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About the Achilles tendon
Tendons are long, tough, fibrous tissues that connect muscles to bones. The Achilles tendon is the largest and strongest tendon in your body. It sits at the back of your ankle and foot and connects your calf muscle to your heel bone.
The Achilles tendon allows us to walk, run and jump by raising the heel off the ground. Overstressing it can injure it.
About Achilles tendinopathy
Achilles tendinopathy is the development of inflammation and degeneration of the Achilles tendon.
It is typically not related to a specific injury, but occurs due to over stressing of the Achilles tendon due to overuse or over stretching.
This causes inflammation, most commonly to the area where the tendon attaches to the heel bone (as pictured).
It can occur at the point where your Achilles tendon attaches to the heel bone or slightly higher into the body of the tendon.
This inflammation makes it painful to walk, stand for long durations and use your foot for everyday activities. Most people experience pain in one foot or another, but it can often occur in both feet at once.
Types of Achilles tendinopathy
There are 2 types of Achilles tendinopathy, dependant on which part of the tendon is affected.
Noninsertional Achilles tendinopathy
This is when the fibres in the middle portion of the tendon start to break down, swell and thicken. It tends to affect people who are younger and more active.
Insertional Achilles tendinopathy
This is when the fibres that attach the Achilles tendon to the heel bone become painful and inflamed. It typically occurs with overuse of the tendon and can affect people of any age.
Symptoms
Common symptoms of Achilles tendinopathy include:
- heel and ankle pain
- stiffness or tenderness in the tendon
- leg weakness
- swelling around the Achilles tendon.
You may notice more discomfort:
- after you are active or the day following exercise
- going upstairs or uphill
- first thing in the morning (it settles throughout the day).
What Achilles tendinopathy feels like
Achilles Tendinopathy usually causes a pain in the heel at the base of the foot. The pain can vary from day to day and can be more painful depending on the type of activity you are doing and the time of day.
Some types of pain you may experience include the following:
- Pain when moving your ankle up and down.
- Dull, constant ache that varies throughout the day, depending on your activity levels.
- Sharp stabbing pain when you step up or push off from your foot, more so when you climb stairs or walk uphill.
- Pain following an increase in exercise, which may temporarily be relieved but comes back when you stop.
- Increased pain first thing in the morning, after you have been lying down for a long period of time.
Causes
Achilles tendinopathy is a common condition. It is associated with people who:
- Play sports, especially sports that involve repetitive stopping and starting.
- Run or dance.
- Have jobs that put a lot of stress through the feet and ankles.
- Participate in less frequent exercise (weekends only), meaning their bodies are less used to the stress.
There are also several anatomical (body structure) risks that may be contributing factors, including:
- tight or weak calf muscles
- a bone spur (extra bone growth on the heel, causing rubbing of the tendon)
- flat feet (flat arches)
- overpronation (rolling over on your ankles when your walk).
Diagnosing Achilles tendinopathy
We can diagnose Achilles tendinopathy with a physical examination and medical history of any ongoing foot problems (presence of bone spurs).
Typically pain and inflammation is present at the base of your heel or within the mid portion of your Achilles tendon.
In rare circumstances we may use diagnostic imaging if another issue or condition is causing the pain. This diagnostic imaging may include:
- X ray
- ultrasound
- MRI scan.
Acute versus chronic Achilles tendinopathy
Acute Achilles tendinopathy is the initial occurrence of symptoms, which can present for up to 6 months. The symptoms will come and go during this time, but often settle without us needing to intervene too much. Gentle stretches and off the shelf insoles can be a beneficial way to treat the condition.
If your symptoms persist for longer durations (longer than 6 months) and without relief, the initial acute condition can result in a chronic condition. A chronic condition can be difficult to treat and may require a variety of treatments.
Treatment
We can manage this common condition with a variety of at home treatments as well as some over the counter medicine. Once we have confirmed your diagnosis we may suggest one or more of the following treatments to help manage your condition and reduce your pain.
Use the drop-down menu for more information on different types of treatment.
Stretching and massaging
Night splints
We may prescribe night socks (Strasberg socks) for you. These are long stockings that you wear at nighttime to allow a gentle but prolonged stretch of the Achilles tendon while you sleep.
Orthotics (shoe inserts) or insoles
We may prescribe some gel insoles or arch supports that you can put in your footwear to help support your arch.
Supportive footwear
Supportive and well cushioned shoes will help support the arch of your foot.
Avoid wearing sandals, flip flops or flat shoes with no arch support. Avoid barefoot walking.
Over the counter non steroidal anti inflammatory (NSAIDs)
These help reduce pain and inflammation. Seek advice from your GP on the use of NSAIDs to reduce pain and inflammation.
Rest
If possible, for at least a week, limit or reduce the amount of sporting activity that you do and which can make your Achilles tendinopathy worse.
Ice therapy
Ice your foot for at least 10 to 15 minutes twice a day to help reduce your inflammation. The cooling effect will also help to reduce pain in your foot.
Treatments for chronic Achilles tendinopathy
If your condition is chronic (it has been persistent for longer than 6 months), we can offer you other treatment options, providing some of the above treatments have already been tried.
These options may include the following.
Extracorporeal shockwave therapy (ESWT)
This is a non invasive procedure by which we direct a series of high or low energy shockwaves through your Achilles tendon. ESWT involves focused shockwaves into the target area to stimulate an increase in blood circulation. This creates an inflammation response, which is said to increase the body’s own healing processes. Focused shockwaves are high energy acoustic waves that come together to achieve maximal energy at the target site. This overstimulates the nerves, which can reduce sensitivity and pain in chronic conditions.
We commonly use ESWT in patients who have not responded to more conservative treatments. A course of ESWT usually requires 1 treatment session a week for 3 follow on weeks. Ideally treatment will not take place any more than 2 weeks apart. This treatment method must be accompanied by a comprehensive rehabilitation programme.
Proximal Medial Gastrocnemius Release (PMGR)
This is a minimally invasive surgical procedure which involves releasing a small piece of fascia around the top of your calf to allow the muscle fibres to be released. Fascia is a thick band of tissue that runs from your heel to your toes on the bottom of the foot. We then close any subcutaneous (under the skin) layers and skin. We perform this technique to relieve tension in your Achilles tendon.
We usually perform this as a day case procedure in the operating theatre. We generally use this procedure when all other non operative management options have failed. There are some typical complications which can occur after an operation, including:
- bleeding
- infection
- nerve damage
- DVT (deep vein thrombosis)
- wound healing problems
- return of the Achilles tendinopathy condition.
Steroid injection
In rare instances we may suggest a steroid injection into your plantar fascia. Your plantar fascia is a strong fibrous attachment (similar to a ligament) that runs the length of your foot, from the underneath of your heel bone to the ball of your foot and toes.
This injection can be painful and it does not always work. We usually perform the injection using ultrasound guidance, to target the exact area for the injection. This method of treatment has a short term effect, which means symptoms may resolve following the injection but often return quickly. We can repeat these injections to improve symptoms, but the condition often persists.
Other complications include:
- infection
- an increase in pain
- an increase in swelling
- ineffective treatment.
Contact information
Kingston Hospital Orthopaedic Outpatient Department, Monday to Friday 8.30am to 5pm
Telephone: