PARDEE FOOT CLINIC



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Achilles Tendonitis / Tendinosis

Achilles tendonitis is the most common type of tendonitis in the foot and [Achilles Tendonitis common area of pain] ankle. The pain is generally about 2 inches above the heel bone in the area which many refer to as the heel cord. Pain is accompanied by stiffness, especially at the first step in the morning, or rising after long periods of rest. There may be some swelling and extreme tenderness to the touch. Achilles tendonitis can also occur at the insertion of the tendon on the heel bone (calcaneus). This type of tendonitis is termed insertional Achilles tendonitis. Pain is located directly on the back of the heel and the area may be very tenderto the touch. Stiffness upon rising may also accompany this type of Achilles tendonitis. As the condition progresses out of the inflammatory phase (first 2-4 weeks) and into the degenerative phase, the swelling and intense tenderness will decrease and can be replaced with what looks like a lump or [Insertional Achilles Tendonitis area of pain] nodule on the back of the heel. This is Achilles tendinosis (tendinosis) and can take months and even up to a year to heal.

Achilles tendonitis typically develops after an increase or change in a certain activity. Many runners will develop tendonitis when they return to their training routine. Adding hills or stairs to a running routine or running on uneven surfaces or trail running can contribute to the development of tendonitis. Sports which involve quick sprints like basketball, soccer or tennis can contribute to the developed of Achilles tendonitis. The Achilles tendon is under the most stress when running or walking up steep hills, and this activity continues to be one of the most common aggravating activities. Changing to a new pair of shoes, especially a pair of shoes without a wedge at the heel or lift at the heel can add to the stress on the Achilles tendon. Starting a new job that requires a specific type of shoes, climbing up and down stairs or squating can cause tendonitis.



Treating Achilles Tendonitis



It is important to recognize the aggravating activity so that it can be eliminated during the healing process. Recognizing the problem and treating the tendonitis as soon as it develops will prevent progression to tendon degeneration. The initial treatments focus on taking the stress off of the achilles tendon, resting and decreasing inflammation.



Eliminate the aggravating activity: If you are a runner or a walker, switch to biking or swimming for 2-4 weeks during the healing process. If you are a cyclist, avoid hills, steep climbs and don't drop your heel while pedaling.

 
Ice massage: Ice the back of the heel and tendon for at least 20 minutes twice a day (3-4 times a day if possible). The most effective icing method is to place ice directly on the heel and massage the heel with the ice for 20 minutes. This will cause discomfort and possibly some pain, but should eventually lead to some numbness. Extended periods with ice directly on the skin could result in mild frostbite, so always keep the ice moving and don't leave the ice directly on the skin for long periods of time. If the direct ice massage is too painful, rest your heel directly on an ice pack or a bag of frozen peas.



Wear shoes with a heel: The best shoes to take stress off of the [Dansko Shoe with rocker bottom] Achilles tendon is a shoe with a wedge or heel (1 inch), a rigid midsole and a rocker on the bottom. The best example of this shoe is a Dansko. Those with insertional Achilles tendonitis may find the rigid heel counter on the Dansko shoe uncomfortable.


This is not the only acceptable shoe, but the Dansko shoe is a good example. A true rocker bottom sole is not necessary, but a rocker at the toe area as demonstated in this picture, helps with push off during walking and decreases the stress on the Achilles tendon. Avoid flexible, soft shoes and don't go barefoot. More on shoes.

 
Try heel lifts: Heel lifts can be placed in any shoe and will lift the heel, effectively taking stress off the Achilles tendon. The concept is the same as wearing a shoe with a wedged heel. [Diagram of the motion dorsiflexion]



To better understand the concept behind heel lifts, look at the images o n the right. When foot is forced up at the ankle (when walking uphill) the tendon is placed on stretch. There is a considerable amount of tension on the calf muscle and the Achilles tendon. It's like taking a cord and pulling it at both ends until it becomes taut.

When the foot flexes down at the ankle [Plantarflexion motion image] (plantar flexion) the tension is taken off of the Achilles tendon and the calf muscle. It would be like giving the cord in the example above more slack. The less tension and less stress on the tendon, the faster the tendon will heal. A heel lift is used or wedged heel shoe takes stress off of the Achilles tendon.

 Calf Stretching: Start with gentle stretching during the initial stages of [Theraband calf stretch diagram] tendonitis. When seated, take a belt or a towel and place it around the ball of  your foot. Keep the knee extended and gently pull the foot towards you. You should start to feel a stretch in the calf muscle. Continue to gently pull the foot toward you until you feel some pain. Back off a little and then hold the stretch for 60 seconds. Repeat this stretch 10 times, twice a day. Try to stretch before getting out of bed in the morning, or before you get up after long periods of rest. This stretch should not be painful. Aggressive stretching during the initial phases of tendonitis can aggravate the condition.

 
Take anti-inflammatory medications: Ibuprofen and Naproxen are two common anti-inflammatory medications which can be bought over the counter. They will reduce pain and decrease inflammation. Used in combination with the other treatments mentioned, they can be an effective therapy. But, it is also important to realize that they can mask the pain and they are not addressing the cause of the problem. 


Treating Achilles Tendinosis

If the tendonitis has not improved within 2 - 4 weeks, an appointment with Pardee Foot Clinic is recommended. After 4 weeks, the condition has most likely progressed to tendonosis. At this point, the treatment regimen will change slightly and a referral to physical therapy is recommended. Icing can still be done because this will help decrease the number of new blood vessels formed within the area and act as an analgesic. But, it is no longer necessary as an anti-inflammatory. Anti-inflammatory medications are not necessary at this point either, although they can help reduce the pain. This is something to be discussed with your doctor and may vary on an individual basis.