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Achilles tendon – causes and treatment

20 Jan 2021

Have you recently taken up a fitness regimen that involves a lot of walking/running? It is important to progress slowly rather than overdoing it to avoid common problems involving the heel, says Dr Biswajit Dutta Baruah, Consultant orthopedic surgeon, KIMS Oman Hospital 

Heel pain is particularly common among those who are active in exercises that involve walking, running or jumping. There are two major causes of heel pain based on their site of occurrence. One affects the back of the heel related to Achilles tendon and the other affects the undersurface of the heel in relation to the plantar fascia. Today, I will elaborate on Achilles tendon as a source of heel pain.

Philip Verheyen, a Dutch surgeon was the firstin 1693 to name the Achilles tendon after the venerated Greek hero Achilles. Thetis the Greek goddess dipped the body of her son Achilles into the River Styx seeking to make him invulnerable to injury. As she held him by his heel, it was left untouched by the magical water leaving the region vulnerable. Eventually he was killed by a poison arrow that struck the heel.Thus giving rise to the phrase Achilles heel referring to weakness in spite of overall strength. 

Achilles tendon is a thick cord-like structure serving to connect the powerful calf muscles (gastrocnemius and soleus) at the back of the leg to the heel bone (calcaneum). The tendon is a conduit for the force generated by the calf muscles and helps a person to push the ground during an activity. The tendon is subjected to about four times the body weight when walking and about seven times the body weight when running.

With a repetitive activity like walking and running the tendon is subjected to manifolds of this magnitude of load during a single day’s exercise. Curiously among the bipeds – those who walk on two legs, a human is uniquely distinct in having a strong Achilles tendon in comparison to the chimpanzee or the ape. Human heels were designed naturally for walking and running.

Sudden enthusiasm for exercise

It’s not surprising therefore, to see walkers and runners present to the clinic with heel pain. Mostly it is seen in those who started an exercise recently because their physician frowned at their high cholesterol levels. In their zeal and enthusiasm to keep their physician happy, and over-estimation of their physical capacity, often patients end up over-doing exercise leading to injury. 

In trying to do too much in too soon a time, and by the nature of repetitiveness, loads exceed the physical strength of the tendon leading to injury. Doctors refer to this as overuse injury. Most common region to be affected is at the site of attachment of the tendon onto the heel bone.

Clinical analysis

Although it was common to refer to this as tendinitis, these days surgeons refer to this as insertional tendinopathy. At times, severe bouts of inflammation is accompanied by calcium salt deposits. This often results in severe swelling, pain and redness at the back of the heel. Bumps may become visible at the back of the heel. A few patients with high uric acid levels are prone to having salt deposits.

There is a fluid filled sac that separates the tendon from the heel bone. Inflammation may predominantly affect the bursa rather than the tendon itself. In such cases, pain and inflammation is a little higher than at the site of attachment of the tendon. Physicians refer to this as bursitis. It takes clinical acumen to differentiate between the two.

Pain along the length of the tendon is possible when there is inflammation of the membrane that covers the tendon (tenosynovitis). This is commonly seen among those who stand for prolonged periods of time.

Uncommonly, when patients ignore the pain and continue to aggressively pursue running and jumping, the tendon may tear out of its attachment. Tendon degeneration in a middle aged person also contributes to a tear easily. This is obvious by the loss of strength in the calf muscles and inability to walk. 

Most patients with heel pain can be diagnosed by ultrasound scans. Scans help to identify the site of inflammation and thereby differentiate between tendinopathy, bursitis and tenosynovitis. Calcification can be picked on a simple xray. When a tear is suspected, especially partial tears, MRI scan may be performed. 

Remedies

Most of the patients respond well to anti-inflammatory medications, both oral and topical. Icing the back of the heel and elevating the limb over a pillow can help reduce the swelling. Resting the leg is necessary to control inflammation. Inflammation weakens the tendon attachment to the bone, therefore it is important to avoid running and jumping to prevent tears or ruptures.

Those with calcific deposits may continue to have the bumps permanently. This may necessitate wearing one size bigger footwear to avoid friction of the skin over the bump. Those with high uric acid levels will do well by hydrating by the clock, which means you drink water or juices on an hourly basis rather than waiting till you get thirsty. This may mean more trips to the washroom but your kidneys will ensure that the extra uric acid is flushed out with urine.

Reducing protein intake in the form of chicken, mutton, beef, fish, eggs for meat eaters and,  dal, paneer and cheese for vegans, will ensure decreased production of uric acid. Medication may be necessary to bring down high levels of uric acid as well.

Physiotherapy is usually prescribed for 6-8 weeks. Shockwave therapy is known to be helpful. This involves applying a pulsatile (series) of low intensity sound waves to the site of involvement. Eccentric loading exercise is a type of exercise that can be done on a step or at the floor level to help overcome the tightness in the tendon.

For those with persistent inflammation and pain, cortisone (steroid) shots around the tendon can help control inflammation. Most patients recover well at this point. A few may continue to have bothersome pain and difficulty in walking.

Surgical intervention

Bursoscopy (keyhole surgery) is employed by a few surgeons to clean the inflamed fluid filled sac in front of the achilles tendon. This is often not successful in those with involvement of the tendon or calcification at the site of tendon attachment. Therefore getting the diagnosis right early is critical to selecting the appropriate treatment strategy.

Few patients may need cleaning up at the site of tendon attachment. In the majority of the patients this cleaning process will involve removal of calcific deposits and degenerated tendon bits, and thereby surgical reattachment of the tendon to the heel bone (calcaneum) becomes necessary.

Several methods are available to surgeons to accomplish this using absorbable screws and tendon augments. At times, adjacent tendons are used to strengthen the repair process. The ankle is often rested in a cast following surgery to allow the repair to consolidate over time. This is followed by extensive physiotherapy. A successful repair allows the patient to return to sporting activities.

In summary, Achilles tendinitis is a disabling condition that affects mostly those involved in extensive walking and running exercises. Reducing the amount of time spent in doing the exercise or reducing the intensity of exercise by decreasing speed or avoiding inclines may be the first step necessary to relieve pain. Most patients recover well to normal functions with non-operative treatments. Only a few may need surgery. A rigorous exercise regimen will help in the path to recovery.

 

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