Where is the Achilles tendon, and what does it do?

The Achilles tendon is a strong, fibrous band that connects the calf muscle to the heel. The calf is actually formed by two muscles, the underlying soleus and the thick outer gastrocnemius. Together, they form the gastroc-soleus muscle group. When they contract, they pull on the Achilles tendon, causing your foot to point down and helping you rise on your toes. This powerful muscle group helps when you sprint, jump, or climb. Several different problems can occur that affect the Achilles tendon, some rather minor and some quite severe.

Tendocalcaneal Bursitis

A bursa is a fluid-filled sac designed to limit friction between rubbing parts. These sacs, or bursae, are found in many places in the body. When a bursa becomes inflamed, the condition is called bursitis. Tendocalcaneal bursitis is an inflammation in the bursa behind the heel bone. This bursa normally limits friction where the thick fibrous Achilles tendon that runs down the back of the calf glides up and down behind the heel.

Achilles Tendonitis | Aviolent strain can cause trauma to the calf muscles or the Achilles tendon. Sometimes this is referred to as tendonitis. This injury can happen during a strong contraction of the muscle, as when running or sprinting. Landing on the ground after a jump can force the foot upward, also causing injury. The strain can affect different portions of the muscles or tendon. For instance, the strain may occur in the center of the muscle. Or it may happen where the muscles join the Achilles tendon (called the musculotendinous junction).

Achilles Tendinopathy/Tendonosis

Chronic overuse may contribute to changes in the Achilles tendon as well, leading to degeneration and thickening of the tendon. Studies show there is no sign of inflammation with overuse injuries of tendons. Most experts now refer to this condition as tendinopathy or tendonosis instead of tendonitis.

Achilles Tendon Rupture

In severe cases, the force of a violent strain may even rupture the tendon. The classic example is a middle-aged tennis player or “weekend warrior” who places too much stress on the tendon and experiences a tearing of the tendon. In some instances, the rupture may be preceded by a period of tendonitis, which renders the tendon weaker than normal.

How do these problems develop?

It’s not entirely clear why these problems develop in some people but not in others. Changes in the normal alignment of the foot and leg may be part of the problem. Anyone with one leg shorter than the other is at increased risk of Achilles tendon problems

For the athlete, sudden increases in training may be a key factor. Runners may add on miles or engage in excessive hill training while other athletes increase training intensity. Other risk factors include obesity, diabetes (or other endocrine disorders), aging, exposure to steroids

As we age, our tendons can degenerate. Degeneration means that wear and tear occurs in the tendon over time and leads to a situation where the tendon is weaker than normal. Degeneration in a tendon usually shows up as a loss of the normal arrangement of the fibers of the tendon. Tendons are made up of strands of a material called collagen. (Think of a tendon as similar to a nylon rope and the strands of collagen as the nylon strands.) Some of the individual strands of the tendon become jumbled due to the degeneration, other fibers break, and the tendon loses strength.

The healing process in the tendon causes the tendon to become thickened as scar tissue tries to repair the tendon. This process can continue to the extent that a nodule forms within the tendon. This degenerative condition without inflammation is called tendonosis. The area of tendonosis in the tendon is weaker than normal tendon. Tiny tears in the tissue around the tendon occur with overuse. The weakened, degenerative tendon sets the stage for the possibility of actual rupture of the Achilles tendon.

Diagnosis is almost always by clinical history and physical examination. The physical examination is used to determine where your leg hurts. The doctor will probably move your ankle in different positions and ask you to hold your foot against the doctor’s pressure. By stretching the calf muscles and feeling where these muscles attach on the Achilles tendon, the doctor can begin to locate the problem area.

The doctor may run some simple tests if a rupture is suspected. One test involves simply feeling for a gap in the tendon where the rupture has occurred. However, swelling in the area can make it hard to feel a gap.

Another test is done with your leg positioned off the edge of the treatment table. The doctor squeezes your calf muscle to see if your foot bends downward. If your foot doesn’t bend downward, it’s highly likely that you have a ruptured Achilles tendon.

Tendo-calcaneal bursitis usually begins with pain and irritation at the back of the heel. There may be visible redness and swelling in the area. The back of the shoe may further irritate the condition, making it difficult to tolerate shoe wear.

Achilles tendonitis usually occurs further up the leg, just above the heel bone itself. The Achilles tendon in this area may be noticeably thickened and tender to the touch. Pain is present with walking, especially when pushing offon the toes.

An Achilles tendon rupture is usually an unmistakable event. Some bystanders may report actually hearing the snap, and the victim of a rupture usually describes a sensation similar to being violently kicked in the calf. Following rupture the calf may swell, and the injured person usually can’t rise on his toes.

Nonsurgical Treatment

Tendonitis/Tendinopathy

Nonsurgical treatment for tendocalcaneal bursitis and Achilles tendonitis started with a combination of rest (activity avoidance), ice, and anti-inflammatory medications such as ibuprofen or motrin.

In some cases, physical therapy may help alleviate your pain and well as help you restore proper motion and weight-bearing so you can return to your usual activities.

Physical therapy may also include a special program of stretching and eccentric strengthening exercises. Your therapist will instruct you in a home care program.

Tendon Rupture

Nonsurgical treatment for an Achilles tendon rupture is usually not recommended. Non-operative treatment has a lesser chance of healing with a higher prevalence of re-tearing. Many orthopedists feel that Achilles tendon ruptures in younger active patients should be surgically repaired

Surgery

Surgery may also be suggested if you have a ruptured Achilles tendon. Reattaching the two ends of the tendon repairs the torn Achilles tendon. This procedure is usually done through an incision on the back of the ankle near the Achilles tendon. Numerous procedures have been developed to repair the tendon, but most involve sewing the two ends of the tendon together.