Achilles tendon injury: causes, symptoms, diagnosis, treatment and rehabilitation

Achilles tendon injury: causes, symptoms, diagnosis, treatment and rehabilitation
May 16, 2014 12:18 AM

What is Achilles tendon? Achilles tendon is the tendon of lower leg and it is also known as calcaneal tendon and tendo calcaneus. It is a tough tendon that connects the muscles of calf to the heel bone (calcaneus). It is perhaps the longest and strongest tendon of human body. It virtually supports the entire weight of human body.

In addition to providing support to human body in maintaining posture, this tendon also plays an important role in everyday movements. When the muscles of calf contract Achilles tendon is pulled upward resulting in the movement of heel. This movement helps us in walking, running and standing. Although it is the strongest tendon of human body but it is also very vulnerable to injuries, tears and inflammation.

What can go wrong with Achilles tendon?

Achilles is the most frequently used tendon of human body and it receives a lot of insult due to wear and tear. No wonder it is prone to injuries and different conditions.

Following is the list of conditions that can commonly affect Achilles tendon:

Achilles tendon tear

Tear of Achilles tendon is more common than you might think. This tear can be small (micro-tear) or can be large. It results in excruciating pain, swelling and difficulty in the movement of foot. This tear might occur suddenly or might build up over time.

Achilles tendon rupture

To make things worse Achilles tendon can rupture totally. The rupture might be heard as a “pop” sound and is followed by intense pain and inability to move the foot. This condition requires surgical correction and long term rest.

Achilles tendinits

This condition is not as severe as the above mentioned conditions but it is definitely more cumbersome as the pain worsens over time. As mentioned before Achilles tendon is perhaps the most used tendon of human body so it’s natural that it has to withstand the insult of wear and tear. In this condition the tendon gets inflamed (swollen) and the movements become extremely painful.

Achilles tendinosis

This condition seems harmless but causes complications in longer run. Due to increasing age, some diseases and overuse the tendon gets thick and becomes more prone to get injured or ruptured.

Causes of Achilles tendon injury

Achilles tendon is the most important tendon of human body. The importance of this tendon is even more among athletes and runners. Any rupture, injury or inflammation can leave a person practically handicapped.

Following are the most important causes of Achilles tendon injuries:

  • Overuse is perhaps the most important cause of Achilles tendon injuries. These injuries usually develop over time. Unattended injuries become serious problems in longer run. So if you keep on using your feet more than your limits then you’re more prone to develop Achilles tendon injuries.
  • Achilles tendon injuries are most common among athletes. If you’re a professional athlete then you must know the importance of doing things slowly and not changing the level of difficulty suddenly. But enthusiastic athletes and runners usually make a mistake by stepping up the level of their activity too quickly. The result is increased risk of Achilles tendon injuries.
  • A proper warm up before running, lifting weights and even normal exercise is very important to avoid unwanted injuries. You might love running or lifting heavy weights but before doing such heavy workout make sure to spend a few minutes doing the necessary warm up exercises.
  • Women also make another group of individuals that are more prone to Achilles tendon injuries. The reason for that is wearing high heels more than usual. Wearing heels put your tendon in an awkward position and make you more prone to acquire injuries.
  • Sometimes the cause of Achilles tendon injuries is some condition of feet. For instance people with flat feet are more likely to develop injuries of Achilles tendon. The arched structure of foot gives support while movements. In such individuals the arch of foot is collapsed and it puts more burden on Achilles tendon and associated muscles.

What are the symptoms of Achilles tendon injury?

How to tell if the pain you’re having is due to some injury of Achilles tendon and no other reason.

Following are the most important symptoms of Achilles tendon injury:

  • Pain is the first and the foremost symptom of Achilles tendon injury. The nature of pain differs depending on the type of injury. In the case of Achilles tendon rupture the pain is severe and abrupt. However, the pain in case of Achilles tendinitis is mild, develops slowly and worsens over time. The pain usually worsens while doing any activity that involves the movement of feet. Another way to elicit pain of Achilles tendon injury is asking the patient to stand on his toes. The patient will be unable to do so due to excruciating pain. The pain also worsens upon standing for long time.
  • Tenderness is another important symptom of Achilles tendon injury. The area above heel, in particular, becomes very sensitive to touch and even touching that area elicits excruciating pain.
  • Swelling of ankle and feet is another presenting complaint of patients with Achilles tendon injury. Swelling might be followed by redness of ankle and foot.
  • The muscles of back of lower leg become very stiff and movements become very painful and difficult.
  • If you’ve suffered a full blown rupture of Achilles tendon then you might have heard a popping sound while the rupture was in progress.
  • Another important feature of Achilles tendon rupture is difficult (in case of tear or tendinitis) or total inability (in case of rupture) to flex the foot because Achilles tendon is mainly associated with flexing the feet.

Risk factors for Achilles tendon injury

The most important risk factors for Achilles tendon rupture, tears and inflammation include:

  • Age is the most important risk factor for Achilles tendon injury. Most of the people get Achilles tendon injuries during the 30s or 40s of their life.
  • Sex is another factor that defines Achilles tendon injuries. The chances of males to get Achilles tendon injury are five times more as compared to females. But the chances of females to get Achilles tendon injuries increase significantly if they’re in the habit of wearing high heel shoes for long periods.
  • Individuals involved in sports making more use of legs and Achilles tendon are highly likely to develop Achilles tendon injuries. Such sports include:
    • Football
    • Baseball
    • Sprinting
    • Tennis
    • Volleyball
    • Gymnastics
    • Dancing
  • Excessive use of steroids has been implicated as a risk factor Achilles tendon injury. Excessive use of steroids makes the tendon fragile and more susceptible to injury.
  • Use of certain medicines has been linked with increased risk of Achilles tendon injuries. Such medicines include ciprofloxacin and levofloxacin.

How to diagnose Achilles tendon injuries?

The diagnosis of Achilles tendon rupture, injury or inflammation is based on three important things: proper history, examination and further investigations.

Your doctor will assess the type and extend of your injury by taking history. He might ask you questions like when you got that injury; the nature of your pain, if it is sudden and intense or gradual and mild; the movements during which you feel maximum pain (during ankle movements, flexion of foot etc); the aggravating and relieving factors and so on.

The second important thing in making the diagnosis is proper physical examination. The doctor will confirm his preliminary diagnosis of Achilles tendon injury by asking you to try to stand on the toes of your feet.

Difficulty or complete inability to do so confirms an underlying Achilles tendon injury (complete rupture, tear or inflammation). Another test that doctors usually perform to confirm Achilles tendon injury is Thompson’s test. In this test your doctor would ask you to lie face down on the examination table.

He, then, would ask you to bend you knee. The doctor will gently squeeze your calf muscles. If the function of Achilles tendon is intact, it would trigger an involuntary movement of foot away from the leg (a movement known as plantar flexion).

If the function of Achilles tendon is compromised, plantar flexion would be absent. If diagnosis is still hazy and further confirmation is needed then doctor would ask you to get your ankle and leg MRI and CT scans done.

These tests would accurately determine the nature, location and extend of injury. This would help the doctors decide treatment options for you.

If MRI shows minor tissue tears then there is no need to go for surgery. Use of medicines and physiotherapy can help in such situations. If tests show full blown tear of Achilles tendon then surgery might be needed.

Treatments for Achilles tendon injuries

A number of treatments are available for Achilles tendon injuries and selection of treatment options depend on the extent of your injury.

The treatment options range from use of medications, conventional homemade therapies, surgery and different exercises.

Our main focus here would be to mention different types of exercises that can be used for the treatment of Achilles tendon injuries but other treatment options are also mentioned here.

Medicines

Over the counter medicines like aspirin and ibuprofen can be used in the case of Achilles tendon injuries. These medicines don’t promise recovery. The only purpose of these medicines is to decrease the excruciating pain associated with Achilles tendon injury. Doctor might also prescribe you some steroids to reduce the inflammation and swelling that follows Achilles tendon injury.

Rest

As mentioned before, Achilles tendon injuries are most common among individuals that make a lot of use of their legs, such as athletes. Achilles tendon injury, therefore, is the result of persistent wear and tear. So, appropriate rest can do you two goods. First it can help prevent Achilles tendon injuries in the first place. Second rest can decrease the pain that follows Achilles tendon injury and can also speed up the process of healing and recovery.

Icing

This is another popular homemade method that can be used to decrease pain. This method, again, doesn’t improve the healing of your injury but only improves pain and swelling that comes with Achilles tendon injury. Take some cubes of ice and place them in a plastic bag. Place that bag on the place that hurts the most. Gently rub the bag over that place for 20-30 minutes. Repeat this icing maneuver 2-3 times a day for as long as the pain lasts.

Heat treatment

This is another method that can soothe the pain and swelling. Heat water and add small amount of salt in it. Dip your feet in that water and gently rub the affected area with a towel. Keep doing this massage for 20-30 minutes. Repeat the procedure 2-3 times a day for as long as the pain lasts.

Massage

This is another conventional homemade therapy that can help reduce pain and swelling. Apply small amount of olive oil on your ankle, feet and legs. Gently rub the affected areas and don’t use much force. Keep doing this massage for 15-20 minutes for 2-3 times a day for as long as the pain subsides.

Compress your legs

Wearing elastic foot, ankle and feet bandages can help reduce the swelling and pain. Keep your leg elevated. Elevation of leg can help in draining the fluid that accumulates in the ankle tissues after injury and causes swelling and pain. Keep your leg slightly elevated as compared to the rest of your body when you’re sitting or sleeping.

Surgery

If your injury is full blown tendon tear type then above mentioned methods will just help subside pain and swellings. To restore your normal foot movements you would need reconstruction surgery of your Achilles tendon.

Exercises for Achilles tendon Rupture

Some exercises for Achilles tendon rupture are mentioned below:

  • Exercises that improve stretching and flexibility also help in the healing of tendon without causing significant pain. Other than stretching and flexibility exercises, some strengthening exercises which will help you regain the strength you had lost while the tendon was healing, are mentioned below:
    • An exercise for treating Achilles tendon rupture is sitting on a chair with knees bent at right angles, keeping your heel and feet flat on the floor. Now keeping your heel on the ground, lift your foot in the upwards direction. Remain in this position for some time and relax. Repeat this exercise approximately 10 to 20 times.
    • Stand on the bottom step of the stairs with your legs apart. You can hold the stair rail for support. Now lower your knees while keeping them straight. Remain in this position for 20-60 seconds. Repeat the exercise about six times. You can perform this exercise twice a week.

Rehabilitation therapy, which follows the surgery, for Achilles tendon is also quite helpful. For patients with partial rupture, rehabilitation is started as soon as the pain diminishes. Patients undergoing the repair of Achilles tendon don’t need physical therapy during the phase of healing.

But physical therapy is highly recommended once the incision has healed. One major type of rehabilitation exercise is the mobilization of the ankle after the injury. After the removal of the cast, the ankle is gently massaged and mobilized to reduce the stiffness.

Active exercises are done after a period of two weeks or so and a total of 12-16 weeks is required to see results of the therapy. The initial exercises are calf muscle stretching, with and without weights on foot. After the initial exercises, other exercises like jogging, jumping and sprinting can be done.

Exercises for Achilles tendon Sprain

In the Achilles tendon sprain, the calf muscles and the heel muscles are damaged in addition to the tendon. These calf muscles and the muscles on the shin are needed to protect the body against shock and high impact exercises. In case the Achilles tendon is overused, it can lead to serious consequences like degeneration and recurrent injuries, which results in a sprain.

Similar to the case with the Achilles tendon rupture, Achilles tendon sprain can be treated through physical therapy. Some exercises for Achilles tendon sprain have been mentioned below:

  • The calf stretch is considered as one of the most beneficial exercises for Achilles tendon sprain. For this exercise, stand about a foot from the wall, extending one leg behind you. Keep the feet flat on the floor all this time. After that, move your hips forward while at the same time keep the back flat. Now lean on to the wall until you feel tension in the calf muscle. Remain in this position for about 10 seconds and after that, stretch the other leg.
  • There is another kind of stretch for Achilles tendon sprain in which you have to stand at arm’s length distance from the wall. Now putting your hands on the wall, keep your back and legs straight, making sure your heels are flat on the floor. Now move your chest towards the wall. Remain in this position for some time. After that, relax and repeat the exercise at least two times.
  • There is yet another type of exercise known as Achilles tendon stretch. For this exercise, stand with one leg in front of you and the other one slightly extended back. Now lower your hips downwards while keeping the heels flat on the ground and the toes straight ahead. Remain in this position for a few minutes. After that repeat the exercise.

Other than the above mentioned exercise, you can do different stretches of calf muscles for at least twenty minutes or so. You can also perform jogging and running to heal your body quickly.

Yoga for Achilles tendon injuries

The yoga practices help the person to relax the tendons of the body without putting them through much pressure. Author of the Yin Yoga Kit, Biff Mithoefer, has the view that holding a yoga pose for an extended period of time while relaxing the body muscles makes the structure of connective tissues correct.

Yin Yoga is different from a typical yoga. It involves easing into a prone or seated yoga pose without warming up the body. The poses, in typical yin yoga are done for 5 to 20 minutes. However precaution should be taken while performing the yoga poses as some of them may worsen the Achilles tendon injury. Moreover, going past your ordinary comfort level can also worsen the conditions, thus increasing the chances of injury. So if you suspect Achilles tendon, you need to consult your doctor before continuing the yoga practice.

Physiotherapy for Achilles tendon Injury

Achilles tendon is one of the strongest and the thickest tendon in the whole body. So Achilles tendon rupture is a very serious condition. The usual treatments for Achilles tendon rupture are physical therapy or rehabilitation. Physical therapy can decrease the pain in the body, thus allowing the person to return to the normal daily life activities. A rehab program should also be followed after surgery, which can help greatly in the strengthening and healing of the tendon and muscles.

Physiotherapy or physical therapy, in plain simple words, is the healing of disease through mechanical means, that is, through exercise. Some physical therapies for Achilles tendon rupture are mentioned below:

  • The flexibility and stretching exercises will help in the healing of the tendon without becoming chronically painful or shortening.
  • Ultra sound therapy improves the blood circulation in a person’s body, which will help greatly in the healing process.
  • Deep massaging can also help in the strengthening of lower leg which can help in the prevention of further injuries.

Achilles tendon exercises for Toddlers

Although not quite as common as in adults, there can be Achilles tendon injuries in toddlers too. Some tips for Achilles tendon exercises in toddlers are mentioned below. As the kid can’t perform these exercises himself, the parent, guardian or the doctor is to help the toddler perform these exercises.

  • The first way to exercise Achilles tendon in toddlers is the toe stretch. For this exercise, make the kid sit on a chair and extend his affected leg so that the heel is on the floor. Now stretching downwards, pull his big toe up and back. Hold the toe in this position for 15 to 30 seconds. Repeat the exercise up to three to four times on daily basis.
  • Calf stretch, similar to the one done by adults, can also be done on toddlers. For this exercise, place the kid’s hands on the wall for balancing. Now put his left leg back and keep his back straight. Now, while bending the right leg slightly, press his hips forward. Hold the kid in this position for at least 15 to 30 seconds and repeat the exercise 3 to 4 times on each leg.
  • Another exercise for toddlers is the calf-planter fascia stretch. For this exercise, make the kid sit with the legs extended and the knees straight. Now loop a towel around the stretched leg. After this, pull back the towel, so that the toe moves towards the kid. Hold the kid in this position for at least 15 to 30 seconds. Repeat the exercise 2 to 4 times on daily basis.

Other than the above mentioned exercises, some tips for toddlers are mentioned below:

  • Increasing the intensity and the length of exercises gradually will help greatly. It is especially important in case your kid has been inactive for quite some time.
  • Warm up your kid before the exercises. This will also help greatly. In case the muscles of your kid are tight, the Achilles tendons of your kid will have to work harder to compensate for it. This can cause rebound injury.
  • A variation in the exercise routine is also helpful in keeping the person in good shape, thus keeping the individual muscles from getting overused.
  • If you notice any symptom of Achilles tendonitis in the kid, stop him for doing exercise or other activities that put stress on his feet.

Achilles tendon Exercises after Achilles Tendon Surgery

Some exercises after Achilles tendon surgery are mentioned below:

  • An ankle circle is an important exercise that can be performed after Achilles tendon surgery. For this exercise, remove the brace from the ankle. Now move the foot in a circular motion. You can make 10 circles to the left and 10 to the right, three times every day.
  • Ankle flexion extension can also be done after Achilles tendon surgery. For this exercise, again remove the brace and move the foot in gentle up and down motions. Repeat the exercise up to 20 times a day. Keeping the brace on, you can ride a bicycle for 10 to 20 minutes or as long as you wish. Keeping the brace on; move your body towards the un-operated side. Now raise the limb up to a 45 degree angle. Hold the leg in this position for a second or so, and then lower the body. You can repeat the exercise up to 20 times a day.
  • Yet another exercise for Achilles tendon is the straight leg lift. For this exercise, keeping the brace on, tighten the quadriceps muscles of the body so that the knees are flat and fully extended. The last exercise that can be performed after Achilles tendon surgery is the standing hamstring curl. For this exercise, keeping the brace on, face a table for balance and support. Now standing on the un-operated leg, bend the operated leg. Hold it in this position for a second or so. After that lower the foot back towards the floor. Repeat this exercise 5-10 times at a time.

Prognosis of Achilles tendon injury

The prognosis of Achilles tendon injury is usually good. The injury heals completely but healing requires time. Usually it takes as much as 6-8 weeks for the tendon injury to heal properly. It would require some additional weeks for the muscle activity to return back to normal. Depending on the type of injury and the type of sport you’ve to return to, it might take as much as 4-14 months for complete recovery and return to normal functionality.

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Written by: Michal Vilímovský (EN)
Education: Medical student, 3rd Faculty of Medicine, Charles University, Prague, Czech Republic
Published: May 16, 2014 12:18 AM
Next scheduled update: May 16, 2016 12:18 AM
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