What are Achilles Tendinitis and how can they be treated?

Nonsurgical options are first line treatments and in most cases will provide pain relief, although it may take a few months for symptoms to subside. Even with early treatment, the pain may last longer than 3 months. If the pain has been present for several months before seeking treatment, it may take 6 months before the treatment methods take effect.

Rest: The first step in reducing pain is to decrease or even stop the activities that worsen the pain. Stopping high-impact exercises (such as running) and 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 allow you to stay active.

Ice: Placing ice on the most painful area of the Achilles tendon is helpful and can be used as needed throughout the day.

Non-steroidal anti-inflammatory medication: Drugs such as ibuprofen and naproxen (check with GP if you are on other medications or if using these drugs for more than a month) help to reduce pain and swelling. They do not reduce the thickening of the degenerated tendon.

The following exercises can help to stretch the calf muscles and reduce stress on the Achilles tendon.

• Eccentric Stretching Protocol –  Eccentric stretching aims to stretch the calf muscle.
• Bilateral heel drop – Stand at the edge of the bottom step of a stair or a platform with just the front half of your foot. This position will allow your heel to move up and down. Care must be taken to ensure that you are balanced correctly to prevent falling and injury. Be sure to hold onto a railing or bannister to help you balance. Slowly lower your heels to the lowest point possible by bending at the ankle (dorsiflexion). Hold the position for 30-60 seconds and relax. Repeat this exercise 20 -30 times. A strong pull in the calf should be felt during the stretch. This exercise should be done in a slow, controlled fashion. Rapid movement can create the risk of damage to the tendon. As the pain improves, you can increase the difficulty level of the exercise by holding a small weight in each hand.
• Single leg heel drop – This exercise is performed similarly to the bilateral heel drop, except that all your weight is focused on one leg. This should be done only after the bilateral heel drop has been mastered.

Physiotherapy: Physiotherapy is very helpful in treating Achilles tendonitis and a physiotherapist can guide the stretching exercise programme. It has proven to work better for noninsertional tendonitis than for insertional tendonitis.

Supportive shoes and orthotics –  Pain from insertional Achilles tendinitis is often helped by certain shoes, as well as orthotic devices. For example, shoes that are softer at the back of the heel can reduce irritation of the tendon. In addition, heel lifts can take some strain off the tendon.

Heel lifts are also very helpful for patients with insertional tendonitis because they can move the heel away from the back of the shoe, where rubbing can occur. They also take some strain off the tendon. Like a heel lift, a silicone Achilles sleeve can reduce irritation from the back of a shoe.

If your pain is severe, your doctor may recommend a walking (airboot) boot for a short time. This gives the tendon a chance to rest before any therapy is begun. Extended use of a boot is discouraged, though, because it can weaken your calf muscle.

Extracorporeal shockwave therapy (ESWT) – During this procedure, high-energy shockwave impulses stimulate the healing process in damaged tendon tissue. ESWT is noninvasive—it does not require a surgical incision and there is minimal risk involved.

PRP (platelet) Injections – may be tried before considering surgery.

Cortisone – a type of steroid, is a powerful anti-inflammatory medication. Cortisone injections into the Achilles tendon are rarely recommended because they can cause the tendon to rupture (tear).

Gastrocnemius recession. This is a surgical lengthening of the calf (gastrocnemius) muscles. Because tight calf muscles place increased stress on the Achilles tendon, this procedure is useful for patients who still have difficulty flexing their feet, despite consistent stretching.

In gastrocnemius recession, one of the two muscles that make up the calf is lengthened to increase the motion of the ankle. Complication rates for gastrocnemius recession are low, but can include nerve damage.

Débridement and repair (tendon has less than 50% damage). The goal of this operation is to remove the damaged part of the Achilles tendon. Once the unhealthy portion of the tendon has been removed, the remaining tendon is repaired with sutures, or stitches to complete the repair.

In insertional tendinitis, the bone spur is also removed. Repair of the tendon in these instances may require the use of anchors to help hold the Achilles tendon to the heel bone, where it attaches.

After débridement and repair, most patients are allowed to walk in a removable boot or cast within 2 weeks, although this period depends upon the amount of damage to the tendon.

Débridement with tendon transfer (tendon has greater than 50% damage). In cases where more than 50% of the Achilles tendon is not healthy and requires removal, the remaining portion of the tendon is not strong enough to function alone. To prevent the remaining tendon from rupturing with activity, a tendon transfer is performed. The tendon that helps the big toe FHL – Flexor Hallucis Longus) point down is moved to the heel bone to add strength to the damaged tendon. Although this sounds severe, the big toe will still be able to move, and most patients will not notice a change in the way they walk or run.