Achilles Tendinitis

THE CLINICAL SYNDROME

Achilles tendinitis is being seen with increasing frequency in clinical practice as jogging has increased in popularity. The Achilles tendon is susceptible to the development of tendinitis both at its insertion on the calcaneus and at its narrowest part at a point approximately 5 cm above its insertion. The Achilles tendon is subject to repetitive motion that may result in microtrauma, which heals poorly due to the tendon’s avascular nature. Running is often implicated as the inciting factor of acute Achilles tendinitis. Tendinitis of the Achilles tendon frequently coexists with bursitis of the associated bursae of the tendon and ankle joint, creating additional pain and functional disability. Calcium deposition around the tendon may occur if the inflammation continues, making subsequent treatment more difficult. Continued trauma to the inflamed tendon may ultimately result in tendon rupture.

SIGNS AND SYMPTOMS

The onset of Achilles tendinitis is usually acute, occurring after overuse or misuse of the ankle joint. Inciting factors may include activities such as running and sudden stopping and starting as when playing tennis. Improper stretching of the gastrocnemius and Achilles tendon before exercise has also been implicated in the development of Achilles tendinitis as well as acute tendon rupture. The pain of Achilles tendinitis is constant and severe and is localized in the posterior ankle. Significant sleep disturbance is often reported. The patient may attempt to splint the inflamed Achilles tendon by adopting a flatfooted gait to avoid plantar flexing the affected tendon. Patients with Achilles tendinitis will exhibit pain with resisted plantar flexion of the foot. A creaking or grating sensation may be palpated when passively plantar flexing the foot. As mentioned, the chronically inflamed Achilles tendon may suddenly rupture with stress or during vigorous injection procedures into the tendon itself.

The pain of achilles tendinitis is constant and severe and is localized to the posterior ankle.

TREATMENT

Initial treatment of the pain and functional disability associated with Achilles tendinitis should include a combination of the nonsteroidal anti-inflammatory drugs or cyclooxygenase-2 inhibitors and physical therapy. The local application of heat and cold may also be beneficial. Avoidance of repetitive activities responsible for the evolution of the tendinitis, such as jogging, should be encouraged. For patients who do not respond to these treatment modalities, the following injection technique with local anesthetic and steroid may be a reasonable next step.

Injection for Achilles tendinitis is carried out by placing the patient in the prone position with the affected foot hanging off the end of the table. The possibility of trauma to the Achilles tendon from the injection itself remains ever-present. Tendons that are highly inflamed or previously damaged are subject to rupture if they are directly injected.

The Achilles tendon is the thickest and strongest tendon in the body, yet is also very susceptible to rupture. The common tendon of the gastrocnemius muscle, the Achilles tendon, begins at mid-calf and continues downward to attach to the posterior calcaneus, where it may become inflamed. The Achilles tendon narrows during this downward course, becoming most narrow approximately 5 cm above its calcaneal insertion. It is this most narrow point at which tendinitis may also occur. This injection technique is extremely effective in the treatment of pain secondary to the aforementioned causes of posterior ankle pain. Coexistent bursitis and arthritis may also contribute to posterior ankle pain and may require additional treatment with a more localized injection of local anesthetic and methylprednisolone acetate.

The described technique is a safe procedure if careful attention is paid to the clinically relevant anatomy in the areas to be injected. The use of physical modalities including local heat as well as gentle range of motion exercises should be introduced several days after the patient undergoes this injection technique for ankle pain. Vigorous exercises should be avoided because they will exacerbate the patient’s symptomatology. Simple analgesics and nonsteroidal anti-inflammatory drugs may be used concurrently with this injection technique.

Low intensity laser therapy as well as a coordinated wellness program is also effective in treating this disorder.

Low Intensity Laser Therapy (LILT)

The low intensity Laser (LILT) sends photons (light) into the injured tissues and can penetrate two to three inches to treat affected areas. It uses a natural enhancement of the cellular machinery that can and has been dynamically measured in published studies to promote healing without burning affected tissue. Once the photons find the injured tissues, they stimulate and energize the cells to repair and strengthen at a remarkable rate. The treatment does not hurt, takes about 30 minutes and is very cost advantageous.

Wellness Program

A wellness program whichindividualizes treatment for age, performance and function has been shown in pilot studies to improve the overall health and well being of the individuals evaluated. A well conceived dietary and supplementary regimen based on scientific age–related decline in certain necessary compounds can improve quality of life, correct the ravages of hormone imbalance, balance critical neurotransmitter function without resorting to powerful drugs for depression that often have unfavorable side-effect profiles and restore vitality and youth in daily exercise routines. Furthermore, when wellness products are utilized with success, individuals often seek less costly interventions including unnecessary surgeries and narcotic options to treat pain. For more information go to www.drpwellness.com.