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Achilles Tendon Problems

Achilles Tendon Problems

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Achilles Tendon Problems

Topic Overview

What is the Achilles tendon?

The Achilles tendon connects the calf muscle to the heel bone. It lets you rise up on your toes and push off when you walk or run.

What are common Achilles tendon problems?

The two main problems are:

  • Achilles tendinopathy. This refers to tiny tears (microtears) in the tissue in and around the tendon. These tears are caused by overuse. Achilles tendinopathy is also often called Achilles tendinitis.
  • Achilles tendon tear or rupture. An Achilles tendon also can partially tear or completely tear (rupture) . A partial tear may cause mild or no symptoms. But a complete rupture causes pain and sudden loss of strength and movement.

Problems with the Achilles tendon may seem to happen suddenly. But usually they are the result of many tiny tears in the tendon that have happened over time.

Achilles tendinopathy is likely to occur in men older than 30. Most Achilles tendon ruptures occur in people 30 to 50 years old who are recreational athletes ("weekend warriors"). Ruptures can also happen in older adults.

What causes Achilles tendon problems?

Achilles tendinopathy is most often caused by overuse or repeated movements during sports, work, or other activities. For example, if you do a lot of pushing off or stop-and-go motions when you play sports, you can get microtears in the tendon.

Achilles tendon rupture is most often caused by a sudden, forceful motion that stresses the calf muscle. This can happen during an intense athletic activity or even during simple running or jumping. Middle-aged adults are especially likely to get this kind of injury.

What are the symptoms?

Symptoms of Achilles tendinopathy include swelling in the ankle area and mild or severe pain. The pain may come on gradually or may only occur when you walk or run. You may have less strength and range of movement in the ankle.

Symptoms of an Achilles tendon rupture may include a sudden, sharp pain. Most people feel or hear a pop at the same time. Swelling and bruising may occur. You may not be able to point your foot down or stand on your toes.

How are Achilles tendon problems diagnosed?

Your doctor can tell if you have an Achilles tendon problem by asking questions about your past health and checking the back of your leg for pain and swelling.

If your symptoms are severe or don't improve with treatment, your doctor may want you to get an X-ray , ultrasound scan , or MRI .

How are they treated?

Treatment for mild Achilles tendon problems includes rest, over-the-counter pain medicine, and stretching exercises. You may need to wear well-cushioned shoes and change the way you play sports so that you reduce stress on the tendon. Early treatment works best and can help prevent more injury. Orthotic shoe devices can also help reduce stress on the tendon.

Even in mild cases, it can take weeks to months of rest for the tendon to repair itself. It's important to be patient and not return too soon to sports and activities that stress the tendon.

Treatment for severe problems, such as a torn or ruptured tendon, may include surgery or a cast, splint, brace, walking boot, or other device that keeps the lower leg and ankle from moving. Exercise, either in physical therapy or in a rehab program, can help the lower leg and ankle get strong and flexible again. The tendon will take weeks to months to heal.

Although treatment for Achilles tendon problems takes time, it usually works. Most people can return to sports and other activities.

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Cause

Achilles tendinopathy is most often caused by:

  • Overuse or repeated movements during sports, work, or other activities. In sports, a change in how long, intensely, or often you exercise can cause microtears in the tendon. These tears are unable to heal quickly and will eventually cause pain. A change in your environment, such as going from a flat surface to a hill or from a dirt road to a paved road, can also cause these tears.
  • Injury from repeated push-offs or a stop-and-go motion. These injuries are common in such activities as running, basketball, tennis, or ballet dancing.

Achilles tendon rupture is most often caused by:

  • Sudden, forceful motion that stresses the calf muscle. This can happen during an intense athletic activity or even during simple running or jumping, especially in middle-aged adults. A rupture most often occurs in sports such as basketball, racquet sports (including tennis), soccer, and softball.
  • Overstretching the tendon during any activity when the tendon is already damaged because of Achilles tendinopathy or another condition.

Symptoms

Symptoms of Achilles tendinopathy may include:

  • Pain in the back of the heel, in the Achilles tendon area. Pain may be mild or severe. Swelling may occur.
  • Tenderness in the Achilles tendon area. Tenderness may be more noticeable in the morning.
  • Stiffness that goes away as the tendon warms up with use.
  • Decreased strength and movement, or a feeling of sluggishness in the leg.

Symptoms of an Achilles tendon rupture may include:

  • A sudden, sharp pain that feels like a direct hit to the Achilles tendon. There may be a pop when the rupture occurs. This may be followed by swelling and bruising.
  • Heel pain. (It may be severe.)
  • Not being able to go on tiptoe with the hurt leg.

If you have a partial rupture (tear) of the Achilles tendon, you may have near-normal strength and less pain after the initial injury, compared to what you would have after a complete rupture .

What Happens

Achilles tendinopathy

Achilles tendinopathy starts with repeated small tears in the tendon. These tears may cause no obvious symptoms. Or they may cause mild to severe pain during movement. As the tearing continues, the leg may weaken and the tendon pain may become constant. Abnormal growths (nodules) may form in the tendon, and it may thicken.

Without rest and treatment of Achilles tendinopathy, you may develop long-lasting (chronic) pain.

Achilles tendon tear or rupture

An Achilles tendon can partially tear or completely tear (rupture) . A tear usually occurs in the tendon about 1.5 in. (3.8 cm) to 2.5 in. (6.4 cm) above where it attaches to the heel bone. Some doctors believe that this area is most likely to tear or rupture because of a limited blood supply.

If you don't treat an Achilles rupture, you will feel weakness in your first steps when you walk. It may feel like walking in the sand. Over time, walking will become difficult.

Other Achilles tendon problems

Other conditions can affect the Achilles tendon area. These other conditions are caused by inflammation. They include:

What Increases Your Risk

Things that increase your risk for Achilles tendinopathy or rupture include:

  • Sports and physical activity. Overuse and repeated movements can cause injury and weaken the Achilles tendon. Playing sports increases the risk of an injury. Activities at work (such as in construction) and at home (such as gardening) may also increase your risk.
  • Sports training errors. Not warming up before running or other activities or suddenly changing your training program can increase your risk for injury. Increasing your distance, running uphill more often, or changing your ground surfaces too quickly can increase your risk. Decreased flexibility may also increase the risk of tendon problems.
  • Age. Most cases of Achilles tendinopathy or rupture occur in people older than 30.
  • Weight. If you are very heavy, you have a greater risk.
  • Being male. Men are more likely than women to have an Achilles tendon injury.
  • Footwear. You may increase your risk if you wear shoes that are worn out, that do not support your feet, or that do not cushion your heel.

Other risk factors for an Achilles tendon rupture include:

  • A previous injury or rupture to the Achilles tendon.
  • Corticosteroid injections in the Achilles tendon. They can weaken the tendon.
  • Long-term use of quinolone antibiotics. Quinolones include ciprofloxacin and ofloxacin.
  • Having osteoarthritis, gout, or rheumatoid arthritis.

When should you call your doctor?

Call your doctor right away if you think you have an Achilles tendon problem (at or above the back of your ankle) and:

  • The back of your heel and ankle are very painful.
  • You felt a sharp pain like a direct hit to the Achilles tendon.
  • You heard a pop in your Achilles tendon when you were injured.
  • You aren't able to walk comfortably.
  • Your Achilles tendon area has begun to swell.
  • You have signs of damage to the nerves or blood vessels. Signs include numbness, tingling, a pins-and-needles feeling in your foot, and pale or bluish skin.

If you have had an Achilles tendon injury in the past and you have reinjured your Achilles tendon, call your doctor to find out what you need to do. Rest your lower leg and foot until treatment begins.

Watchful waiting

Watchful waiting is a period of time during which you and your doctor observe your symptoms or condition without using medical treatment. Watchful waiting is not a good idea if you have severe pain in the Achilles tendon area. If you think you have injured your Achilles tendon, call your doctor. Early treatment is most effective.

If you think you have Achilles tendinopathy and you have mild symptoms, rest your lower leg and foot for a couple of days. Follow the other steps in Home Treatment . If you have weakness, cramping, or constant pain in your Achilles tendon, call your doctor.

Who to see

Health professionals who can diagnosis and treat an Achilles tendon problem include:

You may be referred to a physical therapist for exercises to rebuild strength in your Achilles tendon and leg muscles.

Exams and Tests

Most doctors diagnose an Achilles tendon problem through a medical history and physical exam. This includes checking for tenderness, watching how you walk and stand, and comparing the range of motion of your two legs.

Other tests may be done to clarify a diagnosis or to prepare for surgery. These tests include:

Treatment Overview

Early treatment usually results in better healing.

Achilles tendinopathy

To treat Achilles tendinopathy:

  • Use home treatment. This includes resting your lower leg and foot, stretching the area, wearing cushioned shoes or other orthotics , and switching sports or modifying how you do sports that may have caused the problem.
  • Reduce pain by using ice or taking over-the-counter pain relievers, such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) , as directed. Be safe with medicines. Read and follow all instructions on the label.
  • Follow any physical therapy that your doctor has prescribed. This may include stretching and strengthening exercises, deep massage, heat, or ultrasound.

If your Achilles tendon shortens and stiffens while you sleep, your doctor may suggest that you wear a night brace to keep your foot in a neutral position (not pointing up or down).

If you keep having pain or stiffness in the ankle area, your doctor may prescribe a walking boot or other device for 4 to 6 weeks. This keeps your lower leg and ankle from moving. It allows the tendon to heal.

If you still have Achilles tendon pain after more than 6 months of consistent treatment and rest, you might need to consider surgery.

Achilles tendon rupture

Treatment for an Achilles tendon rupture includes:

  • Surgery followed by rehabilitation (rehab) . This is the most common treatment for younger adults.
  • Immobilizing your leg, followed by rehab. This prevents movement of the lower leg and ankle. It allows the ends of the Achilles tendon to reattach and heal.

What to think about

Don't smoke or use other tobacco products. Smoking slows healing, because it decreases blood supply and delays tissue repair.

If you have an Achilles tendon rupture, your decision about whether to have surgery will depend in part on your:

  • Age and activity level. For example, if you are an older adult who doesn't do activities that may cause another rupture and who doesn't want the added risk of surgery, you may choose to use a cast or similar device.
  • Medical condition. If you have another medical condition—such as diabetes or heart or lung disease—that raises the risks associated with surgery, you may choose to use a cast or similar device.
  • Time since injury. Over time, the torn ends of the tendon shorten and pull away from each other. If they are too far apart, the surgery is less likely to work. If surgery is chosen, many surgeons will wait a few days for the swelling to go down, then do the surgery as soon as possible. Surgery is usually done within 4 to 6 weeks.

Prevention

Most Achilles tendon injuries occur during sports. If you had an Achilles tendon problem in the past, it is especially important to try to prevent another injury. To help prevent injury, try to:

  • Warm up. Before any sport or intense activity, gradually warm up your body by doing 5 to 10 minutes of walking or biking.
  • Cool down and stretch. After intense activity, gradually cool down with about 5 minutes of easy jogging, walking, or biking, and 5 minutes of stretches.
  • Avoid any sport or intense activity that you are not in condition to do.
  • Wear shoes that cushion your heel during sports or any strenuous activity.
  • Wear heel pads or other orthotics that are designed to reduce stress on the Achilles tendon.

Home Treatment

Home treatment is often used for Achilles tendinopathy as part of physical therapy or rehabilitation (rehab) after an Achilles tendon rupture.

Achilles tendinopathy

Follow these steps to rest, heal, and strengthen your Achilles tendon and prevent further injury:

  • Rest your Achilles tendon. Avoid all activities that strain the tendon, such as stair climbing or running. Try other activities, such as swimming, while you give your tendon the days, weeks, or months it needs to heal. Your doctor will tell you what you can and cannot do.
  • Reduce pain by icing your Achilles tendon and taking nonprescription pain relievers such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) as directed. Be safe with medicines. Read and follow all instructions on the label.
  • Follow your physical therapy program if one has been prescribed for you. Do gentle stretching and strengthening exercises. Focus on calf stretches .
  • Don't smoke or use other tobacco products. Smoking slows healing, because it decreases blood supply and delays tissue repair.
  • Wear footwear that protects the tendon while it heals.
    • Quality athletic shoes that support your arches and cushion your heels can make a big difference in your comfort and healing. If needed, talk to your physical therapist or podiatrist about heel pads or orthotics .
    • A bandage that keeps your foot in a neutral position (not pointing up or down) can restrict the motion of the Achilles tendon.
    • A silicone sleeve or pad can distribute pressure on the Achilles tendon.

If your Achilles tendon shortens and stiffens while you sleep, your doctor may suggest that you wear a night brace to keep your foot in a neutral position.

Achilles tendon rupture

No matter how you treat an Achilles tendon rupture, after treatment it's important to follow your rehab program . This program helps your tendon heal and helps prevent further injury.

Medications

You can use medicine to relieve pain from Achilles tendinopathy or an Achilles tendon rupture. The medicine may be prescription or nonprescription. Be safe with medicines. Read and follow all instructions on the label.

  • Acetaminophen (such as Tylenol) can relieve pain.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) are also often used to treat pain. But most tendon problems don't involve inflammation, so NSAIDs usually aren't needed. These drugs include ibuprofen (such as Advil and Motrin) and naproxen (such as Aleve).

Corticosteroid injections, which sometimes are injected around tendons or into joints to reduce pain and inflammation , aren't used to treat Achilles tendinopathy. They may increase the risk of a tendon rupture.

Surgery

Achilles tendinopathy

Surgery usually isn't needed to treat Achilles tendinopathy. But in rare cases, someone might consider surgery when rubbing between the tendon and the tissue covering the tendon (tendon sheath) causes the sheath to become thick and fibrous. Surgery can be done to remove the fibrous tissue and repair any small tendon tears. This may also help prevent an Achilles tendon rupture.

Achilles tendon rupture

Surgery is often used to reattach the ends of a ruptured Achilles tendon. It may provide a better chance of preventing the tendon from rupturing again compared to using a cast or other device that will keep your lower leg and ankle from moving ( immobilization). footnote 1

Surgery works best when you have surgery soon after your injury. Recovering from surgery may take months. Most surgeons will wait a few days for swelling to go down, then do the surgery as soon as possible. Surgery is usually done within 4 to 6 weeks. You will also need a rehabilitation (rehab) program to help heal and strengthen the tendon.

Surgery choices

Surgery for an Achilles tendon rupture can be done with a single large incision, which is called open surgery. Or it can be done with several small incisions. This is called percutaneous surgery.

What to think about

The differences in age and activity levels of people who get surgery can make it hard to know if Achilles tendon surgery is effective. The success of your surgery can depend on:

  • Your surgeon's experience.
  • The type of surgery you have.
  • How damaged the tendon is.
  • How soon after rupture the surgery is done.
  • How soon you start your rehab program after surgery.
  • How well you follow your rehab program.

Talk to your surgeon about his or her surgical experience. Ask about his or her success rate with the technique that would best treat your condition.

Other Treatment

Other treatments are often used for Achilles tendinopathy or rupture. Before using other treatments, you most likely will try rest and medicine to reduce pain and swelling.

Achilles tendon rupture

A cast or similar device can be used to prevent the lower leg and ankle from moving (immobilization). This type of treatment may take as long as 6 months to completely heal a tendon. This is usually followed by a rehabilitation (rehab) program that helps you regain strength and flexibility in the tendon and leg. The rehab program may include physical therapy.

Achilles tendinopathy

Common physical therapy treatments include:

If other treatment doesn't reduce your pain, your doctor may recommend using a cast or other device for 4 to 6 weeks. These devices can prevent your lower leg and ankle from moving and allow the tendon to heal. This is then followed by physical therapy and changes in your activities.

Experimental treatment

Medical researchers continue to study new ways to treat tendon injuries. Talk to your doctor if you are interested in experimental treatments. Some of the treatments being studied include:

  • Nitric oxide and glyceryl trinitrate, applied topically (to the skin) over the injury.
  • Ultrasonic, or shock, waves directed at the injured tendon (shock wave therapy) for pain caused by calcific tendinitis (calcium built up in the tendons). For more information, see the topic Calcium Deposits and Tendinitis (Calcific Tendinitis) .
  • Platelet-rich plasma (PRP). In this procedure, blood is drawn from the person and spun at high speeds to separate out the blood cells called platelets. Then the platelets are injected back into the body at the injury site.

References

Citations

  1. Khan RJK, Smith RLC (2010). Surgical interventions for treating acute Achilles tendon ruptures. Cochrane Database of Systematic Reviews (9).

Credits

Current as of: June 26, 2019

Author: Healthwise Staff

Medical Review:

Anne C. Poinier MD - Internal Medicine

E. Gregory Thompson MD - Internal Medicine

Adam Husney MD - Family Medicine

Kathleen Romito MD - Family Medicine

David Bardana MD, FRCSC - Orthopedic Surgery, Sports Medicine

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