the bump and feel better when wearing backless shoes. Patients also commonly have less pain while wearing a shoe with a slight heel versus shoes that are flat.

What causes achilles tendinosis?
Achilles and calf tightness is a common cause of achilles tendinosis. In addition, insertional achilles tendinosis is often associated with a heel bone spur. This spur may rub against the achilles tendon and lead to breakdown and small tears. It is similar to a rope being rubbed against a sharp rock. This is also known as 'Haglund’s Syndrome'. Pain and swelling occur as the cumulative effects of chronic wear and tear on the tendon.  

How is achilles tendinosis diagnosed?
A thorough history is taken and an examination is performed. Patients will usually have pain right on the tendon or at the back of the heel. They may also have swelling and thickening of the tendon. X-rays may be taken to see if there are any bone spurs. An MRI or ultrasound may also be performed to further evaluate how much of the tendon is affected and to look for any tears.

What are treatment options?
Treatment depends on the length and severity of the symptoms, with many patients improving without surgery. However, in some cases, a referral for surgery may be required. The specifics of the surgery depend upon the location and extent of the tendinosis.

A multi-faceted formal approach is in order that includes:

  • Chiropractic mobilizations;
  • Heel cups to try and improve pain by taking some of the stress off of the Achilles tendon when walking.
  • Custom prescribed foot orthotics;
  • A walking boot or other brace may be recommended;
  • Low-Level Laser Therapy (Photobiostimulation) to promote soft-tissue repair, reduce pain and swelling, promote collagen repair, and, improve micro-circulation and lymphatic drainage;
  • Manual therapy such as deep tissue release, active release therapy, Graston technique and 'Rolfing'… basically techniques that involve trying to break down and remodel the dysfunctional collagen tissue;
  • Ultrasound; Extracorporeal Shockwave Therapy... these modalities promote improved circulation and tissue repair;
  • Appropriate stretches and eccentric strengthening exercises that promote better collagen fiber orientation and linkages, and to improve mobility within the calf muscle;
  • Massage Therapy (RMT);
  • Drinking plenty of water;
  • Supplementing with fish oil, Vitamin C, Glucosamine Sulfate, Chondroitin, MSM, proteolytic enzymes like Bromelain and a diet based on whole foods;
  • Kinesiology Tape techniques;
  • Recently, medical literature mentions that platelet rich plasma as a treatment for Achilles tendinosis. This involves taking one’s own blood and isolating growth factors that are involved in healing. This serum is then injected into the inflamed tendon;
  • Medically prescribed oral medications may help reduce the swelling and pain, including prescribed topical nitroglycerin patches; and
  • Activity/​work modifications; adequate sleep; rest and time.
     

Frequently Asked Questions:

  1. If I am treated without surgery for achilles tendinosis will it come back? - While most patients will achieve lasting relief after treatment for achilles tendinosis, symptoms may return. The risk decreases if the patient continues to do routine stretching even after the symptoms resolve. However, athletes and runners in particular are at a slightly higher risk for this condition because of the high demands on the achilles. These patients should pay close attention to stretching and shoe-wear to prevent chronic recurrence.
  2. What are the outcomes for those who have surgery for achilles tendinosis? - Surgery can predictably return patients to activity. Success rates have been reported between 80 and 90 percent, which means that eight to nine out of 10 people improve with surgery. Some of the variability depends on the amount of tendon that is diseased at the time of surgery.

Patients improve with both conservative and operative management of achilles tendinosis. Physical therapy has been shown to help most patients with this condition and should be tried before surgical management is proposed.

Conclusion:

Achilles tendon injuries can be successfully rehabilitated conservatively with hands-on treatment. Steroid injections and casting are seldom used these days. Once the local inflammation has been controlled, improved blood flow to the region of relative avascularity is necessary. Chiropractic joint mobilization techniques, correct stretching and strengthening exercises can be demonstrated and monitored in Dr. Pisarek's office. One of the most important long-term goals is to reduce any tendency to pronate excessively. In addition to custom-made orthotics (Footmaxx) , all runners should be encouraged to wear well-designed shoes that provide good heel stability with a small amount of additional heel lift. This helps prevent achilles tendon problems, and is especially important in athletes who run more than a few miles at a time.

Prevention of Achilles Injuries:

Prevention of achilles tendonitis can be achieved with slowly increasing activity, purchasing quality foot wear, stretching, and cross-training. People who have had a history of achilles problems need to be conservative with their exercise and training programs. Big problems and injuries to the achilles tendon occur most commonly after ignoring small problems and pains. Pain is a warning sign something is wrong. Ignoring the problem often creates a more extensive injury.

Prevent small achilles injuries from becoming large injuries that require more time and treatment to correct by calling Dr. Pisarek today at (416) 633-3000.

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