Treatments vary for Achilles heel

Have you heard of the phenomenon of the weekend warrior? It’s not just a cliche, but a real thing, the desk-bound office worker, who sits at a desk for the 40-hour work week, then glued to the television after another tough workday. On the weekend, he goes to war on the local football field, the neighborhood hard court, or whichever is his game of choice. This type of combatant may be limited in his conditioning, but not his enthusiasm, and he harkens back to the days of yore, when he did battle with the energy and vitality of youth. He is no longer young in body, only in spirit. This is the prototypical weekend warrior.

The neighborhood basketball game (or whichever sport may be appropriate to the season) is played with considerable vigor, and injuries do happen. This oft-repeated scenario frequently turns ugly when a participant grabs at the back of his ankle, having experienced the sensation of being shot, or hit with a bat in the area.

In actuality, he likely has suffered an acute rupture of the Achilles tendon (the thick cord which connects the heel bone to the calf muscles). This is a disabling injury since you cannot propel yourself forward, ie walk normally, without an intact Achilles. Very importantly, this is not an injury that will heal on its own, and generally surgery is required to repair the torn structure.

At this juncture, some of you reading this may wonder if this is the cause of the pain you have been experiencing behind your heel. Fortunately, this is unlikely. Much more common is the inflamed Achilles tendon, or, in contrast (and actually different) the chronically diseased tendon. The former is termed tendonitis, and the latter tendinosis. To those of us studying this sort of thing, the distinction is critical.

Tendonitis is usually the diagnosis for an acute injury when the tendon is overloaded, causing pain and swelling from tiny tears in the injured tissue. On the other hand, tendonosis occurs from repetitive trauma to a tendon. This chronic microtrauma leads to a loss of continuity of the fibers which constitute the Achilles tendon.

With tendinosis, the fibers are no longer aligned correctly, and fail to link together properly, resulting in loss of strength and further injury when used. Inflammation is not generally present with tendonosis.

Tendinitis can affect people of any age, but is more common among adults who do a lot of sports, or those who do not warm up properly for their activity. Elderly individuals are also susceptible to tendinitis because our tendons tend to lose their elasticity and become weaker as we get older.

Those afflicted with rheumatoid arthritis are also more susceptible. Those with poor foot mechanics are more inclined to develop this condition, as are those who wear old, collapsed shoes.

Inflamed tendons are more likely to rupture, so a failure to treat can have dire consequences. If the sheath around the tendon becomes inflamed, rather than the tendon itself, the condition is called tenosynovitis, although it is certainly possible to suffer from both tendinitis and tenosynovitis simultaneously.

How do the symptoms differ between these two conditions? Very little. The symptoms of tendonitis start gradually. Aching and burning pain is noted, especially with morning activity. It may improve slightly with initial activity, but becomes worse with further movement. Tendonitis is aggravated by exercise.

Over time, less exercise is required to cause the pain. Symptoms occur where the tendon attaches to the bone; and usually include pain, especially if the affected area is stressed (which occurs when you stand or walk!). The sufferer often relates a feeling that the tendon is crackling or grating as it moves, a sensation which can also be experienced by touching the area.

This last sensation can also be seen with tendinosis. One may note swelling in the affected area, which will be at the back of the heel bone with tendinitis, and higher up with tendinosis. Common with tendinitis is a feeling of warmth in the area, as well as some redness. In contrast, when a rupture has occurred, a gap may be felt in the line of the tendon. Movement of the injured part will be very difficult.

An excellent reason to differentiate between tendonitis and tendonosis is so that more appropriate treatment techniques can be utilized. Treatment for tendonitis starts with good old fashion RICE (rest, ice, compression, elevation) to reduce inflammation and allow healing. The tendonitis should heal in about 6 weeks and will benefit from anti-inflammatory medicine, cortisone injections, and physical therapy.

When it comes to tendonosis, anti-inflammatory medicines and cortisone injections are not indicated, nor are they the best course of treatment, because they inhibit collagen repair. Tendonosis healing time is 3-6 months once it becomes chronic. Studies show that it takes up to 100 days to rebuild collagen. The primary treatment plan for tendonosis is to break the injury cycle and reduce stress on the tendon with rest, appropriate bracing to support the structure, physical therapy, and by improving body biomechanics.

This latter goal can be assisted using prescription foot supports (aka foot orthotics). These devices, when properly prescribed, can help to control motion of the heel bone, and so reduce physical irritation of the tendon. Therapy should include light stretching to preserve motion and increase circulation, cross friction massage, and a specialized strengthening technique (eccentric stretches).

Other new developments in the treatment of these kinds of conditions include the use of PRP, in which a sample of blood is spun down to obtain platelets (a component of blood that helps to seal a cut). Unfortunately, despite the early hype, this method has not proven itself to be notably beneficial.

Cold lasers have no complications or side effects, and have been shown in a variety of studies to be beneficial in problems of this genre. Extra-corporeal shock wave devices were developed from lithotripsy machines, whereby sound waves are generated to break up kidney stones. Once again, although helpful, a lack of insurance coverage (for what is a pricey device) limit’s its use.

As always, a great variety of surgical procedures have been developed. As is generally the case, the possible complications make Achilles tendon surgery an option to be avoided if conservative measures are not yet exhausted. The exception is for the aforementioned acute tendon rupture, in which surgery is often the only viable option.

Are you hoping for a take-home, closing message, like “don’t participate in sports”? On the contrary, getting fit is key, by gradually introducing stress to the tendons of the lower extremity, stimulating them to “get in shape!” Be smart about your exercise program by using the techniques that have been developed over the course of the 50-year fitness craze. But it’s not a craze; you’re just crazy if you don’t get out, get active, and do something, anything, that stimulates your heart, your lungs, your legs. You’ll feel better, live longer, and be happier!

Editor’s note: Dr. Conway McLean is a podiatric physician now practicing foot and ankle medicine in the Upper Peninsula, having assumed the practice of Dr. Ken Tabor. McLean has lectured internationally on surgery and wound care, and is board certified in both, with a sub-specialty in foot orthotic therapy. Dr. McLean welcomes questions, comments and suggestions at drcmclean@penmed.com.