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HSS Presents: Chronic Achilles Tendon Problems

EAST RUTHERFORD, NJ - has called upon our good friends at Hospital for Special Surgery, the official hospital and team physicians of the New York Giants, to help fans learn about the many different ailments affecting NFL players today. Stay tuned to each month for
new information on these injuries.

Aaron Krych, MD
Fellow, Sports Medicine and Shoulder Service
Hospital for Special Surgery

Russell F. Warren, MD
Team Physician, New York Giants
Attending Orthopedic Surgeon, Hospital for Special Surgery

Scott A. Rodeo, MD
Associate Team Physician, New York Giants
Co-Chief, Sports Medicine and Shoulder Service & Attending Orthopedic Surgeon, Hospital for Special Surgery

The Achilles tendon is located in the back of the leg where the gastrocnemius and soleus muscles of the calf come together and attach to the calcaneus, otherwise known as the heel bone. The Achilles tendon, which is the strongest tendon in the body, allows people to push off in walking, running and jumping.

Achilles tendon problems are some of the most common conditions seen by sports medicine doctors.  Chronic, long-lasting Achilles tendon disorders range from overuse injuries to tearing of the tendon. Pain in the heel can often be caused by a combination of distinct problems with the Achilles tendon, including the following:

  • Paratenonitis
  • Tendinosis
  • Insertional Tendonitis
  • Retrocalcaneal Bursitis
  • Subcutaneous Tendo-Achilles Bursitis

What is Paratenonitis?

Paratenonitis is an Achilles tendon injury caused by overuse. It involves inflammation of the covering of the Achilles tendon. In acute cases, the tendon can appear "sausage-like" because it is severely swollen. Marathon runners often experience this type of swelling after long runs. Symptoms are typically aggravated by running and relieved by rest. Runners may complain of stiffness and discomfort at the beginning of the run, but may run through the discomfort. If left untreated, however, paratenonitis may progress to the point that any running becomes difficult.

What is Tendinosis?

Most pain within the Achilles tendon may be classified as tendinosis because it involves tendon degeneration, not inflammation. In addition, the tendon may become weakened and lose its structure. Although aging may play a part in this process, repetitive minor trauma to the tendon without proper healing can also play a role. Areas of tendinosis may eventually progress to partial or complete ruptures if they experience high loads, as are seen with physically demanding sports such as football and basketball, especially during push-off and landing activities. 

What is Insertional Tendonitis?

Insertional tendonitis involves inflammation where the Achilles tendon inserts into the heel bone. People with this condition often have tenderness directly over the insertion of the Achilles tendon, which is commonly associated with calcium formation or a bone spur forming just above the insertion point. This condition can occur along with retrocalcaneal bursitis (see below) and a bony enlargement of the heel bone, known as Haglund's deformity, which is referred to as a "pump bump." Haglund's deformity is often seen in women who wear high-heeled shoes as well as in hockey players because of the skate rubbing on the back of the heel.  

What is Retrocalcaneal Bursitis?

Retrocalcaneal bursitis is caused by movement-related irritation of the retrocalcaneal bursa, the fluid-filled cushioning sac between the heel bone and the Achilles tendon. This condition involves pain in front of the Achilles tendon, in the area between the tendon and the heel bone. The bursa can become inflamed or thickened and stick to the tendon. Pain may result from squeezing the tendon itself or the space just in front of the tendon. Although retrocalcaneal bursitis in both tendons can be associated with rheumatoid arthritis in 10 percent of people, most occurrences in athletes only involve one side and are not associated with a systemic disease.

What is Subcutaneous Tendo-Achilles Bursitis?

This type of injury results from external pressure, often by poor-fitting shoes, causing friction between the Achilles tendon and the sheath around the tendon. In addition, biomechanical factors may play a role when a person walks with too much internal or external rotation of the foot. The whipping action involving internal and external rotation during running can cause stress on the Achilles tendon, also resulting in subcutaneous (under the skin) tendo-Achilles bursitis.

How Do Doctors Diagnose and Treat Achilles Tendon Disorders?

Doctors commonly use ultrasound and magnetic resonance imaging (MRI) to evaluate heel pain. These diagnostic methods, along with a physical examination and history, can help sports medicine physicians to properly diagnose Achilles tendon conditions and recommend treatment on an individual basis.

For the distinct disorders above, numerous forms of treatment have been used, depending on the nature of the injury. Most people who have injuries related to overuse of the tendon undergo non-surgical treatment, which begins with rest and modification of activities. Sometimes changing to a cross-training program with bicycling and water therapy can be helpful. A small heel lift that can be inserted within the shoe may be useful in reducing the stress on the Achilles tendon. 

In acute cases of Achilles tendon injury, especially when inflammation is involved, non-steroidal anti-inflammatory medications such as ibuprofen can be beneficial. In addition, treatment involves ice massages, stretching, strengthening exercises and correcting alignment problems under the guidance of a physician, athletic trainer or physical therapist. When these fail to relieve symptoms, injections of cortisone or platelet-rich plasma (see HSS update on PRP from October 2010) may be considered. A small group of patients who do not benefit from these therapies may require surgery.

Key Points to Remember

  • Chronic Achilles tendon injuries in athletes are often a range of disorders that are frequently seen in combination.
  • Treatment of Achilles tendon injuries can be challenging for competitive athletes because it usually involves significantly modifying activities, if not stopping them entirely.
  • Non-surgical therapy is successful in most people who have Achilles tendon injuries

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