Have you ever had pain in the back of the heel, close to the bone, that is worse with walking and stretching? Then you may have had Achilles tendonitis.

What is the Achilles tendon?
A tendon is a band of tissue that connects a muscle to a bone. The Achilles tendon runs down the back of the lower leg and connects the calf muscle to the heel bone. Also called the "heel cord", the Achilles tendon is the largest tendon in the body and facilitates walking, running and jumping by helping to raise the heel off the ground.
Achilles tendonitis is the inflammation of the Achilles tendon. Inflammation is the body's natural response to injury or disease, and is often short-lived. Over time, if not resolved, the condition may progress and degenerate the tendon, leading to Achilles tendonitis. The tendon loses its highly organized structure and develops very tiny tears. In rare cases, chronic degeneration may result in the rupture of the tendon.
There are two types of Achilles tendinitis, based on which part of the tendon is inflamed. Inflammation may occur in the middle portion of the tendon, where it has begun to break down with tiny tears, swelling, and thickening. This commonly affects younger, active people. Tendonitis involving the lower portion of the heel, where the tendon attaches to the heel bone, causes damage to the tendon fibers and may also calcify (harden), causing a bone spur (extra bone growth) to form. This affects the insertion of the tendon and can occur at any time, even in patients who are not active.

Causes
Achilles tendinitis is typically not related to a specific injury. The problem results from repetitive stress or over-use of the tendon. This often happens when we push our bodies to do too much, too soon. Such activity puts too much stress on the tendon too quickly, leading to micro-injury of the tendon fibers. Because the stress on the tendon is continuing, the body cannot repair the injured tissue. The tendon structure is then altered, resulting in continued pain. Several other factors can make it more likely to develop tendinitis, including a sudden increase in the amount or intensity of exercise activity, tight calf muscles, and a bone spur where the Achilles tendon attaches to the heel bone. Athletes are at high risk for developing Achilles tendonitis. It is also common in persons whose work puts stress on their ankles and feet, such as gardeners, "weekend warriors" (people who participate in athletics only on weekends or infrequently) and people with flat feet.

Symptoms
Common symptoms of Achilles tendinitis include:
o Pain and stiffness along the Achilles tendon especially in the morning, and the pain along the tendon or back of the heel that worsens with activity. The pain can be severe the day after exercising.
o Thickening or nodules may be felt in the tendon. A bone spur may be felt where the tendon attaches to the heel bone.
o Swelling that is present all the time and gets worse throughout the day with activity. If you have experienced a sudden "pop" in the back of your calf or heel, you may have ruptured (torn) your Achilles tendon. See your doctor immediately if you think you may have torn your tendon.

Diagnosis
As the podiatrist examines you, he or she will evaluate the range of motion of the ankle and the condition of the tendon by looking for signs of swelling along the Achilles tendon or at the back of your heel, thickening or enlargement of the Achilles tendon, bony spurs at the lower part of the tendon, and the location of pain. The podiatrist may also order imaging tests such as X-rays and Magnetic Resonance Imaging (MRI)

Treatment
Treatment approaches for Achilles tendonitis is based on how long the injury has been present and the degree of damage to the tendon. In most cases, nonsurgical treatment options will provide pain relief, although it may take sometimes up to three to six months for symptoms to completely subside. Seeking medical treatment promptly is important to ensure the best chance of healing the condition. Treatment options may include:
o Rest: The first step in reducing pain is to decrease or even stop the activities that make the pain worse. If you regularly do high-impact exercises (such as running), switching to low-impact activities will put less stress on the Achilles tendon.
Cross-training activities such as biking, elliptical exercise, and swimming are low-impact options to help you stay active.
o Immobilization: With severe pain, immobilizing the tendon may be needed and may involve the use of a cast or removable walking boot to reduce forces through the Achilles tendon, promote rest and healing.
o Ice: To reduce swelling due to inflammation, apply a bag of ice over a thin towel to the affected area for 20 minutes of each waking hour. Do not put ice directly against the skin.
o Oral medications: Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be helpful in reducing the pain and inflammation.
o Orthotics and supportive shoes: For those with over-pronation or gait abnormalities, custom orthotic devices may be prescribed. Pain from insertional Achilles tendinitis is often helped by certain shoes and orthotic devices. For example, shoes that are open or softer at the back of the heel can reduce irritation of the tendon and heel lifts can move the heel away from the back of the shoe, where rubbing can occur, taking some strain off the tendon.
o Night splints: Help to maintain a stretch in the Achilles tendon during sleep.
o Exercise: Calf stretching is important to help strengthen the calf muscles and reduce stress on the Achilles tendon.
o Physical therapy: May include more stretching and strengthening exercises, soft-tissue massage/mobilization, gait and running reeducation, stretching, and ultrasound therapy.
o Extracorporeal shockwave therapy (ESWT): a non-invasive therapy that does not require a surgical incision and has minimal risks. It is sometimes tried before surgery is considered. During this procedure, high-energy shockwave impulses are applied to the area which stimulates the healing process in the damaged tendon tissue.
o Cortisone injections: Cortisone, a type of steroid, is a powerful anti-inflammatory medication. Cortisone injections into the Achilles tendon are not recommended because they can cause the tendon to rupture (tear).
When is surgery needed?
If non-surgical approaches fail to restore the tendon to its normal condition and pain persists for more than six months, surgery may be necessary. The foot and ankle surgeon will select the best procedure to repair the tendon, based upon the extent of the injury, the location of the damage to the tendon, the patient's age and activity level, and other factors.

Most patients have good results following surgery. The greater the amount of tendon that is injured, the longer the recovery period will be, and the less likely the patient will be able to fully return to their level of sporting activity. Pain, wound infection or healing delays are the most common complications after surgery. Physical therapy is a vital part of recovery and may be required for a long time.
Prevention
To prevent Achilles tendonitis from recurring after surgical or non-surgical treatment, the podiatrist may recommend daily strengthening and stretching exercises to the calf muscles. Wearing proper shoes for the foot type and sporting activity is also important in preventing recurrence of the condition.

For more information on Achilles tendinitis, visit www.apma.org or www.foothealth.com or send questions to foothealth242@gmail.com. If you have foot pain or any concern, visit a podiatrist at Bahamas Foot Centre, Rosetta Street, telephone 325-2996; Bahamas Surgical Associates, Albury Lane, telephone 394-5824 or the Foot & ankle Institute Dean's Lane, telephone 326-5402.

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