tendon is the thickest and strongest tendon in your body, connecting your calf muscles to the back of your heel. Virtually all of the force generated when you ?toe off? the ground during running is
transmitted by the Achilles, and this force can be as much as three times your body weight. And the faster you run, the more strain you put on the Achilles tendon. As such, it?s prone to injury in
many runners, but particularly those who do a lot of fast training, uphill running, or use a forefoot-striking style. Achilles tendon injuries account for 5-12% of all running injuries, and occur
disproportionately in men. This may be because of the faster absolute speeds men tend to train at, or may be due to other biomechanical factors.
There are two large muscles in the calf. These muscles are important for walking. They create the power needed to push off with the foot or go up on the toes. The large Achilles tendon connects these
muscles to the heel. Heel pain is most often due to overuse of the foot. Rarely it is caused by an injury. Tendinitis due to overuse is most common in younger people. It can occur in walkers,
runners, or other athletes. Achilles tendinitis may be more likely to occur if you Suddenly increase the amount or intensity of an activity. Your calf muscles are very tight (not stretched out). You
run on hard surfaces such as concrete. You run too often, you jump a lot (such as when playing basketball), you do not have shoes with proper support, your foot suddenly turns in or out. Tendinitis
from arthritis is more common in middle-aged and elderly people. A bone spur or growth may form in the back of the heel bone. This may irritate the Achilles tendon and cause pain and swelling.
The main complaint associated with Achilles tendonitis is pain behind the heel. The pain is often most prominent in an area about 2-4 centimeters above where the tendon attaches to the heel. In this
location, called the watershed zone of the tendon, the blood supply to the tendon makes this area particularly susceptible. Patients with Achilles tendonitis usually experience the most significant
pain after periods of inactivity. Therefore patients tend to experience pain after first walking in the morning and when getting up after sitting for long periods of time. Patients will also
experience pain while participating in activities, such as when running or jumping. Achilles tendonitis pain associated with exercise is most significant when pushing off or jumping.
Examination of the achilles tendon is inspection for muscle atrophy, swelling, asymmetry, joint effusions and erythema. Atrophy is an important clue to the duration of the tendinopathy and it is
often present with chronic conditions. Swelling, asymmetry and erythema in pathologic tendons are often observed in the examination. Joint effusions are uncommon with tendinopathy and suggest the
possibility of intra-articular pathology. Range of motion testing, strength and flexibility are often limited on the side of the tendinopathy. Palpation tends to elicit well-localized tenderness that
is similar in quality and location to the pain experienced during activity. Physical examinations of the Achilles tendon often reveals palpable nodules and thickening. Anatomic deformities, such as
forefoot and heel varus and excessive pes planus or foot pronation, should receive special attention. These anatomic deformities are often associated with this problem. In case extra research is
wanted, an echography is the first choice of examination when there is a suspicion of tendinosis. Imaging studies are not necessary to diagnose achilles tendonitis, but may be useful with
differential diagnosis. Ultrasound is the imaging modality of first choice as it provides a clear indication of tendon width, changes of water content within the tendon and collagen integrity, as
well as bursal swelling. MRI may be indicated if diagnosis is unclear or symptoms are atypical. MRI may show increased signal within the Achilles.
Use the R.I.C.E method of treatment when you first notice the pain. Although rest is a key part of treating tendonitis, prolonged inactivity can cause stiffness in your joints. Move the injured ankle
through its full range of motion and perform gentle calf and ankle stretches to maintain flexibility. If self-care doesn't work, it's important to get the injury treated because if the tendon
continues to sustain small tears through movement, it can rupture under excessive stress. Your doctor may suggest a temporary foot insert that elevates your heel and may relieve strain on the tendon.
Other possible treatments include special heel pads or cups to wear in your shoes to cushion and support your heel, or a splint to wear at night. Physical therapy may also help allow the tendon to
heal and repair itself over a period of weeks.
Surgery should be considered to relieve Achilles tendinitis only if the pain does not improve after 6 months of nonsurgical treatment. The specific type of surgery depends on the location of the
tendinitis and the amount of damage to the tendon. 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. The procedure can be performed with a traditional, open incision or with a smaller incision and an endoscope-an instrument that contains a
small camera. Your doctor will discuss the procedure that best meets your needs. Complication rates for gastrocnemius recession are low, but can include nerve damage. Gastrocnemius recession can be
performed with or without d?bridement, which is removal of damaged tissue. D?bridement 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 metal or plastic anchors to help hold the Achilles tendon to the heel bone, where it attaches. After d?bridement 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. D?bridement 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, an Achilles tendon transfer is performed. The tendon that helps the big toe 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. Depending on the extent of damage to the
tendon, some patients may not be able to return to competitive sports or running. Recovery. Most patients have good results from surgery. The main factor in surgical recovery is the amount of damage
to the tendon. The greater the amount of tendon involved, the longer the recovery period, and the less likely a patient will be able to return to sports activity. Physical therapy is an important
part of recovery. Many patients require 12 months of rehabilitation before they are pain-free.
Warm up slowly by running at least one minute per mile slower than your usual pace for the first mile. Running backwards during your first mile is also a very effective way to warm up the Achilles,
because doing so produces a gentle eccentric load that acts to strengthen the tendon. Runners should also avoid making sudden changes in mileage, and they should be particularly careful when wearing
racing flats, as these shoes produce very rapid rates of pronation that increase the risk of Achilles tendon injury. If you have a tendency to be stiff, spend extra time stretching. If you?re overly
flexible, perform eccentric load exercises preventively. Lastly, it is always important to control biomechanical alignment issues, either with proper running shoes and if necessary, stock or custom