Painful heel and Achilles Tendinitis

Behind your heel pain, there may be multiple causes, one among those is Achilles tendinitis. Achilles tendon runs on the back of your leg, from the calf muscles to the heel region. It can be felt like a large tight band. When it becomes irritated, it can cause swelling and pain leading to the condition called ‘Achilles tendinitis’. 

What causes painful heel and Achilles Tendinitis?

Though Achilles tendinitis can occur at any age, it commonly affects middle-aged and elderly people. The main cause is repetitive stress. It can cause micro-tears in the tendon. If you continue the same activity over time without giving proper healing time, then it heals to form a tendon of a weaker strength. Achilles pull can be caused due to sudden outburst of activity directly from rest without any prior stretches. High-intensity activity without prior training sessions can also damage the tendon. 

What are the risk factors for Achilles Tendinitis?

Various risk factors that can predispose this condition, such as,

• Genetic variations like ‘flat feet’ can lead to foot in rotation called pronation which can predispose to injury. 
• Inflammatory arthritis like Rheumatoid arthritis, Ankylosing spondylitis, gout and, more importantly, Diabetes can flare up the disease.
• Chronic medications like oral or intravenous steroids and fluoroquinolone group of antibiotics can cause tendon degeneration.
• Most importantly, type of footwear. Prolonged walking and running with formal office shoes can cause compression at the back. Women wearing high heels and improper fit sports shoes can predispose to injury. 

What are the symptoms of Achilles Tendinitis?

Pain is present along the tendon from the calf muscles till the attachment. It is common in the morning just after getting up from bed. It gets relieved with morning activities but reoccurs after the activity. 

Tenderness is present when the tendon or the calf muscles are squeezed. Increasing swelling and thickening of the tendon with continued activity and decreased range of motion at the ankle joint are encountered.

Complications of Achilles Tendinitis, if neglected! 

If the activity leading to stress and injury is continued over some time, it can cause,

1. Tendonosis – a condition where the tendon becomes degenerated, loses its strength and becomes thin and weak. It can lead to partial or complete tears.

2. Bursitis – It is swelling of the fluid contained cushions around the tendon which can cause compression. 

3. Spur – Extra Bone growth can form where the tendon attaches to the heel. This causes pain in every movement when it rubs against the tendon. It becomes even worse in those who wear a shoe for long hours. 

How is Achilles Tendinitis diagnosed?

Achilles tendinitis is easy to be diagnosed. Before starting any self-medication, it is important to consult an orthopedic doctor because treatment which varies depending on the age, cause, type and mechanism of injury. 

Behind the cause of heel pain, there is a triad of conditions such as Insertional Achilles tendinitis, Plantar fasciitis and Retrocalcaneal bursitis. All these disorders also must be checked before starting treatment. 

Physical, bio-mechanical and neurological examination is needed. Blood tests are done to rule out any co-morbid conditions, and radiological tests like X-ray or MRI (magnetic resonance imaging) scans are done to check the state of the disease. 

What are the treatments for Achilles Tendinitis?

 For the early stage of the disease, the following can be done.

• Rest – It is the most important part of the healing of any tendon disease, which is most often skipped or underestimated.

• Ice – The application of a pack of ice instantly helps resolve pain and swelling. It has to be applied for 5-10 mins on each leg. Always avoid applying direct ice on the skin.

• Compression/care – Crepe bandage application can relieve pain physically and decrease swelling reappearance. Immobilization is done by POP (Plaster of Paris) cast in acute tears to prevent further damage by completely avoiding movement at the ankle. In degenerative conditions walking boot or air boot can be provided. At night times splints can be given to maintain the stretch of the tendon. Immobilization is important as it gives time for healing in a normal anatomical place. 

• Elevation – During the night, keeps your foot elevated to decrease swelling, and you can also wear night splints to maintain the Achilles stretch. 

• Exercise –  Physical therapy, which involves stretching, strengthening, mobilization and gait training, is helpful to treat and prevent the re-occurrence of the disease. Heel cord stretch, hand-foot towel stretch and chair heel raise are three exercises for a strong and healthy heel. 

• Orthotics – There is special foot-wear modification customized depending upon the diseases present around the ankle. For example, those with a flat foot with Achilles tendinitis would require a custom shoe with arch and posterior support to make the gait easy and strain-free. Heel lifts are also a type of modification to prevent rubbing of the tendon. 

• Oral medications – Non-steroidal anti-inflammatory drugs (NSAIDs) are helpful in the initial days of acute pain and swelling. They don’t play a part in the progression or prevention of disease.

• Injections –  Direct injections of steroids are less effective in management and can sometimes even deteriorate the strength of the tendon. 

 Is surgery needed?

It is done only in a few conditions where the tendon is completely or partially torn. Reinforcement or reconstruction of the tendon is done using special surgical techniques. 

Treatment will be based on the type of injury and the patient’s age and activity. Surgery is also done in conditions where there is excess calcification or excess bony growth. 

Using keyhole surgery or arthroscopy, the calcifications can be removed, and the tendon can be debrided to give a full range of movement for faster rehabilitation.

Conclusion 

The mythological origin of the term Achilles heel refers to physical vulnerability despite strength. Likewise, it is important to take good care of your strong heel by avoiding the risk factors and following regular stretching and strengthening exercises to prevent the disease and its re-occurrence.