What Is the Achilles Tendon?
The Achilles tendon is a band of tissue that connects a muscle to a bone. It runs down the back of the lower leg and connects the calf muscle to the heel bone. Also called the heel cord, the Achilles tendon facilitates walking by helping to raise the heel off the ground.
Achilles Tendonitis and Achilles Tendonosis
Two common disorders that occur in the heel cord are Achilles tendonitis and Achilles tendonosis.
Achilles tendonitis is an inflammation of the Achilles tendon. This inflammation is typically short-lived. Over time, if not resolved, the condition may progress to a degeneration of the tendon (Achilles tendonosis), in which the tendon loses its organized structure and is likely to develop microscopic tears. Sometimes the degeneration involves the site where the Achilles tendon attaches to the heel bone. In rare cases, chronic degeneration with or without pain may result in rupture of the tendon.
As “overuse” disorders, Achilles tendonitis and tendonosis are usually caused by a sudden increase of a repetitive activity involving the Achilles tendon. Such activity puts too much stress on the tendon too quickly, leading to micro-injury of the tendon fibers. Due to this ongoing stress on the tendon, the body is unable to repair the injured tissue. The structure of the tendon is then altered, resulting in continued pain.
Athletes are at high risk for developing disorders of the Achilles tendon. Achilles tendonitis and tendonosis are also common in individuals whose work puts stress on their ankles and feet, such as laborers, as well as in “weekend warriors”—those who are less conditioned and participate in athletics only on weekends or infrequently.
In addition, people with excessive pronation (flattening of the arch) have a tendency to develop Achilles tendonitis and tendonosis due to the greater demands placed on the tendon when walking. If these individuals wear shoes without adequate stability, their overpronation could further aggravate the Achilles tendon.
The symptoms associated with Achilles tendonitis and tendonosis include:
- Pain—aching, stiffness, soreness or tenderness—within the tendon. This may occur anywhere along the tendon’s path, beginning with the tendon’s attachment directly above the heel upward to the region just below the calf muscle. Pain often appears upon arising in the morning or after periods of rest, then improves somewhat with motion but later worsens with increased activity.
- Tenderness, or sometimes intense pain, when the sides of the tendon are squeezed. There is less tenderness, however, when pressing directly on the back of the tendon.
- When the disorder progresses to degeneration, the tendon may become enlarged and may develop nodules in the area where the tissue is damaged.
In diagnosing Achilles tendonitis or tendonosis, the surgeon will examine the patient’s foot and ankle and evaluate the range of motion and condition of the tendon. The extent of the condition can be further assessed with x-rays or other imaging modalities.
Treatment approaches for Achilles tendonitis or tendonosis are selected on the basis of how long the injury has been present and the degree of damage to the tendon. In the early stage, when there is sudden (acute) inflammation, one or more of the following options may be recommended:
- Immobilization may involve the use of a cast or removable walking boot to reduce forces through the Achilles tendon and promote healing.
- To reduce swelling due to inflammation, apply a bag of ice over a thin towel to the affected area for 20 minutes of each waking hour. Do not put ice directly against the skin.
- Oral medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be helpful in reducing the pain and inflammation in the early stage of the condition.
- For those with overpronation or gait abnormalities, custom orthotic devices may be prescribed.
- Night splints. Night splints help to maintain a stretch in the Achilles tendon during sleep.
- Physical therapy. Physical therapy may include strengthening exercises, soft-tissue massage/mobilization, gait and running re-education, stretching and ultrasound therapy.
When Is Surgery Needed?
If nonsurgical approaches fail to restore the tendon to its normal condition, surgery may be necessary. Dr. Cottom will select the best procedure to repair the tendon, based on the extent of the injury, the patient’s age and activity level, and other factors.
To prevent Achilles tendonitis or tendonosis from recurring after surgical or nonsurgical treatment, the foot and ankle surgeon may recommend strengthening and stretching of the calf muscles through daily exercises. Wearing proper shoes for the foot type and activity is also important in preventing recurrence of the condition.
Achilles Tendon Rupture
What Is the Achilles Tendon?
A tendon is a band of tissue that connects a muscle to a bone. The Achilles tendon runs down the back of the lower leg and connects the calf muscle to the heel bone. Also called the heel cord, the Achilles tendon facilitates walking by helping to raise the heel off the ground.
What Is an Achilles Tendon Rupture?
An Achilles tendon rupture is a complete or partial tear that occurs when the tendon is stretched beyond its capacity. Forceful jumping or pivoting, or sudden accelerations of running, can overstretch the tendon and cause a tear. An injury to the tendon can also result from falling or tripping.
Achilles tendon ruptures are most often seen in “weekend warriors”—typically, middle-aged people participating in sports in their spare time. Less commonly, illness or medications, such as steroids or certain antibiotics, may weaken the tendon and contribute to ruptures.
Signs & Symptoms
A person with a ruptured Achilles tendon may experience one or more of the following:
- Sudden pain (which feels like a kick or a stab) in the back of the ankle or calf—often subsiding into a dull ache
- A popping or snapping sensation
- Swelling on the back of the leg between the heel and the calf
- Difficulty walking (especially upstairs or uphill) and difficulty rising up on the toes
- These symptoms require prompt medical attention to prevent further damage. Until the patient is able to see a doctor, the RICE method should be used. This involves:
- Stay off the injured foot and ankle, since walking can cause pain or further damage.
- Apply a bag of ice covered with a thin towel to reduce swelling and pain. Do not put ice directly against the skin.
- Wrap the foot and ankle in an elastic bandage to prevent further swelling.
- Keep the leg elevated to reduce the swelling. It should be even with or slightly above heart level.
In diagnosing an Achilles tendon rupture, the foot and ankle surgeon will ask questions about how and when the injury occurred and whether the patient has previously injured the tendon or experienced similar symptoms. The surgeon will examine the foot and ankle, feeling for a defect in the tendon that suggests a tear. Range of motion and muscle strength will be evaluated and compared to the uninjured foot and ankle. If the Achilles tendon is ruptured, the patient will have less strength in pushing down (as on a gas pedal) and will have difficulty rising on the toes.
The diagnosis of an Achilles tendon rupture is typically straightforward and can be made through this type of examination. In some cases, however, the surgeon may order an MRI or other advanced imaging tests.
Treatment options for an Achilles tendon rupture include surgical and nonsurgical approaches. The decision of whether to proceed with surgery or nonsurgical treatment is based on the severity of the rupture and the patient’s health status and activity level.
Nonsurgical treatment, which is generally associated with a higher rate of rerupture, is selected for minor ruptures, less active patients and those with medical conditions that prevent them from undergoing surgery. Nonsurgical treatment involves use of a cast, walking boot or brace to restrict motion and allow the torn tendon to heal.
Surgery offers important potential benefits. Besides decreasing the likelihood of rerupturing the Achilles tendon, surgery often increases the patient’s push-off strength and improves muscle function and movement of the ankle.
Various surgical techniques are available to repair the rupture. The surgeon will select the procedure best suited to the patient.
Following surgery, the foot and ankle are initially immobilized in a cast or walking boot. Dr. Cottom will determine when the patient can begin weightbearing.
Complications such as incision-healing difficulties, rerupture of the tendon or nerve pain can arise after surgery. With new mini-open techniques, complications can be decreased.
Whether an Achilles tendon rupture is treated surgically or nonsurgically, physical therapy is an important component of the healing process. Physical therapy involves exercises that strengthen the muscles and improve range of motion in the foot and ankle.
Posterior Tibial Tendon Dysfunction (PTTD)
What Is PTTD?
The posterior tibial tendon serves as one of the major supporting structures of the foot, helping it to function while walking. Posterior tibial tendon dysfunction (PTTD) is a condition caused by changes in the tendon, impairing its ability to support the arch. This results in flattening of the foot.
PTTD is often called adult acquired flatfoot because it is the most common type of flatfoot developed during adulthood. Although this condition typically occurs in only one foot, some people may develop it in both feet. PTTD is usually progressive, which means it will keep getting worse, especially if it is not treated early.
Overuse of the posterior tibial tendon is often the cause of PTTD. In fact, the symptoms usually occur after activities that involve the tendon, such as running, walking, hiking or climbing stairs.
The symptoms of PTTD may include pain, swelling, a flattening of the arch and an inward rolling of the ankle. As the condition progresses, the symptoms will change.
For example, when PTTD initially develops, there is pain on the inside of the foot and ankle (along the course of the tendon). In addition, the area may be red, warm and swollen.
Later, as the arch begins to flatten, there may still be pain on the inside of the foot and ankle. But at this point, the foot and toes begin to turn outward and the ankle rolls inward.
As PTTD becomes more advanced, the arch flattens even more and the pain often shifts to the outside of the foot, below the ankle. The tendon has deteriorated considerably, and arthritis often develops in the foot. In more severe cases, arthritis may also develop in the ankle.
Because of the progressive nature of PTTD, early treatment is advised. If treated early enough, your symptoms may resolve without the need for surgery, and progression of your condition can be arrested.
In contrast, untreated PTTD could leave you with an extremely flat foot, painful arthritis in the foot and ankle and increasing limitations on walking, running or other activities.
In many cases of PTTD, treatment can begin with nonsurgical approaches that may include:
- Orthotic devices or bracing. To give your arch the support it needs, your foot and ankle surgeon may provide you with an ankle brace or a custom orthotic device that fits into the shoe.
- Sometimes a short-leg cast or boot is worn to immobilize the foot and allow the tendon to heal, or you may need to completely avoid all weightbearing for a while.
- Physical therapy. Ultrasound therapy and exercises may help rehabilitate the tendon and muscle following immobilization.
- Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce the pain and inflammation.
- Shoe modifications. Your foot and ankle surgeon may advise changes to your shoes and may provide special inserts designed to improve arch support.
When Is Surgery Needed?
In cases of PTTD that have progressed substantially or have failed to improve with nonsurgical treatment, surgery may be required. For some advanced cases, surgery may be the only option. Dr. Cottom will determine the best approach for you.
Peroneal Tendon Injuries
What Are the Peroneal Tendons?
A tendon is a band of tissue that connects a muscle to a bone. The two peroneal tendons in the foot run side by side behind the outer ankle bone. One peroneal tendon attaches to the outer part of the midfoot, while the other tendon runs under the foot and attaches near the inside of the arch. The main function of the peroneal tendons is to stabilize the foot and ankle and protect them from sprains.
Causes & Symptoms of Peroneal Tendon Injuries
Peroneal tendon injuries may be acute (occurring suddenly) or chronic (developing over a period of time). They most commonly occur in individuals who participate in sports that involve repetitive ankle motion. In addition, people with higher arches are at risk for developing peroneal tendon injuries. Basic types of peroneal tendon injuries are tendonitis, tears and subluxation.
Tendonitis is an inflammation of one or both tendons. The inflammation is caused by activities involving repetitive use of the tendon, overuse of the tendon or trauma (such as an ankle sprain). Symptoms of tendonitis include:
- Warm to the touch
Acute tears are caused by repetitive activity or trauma. Immediate symptoms of acute tears include:
- Weakness or instability of the foot and ankle
As time goes on, these tears may lead to a change in the shape of the foot in which the arch may become higher.
Degenerative tears (tendonosis) are usually due to overuse and occur over long periods of time, often years. In degenerative tears, the tendon is like taffy that has been overstretched until it becomes thin and eventually frays. Having high arches also puts you at risk for developing a degenerative tear. The symptoms of degenerative tears may include:
- Sporadic pain (occurring from time to time) on the outside of the ankle
- Weakness or instability in the ankle
- An increase in the height of the arch
Subluxation means one or both tendons have slipped out of their normal position. In some cases, subluxation is due to a condition in which a person is born with a variation in the shape of the bone or muscle. In other cases, subluxation occurs following trauma, such as an ankle sprain. Damage or injury to the tissues that stabilize the tendons (retinaculum) can lead to chronic tendon subluxation. The symptoms of subluxation may include:
- A snapping feeling of the tendon around the ankle bone
- Sporadic pain behind the outside ankle bone
- Ankle instability or weakness
Early treatment of a subluxation is critical since a tendon that continues to sublux (move out of position) is more likely to tear or rupture. Therefore, if you feel the characteristic snapping, see a foot and ankle surgeon immediately.
Because peroneal tendon injuries are sometimes misdiagnosed and may worsen without proper treatment, prompt evaluation by a foot and ankle surgeon is advised. To diagnose a peroneal tendon injury, the surgeon will examine the foot and look for pain, instability, swelling, warmth and weakness on the outer side of the ankle. In addition, an x-ray or other advanced imaging studies may be needed to fully evaluate the injury. The foot and ankle surgeon will also look for signs of an ankle sprain and other related injuries that sometimes accompany a peroneal tendon injury. Proper diagnosis is important because prolonged discomfort after a simple sprain may be a sign of additional problems.
Treatment depends on the type of peroneal tendon injury. Options include:
- A cast or splint may be used to keep the foot and ankle from moving and allow the injury to heal.
- Oral or injected anti-inflammatory drugs may help relieve pain and inflammation.
- Physical therapy. Ice, heat or ultrasound therapy may be used to reduce swelling and pain. As symptoms improve, exercises can be added to strengthen the muscles and improve range of motion and balance.
- The surgeon may provide a brace to use for a short while or during activities requiring repetitive ankle motion. Bracing may also be an option when a patient is not a candidate for surgery.
When Is Surgery Needed?
In some cases, surgery may be needed to repair the tendon or tendons and perhaps the supporting structures of the foot. Dr. Cottom will determine the most appropriate procedure for the patient’s condition and lifestyle. After surgery, physical therapy is an important part of rehabilitation.