Chronic Achilles Tendinitis

  • Chronic achilles tendinitis (painful heel on the back)

    There are two varieties: Insertional and non-insertional

    Insertional

    At the insertion of the achilles tendon on the back of the heel, pain and swelling can result, often repeatedly. Previous trauma might or might not contribute. More often than not, a spur or bony prominence can be the cause. This is called Haglund's deformity.

    Chronic Achilles Tendinitis

    Backside of both ankles showing swelling-Haglund's Deformity

    Morning stiffness and pain are the presenting symptoms. There can be periodic remissions and exacerbations. The affected area is markedly swollen and wearing shoes and sandals with straps can be difficult.

    X ray showing spur in Haglund's
    X ray showing spur in Haglund's
    MRI showing inflamed area
    MRI showing inflamed area

    Non-insertional

    Tiny fibres of muscle and tendon of the mid portion of tendo-achilles can break and heal leading to swelling and pain. Repetitive minor trauma leads to further inflammation and weakening of the fibres. Mid-portion tendinitis is more common than thought. It affects athletes mostly, but can also affect older, non-atheletic population. Previous achilles tendon tears might contribute.

    Symptoms include swelling and pain. Affected patients can also have weakness or sensation of giving way in the middle of the calf.

     Mid-portion of tendon involved
    Mid-portion of tendon involved
     Mid-portion of tendon involved
    Mid-portion of tendon involved

    Exercises

    Heel lifts

    The patient is asked to stand on toes and support self with hands against a wall. Heels are lifted together and lower after count of 5. This is repeated. This exercise strengthens the calf muscles and reduces traction forces on the heel bone.

    Heel lift exercises
    Heel lift exercises
    Eccentric toe pushes
    Eccentric toe pushes

    Physiotherapy

    A program of heat and therapy will reduce the pain, swelling and stiffness.

    Physiotherapy

    Therapy may be required for longer than usual

    Surgery

    Podiatric surgery is required in cases where bony spur continues to cause inflammation and conservative management has failed.

    Bony prominence being removed
    Bony prominence being removed
    A bone anchor
    A bone anchor


    Principles

    • Bony overgrowth is removed
    • Achilles tendon is protected, and if required is reattached to the bone with the help of bone anchors and stitch.
    • If tendon is badly damaged, plantaris or peroneus tendon augmentation is done.

    Post-operative rehabilitation

    Rocker boot with hinge and heel raise

    Rocker boot with hinge and heel raise

    After surgery actual weight bearing on the foot is deferred for 6 weeks, in order to protect the operated area. Only isometric exercises are given. A boot is worn for 2 months after surgery.