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ACHILLES TENDINOPATHY
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What is it? 
The Achilles tendon is a thick band of tissue along the back of the ankle that attaches the calf muscle to the heel bone. It is under stress during activities that use the calf repeatedly, like jumping and running. Sometimes, just walking can overload the tendon, particularly in people with less flexibility or strength. Being overweight, having diabetes, or having feet that toe-in or toe-out can also affect the tendon. Achilles tendinopathy refers to the condition where the stress to the tendon results with very small tears or damage to or around the tendon. “Tendinitis” is what it is called when the damage is new, typically within 10 days, when the tendon is still inflamed (“itis”). After these first few days and the inflammation has gone away, what is left is a state of damage and the body attempting repair, a state that may cause the pain from “tendinopathy,” or "tendinosis" no longer “tendinitis.”

Symptoms
People with Achilles tendinopathy will have pain and swelling over the tendon. The symptoms are usually worse with a lot of physical activity and better with a hot shower and heat or ice packs.  If there is a tear in the tendon, there can be sudden severe pain along with weakness at the ankle. 

Sports Medicine Evaluation
A sports medicine physician will watch how the athlete walks and have him/her do things that put stress on the tendon, such as going up on the toes one leg at a time, or hopping on one leg. These may cause pain when someone has Achilles tendinopathy. When the doctor presses the area, it is likely to hurt. The calf muscle may also be weaker than the opposite side. 

Treatment
Treatment of Achilles tendinopathy first involves controlling the pain. Ice and anti-inflammatory medications may help. Sometimes shoe inserts, ankle braces or walking boots are needed. Second, it is important to help the calf muscle and Achilles tendon become stronger and more flexible with calf stretching, ankle pump exercises, and doing heel-drops. These exercises, as well as special exercises that use the calf muscle as it lengthens (“eccentric” exercises) can help rebuild the injured tendon and regain strength.  If the pain continues, different types of injections or sometimes surgery may be recommended. 

Injury Prevention 
Keeping the calf and leg muscles strong and flexible can prevent Achilles problems. Correcting walking patterns that have extreme in-toeing or out-toeing may reduce load on the calf muscles and the Achilles tendon. A gradual change of increasing activity is recommended. Getting adequate rest between high levels of physical exercise will also help prevent this overload injury.

Return to Play
It may take 12 weeks to see the effects of a strengthening rehabilitation program. It is important to get as close to normal with the strength of the injured leg before returning to jogging or sports. Some doctors suggest that if someone can do at least 5 heel raises on the injured leg, reaching nearly the same height of the normal leg, then a slow return to jogging can start. Returning to more strenuous sports can take 20 weeks or longer due to the greater stress placed the Achilles tendon.

Authors: AMSSM Members Gloria G. Rho, MD, and Susan M. Joy, MD

References:

Alfredson H, Pietila T, Jonsson P, et al. Heavy-load eccentric calf muscle training for treatment of chronic Achilles tendinosis. American Journal of Sports Medicine 1998 (26): 360-366.

Fahlstrom, M, Jonsson P, et al. Chronic Achilles tendon pain treated with eccentric calf-muscle training. Knee Surg Sports Traumatol Arthroscopy 2003 (11): 327-333.

Murtaugh, Bryan and Joseph Ihm. Eccentric Training for the Treatment of Tendinopathies. Current Sports Medicine Reports 2013: 175-182. 

Category: Foot and Ankle, Overuse Injuries,

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