Heel pain (inflammation of the Achilles tendon) in the Dnieper

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Oleg Loskutov

This article was written together with Oleg Loskutov, Candidate of Medical Sciences, President of the Association for Foot and Ankle Surgery. Contact your doctor

Heel pain is a common condition that occurs when the large Achilles tendon, which runs down the back of the lower leg, becomes irritated and inflamed.

The Achilles tendon is the largest tendon in the body. It connects your calf muscles to your heel bone and is used when you walk, run, climb stairs, jump and stand on your toes. Although the Achilles tendon can withstand heavy loads from running and jumping, it is also prone to tendonitis, a condition associated with overuse and wear of the tendon.

Achilles tendon pain can occur within the tendon itself or at the point where it attaches to the heel bone.

Cause

Achilles tendinitis is usually not associated with a specific injury. The problem occurs due to repetitive stress on the tendons. This often happens when we force our bodies to do too much, too soon, but other factors can increase the likelihood of developing tendinitis, including:

A sudden increase in the amount or intensity of exercise—for example, increasing the distance you run each day by several miles, without giving your body a chance to adjust to the new distance.
Tight calf muscles. Having tight calf muscles and suddenly starting an aggressive exercise program can cause additional stress in the Achilles tendon.
A bone spur is an extra bone growth where the Achilles tendon attaches to the heel bone that can rub against the tendon and cause pain

A bone spur that has developed where the tendon attaches to the heel bone.

Clinical picture

The pathology is characterized by gradual development. At the initial stage, discomfort arises, quickly disappearing after a few minutes of physical activity. A small load, for example, sports, helps to completely eliminate pain. When you feel the tissues affected by inflammation, a slight tingling sensation may occur. Lack of medical care is the reason for the chronicity of the disease. It is characterized by the following clinical manifestations:

gradual increase in the severity of pain. It no longer disappears during training, and the intensity of the discomfort increases significantly;
even after a long rest, the pain does not disappear; it also occurs in the morning;
going up or down the stairs provokes the appearance of pain or its intensification.

When diagnosing Achilles tendonitis of moderate or severe severity, the doctor notes local hyperemia. In the damaged tissues, the temperature locally rises, the calf muscle is very tense, and there is no full flexion of the foot.

Symptoms

Common symptoms of Achilles tendonitis include:

Pain and stiffness along the Achilles tendon in the morning
Pain along the tendon or back of the heel that gets worse with activity
Severe pain the day after training
Tendon thickening
Bone spur (insertional tendinitis)
Swelling that is present all the time and worsens during the day with activity

If you experience a sudden "jump" in the back of your calf or heel, you may have broken (torn) your Achilles tendon. See your doctor immediately if you think you may have torn a tendon.

At the doctor:

After you describe your symptoms and discuss your concerns, your doctor will examine your foot and ankle. The doctor will look for these signs:

Swelling along the Achilles tendon or at the back of the heel
Thickening or widening of the Achilles tendon
Bone spurs in the lower part of the tendon at the back of the heel (insertional tendinitis)
Point of maximum tenderness
Pain in the middle of the tendon (noninsertional tendinitis)
Pain in the back of the heel at the bottom of the tendon (insertional tendinitis)
Limited range of motion in the ankle, particularly decreased ability to flex the leg

Your doctor may order imaging tests to make sure your symptoms are caused by Achilles tendinitis.

X-ray

X-ray tests provide clear images of the bones. An x-ray can show whether the lower part of the Achilles tendon is calcified or hardened. This calcification indicates insertional tendonitis of the Achilles tendon. In cases of severe noninsertional Achilles tendonitis, there may also be calcification in the midportion of the tendon.

Magnetic resonance imaging (MRI)

Although magnetic resonance imaging (MRI) is not necessary to diagnose Achilles tendonitis, it is important for surgical planning. An MRI can show how severe the tendon damage is. If surgery is necessary, your doctor will choose a procedure based on the amount of damage to the tendon.

Diagnostics

An external examination and patient complaints help the doctor make an initial diagnosis. A series of laboratory tests are prescribed to exclude or confirm damage to the Achilles tendon tissue by pathogenic bacteria. Destructive-degenerative changes are established based on the results of instrumental studies:

radiography of the lower leg;
Ultrasound of the ankle joint;
MRI.

On radiographic images, calcified lesions localized in various parts of the tendon can be clearly visible. The diagnosis of tendonitis is made regardless of whether calcifications are present or not on the images. Ultrasonography and MRI are more accurate diagnostic techniques for detailed examination of soft tissues. They help identify foci of inflammation and areas with degenerative changes.

Magnetic resonance examination accurately determines the acute stage of the inflammatory process. This stage is characterized by the accumulation of a large amount of fluid in the tissues of the Achilles tendon in the absence of external edema.

Treatment

Non-surgical treatment

In most cases, non-surgical treatment options will provide pain relief, although it may take several months for symptoms to completely resolve. Even with early treatment, pain may last longer than 3 months. If you have had pain for several months before seeking treatment, it may take 6 months for treatments to take effect.

Rest. The first step in reducing pain is to reduce or even stop activities that make the pain worse. If you regularly perform high-impact exercises (such as running), switching to low-impact exercises will place less stress on the Achilles tendon. Cross-training exercises such as cycling, elliptical exercises and swimming are low-impact options that will help you stay active.

Ice. Placing ice on the most painful area of the Achilles tendon is helpful and can be done as needed throughout the day. This can be done for up to 20 minutes and should be stopped sooner if the skin becomes numb.

Non-steroidal anti-inflammatory drugs. Medicines such as ibuprofen and naproxen reduce pain and swelling. They do not, however, reduce the thickening of the degenerated tendon. You should consult your doctor about using the medicine for more than 1 month.

Exercise. The following exercise can help strengthen your calf muscles and reduce stress on your Achilles tendon.

Stretch calf

The calf is stretching. Lean forward toward the wall with one knee straight and heel on the ground. Place your other leg forward with your knee bent. To stretch your calf muscles and heel cord, push your hips toward the wall in a controlled manner. Stay in this position for 10 seconds and relax. Repeat this exercise 20 times for each leg. As you stretch, you should feel a strong tension in your calf (calf muscle).

Physiotherapy. Physical therapy is very helpful in treating Achilles tendinitis. It has been found to work better for non-insertional tendonitis than for insertional tendonitis.

Exercise therapy for home.

Fall on your heel

Bilateral heel drop. Stand on the edge of a ladder or on a stable raised platform with the front half of your foot on the ladder. This position will allow your heel to move up and down without hitting the stairs. Care must be taken to ensure you are balanced correctly to prevent falls and injury. Be sure to hold on to the railing to help you balance.
Lift your heels off the ground, then slowly lower your heels to the lowest possible point. Repeat this step 20 times. This exercise should be performed in a slow, controlled manner. Moving quickly can create a risk of tendon damage. As the pain improves, you can increase the difficulty level of the exercise by holding a small weight in each hand.
Heel drop on one leg. This exercise is performed similarly to the bilateral heel drop, except that all of your weight is concentrated on one leg. This should only be done after the bilateral heel drop has been mastered.

Cortisone injections. Cortisone, a type of steroid, is a powerful anti-inflammatory agent. Cortisone injections into the Achilles tendon are rarely recommended because they can cause the tendon to rupture.

Supportive shoes and orthopedics. Pain from insertional Achilles tendinitis is often relieved with certain shoes as well as orthotic devices. For example, shoes that are softer at the back of the heel can reduce tendon irritation. Additionally, heel raises can relieve tension on the tendon.

If your pain is severe, your doctor may recommend a walking boot for a short period of time. This gives the tendon a chance to rest before any therapy begins. However, long-term use of boots is not recommended because it can weaken your calf muscles.

Extracorporeal shock wave therapy (ESWT). During this procedure, high-energy shock wave pulses stimulate the healing process of damaged tendon tissue.

Surgery

Surgery should be considered for relief of Achilles tendonitis only if pain does not resolve after 6 months of nonsurgical treatment. The specific type of surgery depends on the location of the tendinitis and the extent of damage to the tendon.

Neutralization and restoration (the tendon has less than 50% damage). The purpose of this surgery 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 sutures to complete the repair.

For insertional tendonitis, the bone spur is also removed. Tendon surgery in these cases may require the use of metal or plastic anchors to help attach the Achilles tendon to the heel bone where it attaches.

After hair removal and recovery, most patients are allowed to walk in a removable boot or cast for 2 weeks, although this period depends on the extent of the tendon damage.

Recovery. Most patients have good results after surgery. The main factor in surgical repair is the amount of tendon damage. The more tendons involved, the longer the recovery period and the less likely the patient will be able to return to sports.

Physical therapy is an important part of recovery. Many patients require 12 months of rehabilitation before they are pain-free.

Complications. Moderate to severe pain after surgery occurs in 20-30% of patients and is the most common complication. In addition, wound infection may occur, and infection in this area is very difficult to treat.

Conservative methods of therapy

At the beginning of treatment, the orthopedist recommends that the patient wear a tight bandage and bed rest for two days with the leg elevated. Cold compresses will help stop inflammation and reduce the severity of pain. Constant cooling of the affected area prevents the formation of extensive hematomas, the dangerous consequences of which are scars. To immobilize the ankle joint:

special cotton ribbons. They do not contain latex, are similar in elasticity to human skin, securely fix the tendon and prevent it from stretching;
orthoses that limit movement. Immobilization is carried out at an angle of 90 °C at night, and in some cases - permanently.

When a severe inflammatory process is diagnosed, the patient is given a splint, splint or plaster cast. Changing your usual lifestyle helps to minimize exacerbations of the disease. Lifting heavy objects and wearing high-heeled shoes is prohibited.

Recovery and rehabilitation

To quickly restore Achilles tissue in case of chronic or acute illness or injury, it is necessary to strictly follow all the instructions of the attending physician.

Clinical recommendations for the rehabilitation period:

reduce the load on the affected leg as much as possible;
move for some time with the help of a cane or crutches (if necessary);
if intense pain occurs or swelling increases, you should immediately inform your doctor about the appearance of other manifestations of the disease;
maintain bed rest immediately after surgery and during severe pain;
reducing pressure on the tendon by purchasing good special shoes;
fix the ankle joint and foot with an orthosis or wear an elastic bandage for a period of one to three months;
Be sure to use physical therapy in the late stages of recovery.

Surgical intervention

Surgical treatment is indicated for the patient if conservative therapy is unsuccessful several months after its initiation. During the operation, the doctor makes an incision in the middle and exposes the tendon. The surrounding altered tissues are excised along with the formed thickenings. In case of extensive destruction, surgical intervention is highly complex:

to restore functional activity, plantar muscle tendons are placed on the excised areas;
strong tension of the tissues is prevented by suturing their incisions in the front in a weakened position for better posterior closure.

In patients with enthesopathy, the tendon bursa is excised after a lateral incision. With a Haglund deformity (the presence of a bone ridge), the heel spur puts excess pressure on the area where the tendon attaches to the heel bone. In this case, the patient is indicated for orthopedic surgery with bone dissection under general anesthesia. The process may use surgical instruments, laser or ultrasound. After tissue excision, the bones are fixed in the desired position using various devices: nails, plates, bone graft, plaster cast. Skeletal traction, which involves inserting a steel pin into the bone and suspending a weight, is widely practiced. The bone gradually stretches and takes on an anatomically correct position.

Throughout the entire postoperative period (1-1.5 months), the patient is advised to wear an orthosis or a plaster boot. When moving, he must use crutches so as not to put stress on the operated leg.