Features March 2019 Issue

Don't Let Your Achilles Tendon Be Your Downfall

The Achilles tendon is vulnerable to injury, inflammation and wear and tear.

Pain at the back of your ankle that's gone on for months (or even years) can be a sign of a problem with your Achilles tendon. You may think of Achilles tendon injuries as happening to athletes. A ruptured Achilles tendon is a common sports-related injury from sudden movements, but problems with this tendon can happen to anyone of any age.

Three Types of Problems

Tendons are fibrous bands that connect muscle to bone. The Achilles tendon, which is the largest tendon in the body, runs down the back of the leg and attaches the muscles in the calf to the heel bone. You can feel it at the back of your ankle.

This tendon is essential for walking and running. It's also vulnerable to injury and wear and tear, which may be the reason it's named after a hero in Greek mythology who was famously strong but whose downfall was a weakness in his ankle.

"There are three types of problems that can affect the Achilles tendon," says Cleveland Clinic orthopaedic surgeon Mark Berkowitz, MD. These are a tear of the tendon (rupture) from an injury, inflammation (tendinitis) and degeneration (tendinosis).



© structuresxx | Getty Images

Wear and tear over time can lead to thickening of the Achilles tendon, which may cause pain at the back of theĀ ankle.

People who play sports, including basketball, soccer and tennis, can rupture the Achilles tendon from bursts of jumping or running. "The classic case is someone who plants his foot and then charges forward," says Dr. Berkowitz. The sudden movement can overstretch the tendon to the point that it tears. While this can happen to anyone, it most often occurs in men ages 30 to 50.

The pain is immediate, and people with these injuries are generally seen promptly. They often undergo surgery to repair the tendon, and usually return to normal activity.


Inflammation of the tendon, called tendinitis, usually is associated with overuse from engaging in an activity your body is not used to. "If you decide to take up jogging and run five miles on the first day, you're Achilles tendon can flare up," says Dr. Berkowitz.

The inflammation in the tendon is associated with the activity, and it's temporary. There is no structural damage. The tendon is still normal, and the condition will resolve as inflammation goes down.

People with certain arthritic conditions, including ankylosing spondylitis and reactive arthritis, also have a tendency to develop Achilles tendon inflammation.

Wear and Tear

The third type of problem comes on gradually from chronic wear and tear that develops over time and accumulates. "There's a thickening of the tendon that you can see, and it doesn't go away," says Dr. Berkowitz. This structural damage is called tendinosis.

"The Achilles tendon is an extremely high stress area," says Dr. Berkowitz. Repetitive movement from walking and running adds up over time. Also, it's thought that there's an area in the Achilles tendon that does not have a robust blood supply. Any tissue in the body with an inadequate blood supply will have trouble healing.

"The combination of high stress, repetition and less-than-ideal reparative capabilities sets up a perfect storm for the accumulation of wear and tear," says Dr. Berkowitz.

Symptoms of tendinosis are pain in the back of the ankle and swelling and stiffness around the tendon. Symptoms tend to come on gradually. Pain becomes worse with activity, particularly long walks or going up hills.

How Is it Diagnosed?

Problems with the Achilles tendon are diagnosed by taking a medical history and conducting a physical examination. The physician will look for tenderness over the Achilles, pain with stretching, and localized swelling or enlargement.

In some cases, imaging studies may be done to determine the extent of the problem. "If someone with tendinosis does not get better with initial treatment, an imaging study may be useful," says Dr. Berkowitz.

X-rays, which show only bone, have limited value. But they may show bone spurs where the Achilles tendon attaches to the heel bone, which may be part of the problem. Visualizing the tendon requires a magnetic resonance imaging scan.


Initial treatment for both tendinitis and tendinosis is immobilization to decrease stress on the Achilles tendon. "The best way to do this is with a walking boot," says Dr. Berkowitz. The boot limits the motion that's transmitted through the Achilles tendon. It also allows people to remain mobile and relatively active while still resting the tendon.

Nonsteroidal anti-inflammatory drugs (NSAIDs) can help as well. Over-the-counter NSAIDs include ibuprofen (Motrin®, Advil®) and naproxen (Aleve®). For an Achilles tendon problem, Dr. Berkowitz prefers the prescription topical NSAID diclofenac (Voltaren Gel®, Pennsaid®), which is applied directly to the skin. A topical NSAID is advantageous because there are fewer potential side effects. Because the tendon is very close to the skin the medication easily penetrates.

For people with ankylosing spondylitis and Achilles inflammation, a biologic medication (such as etanercept [Enbrel®] or adalimumab [Humira®] is required.

A physical therapy program of exercises to stretch the tendon and strengthen surrounding muscles can also be beneficial.

The one treatment that Dr. Berkowitz warns against is a corticosteroid injection. These have been shown to increase the risk for a rupture of the tendon. "If someone offers you a steroid injection for an Achilles problem, don't do it," says Dr. Berkowitz.

If these measures don't help, Dr. Berkowitz might consider trying stem cell therapy. The body naturally contains stem cells, which function as a built-in repair system.

Researchers are investigating whether it's possible to harness the ability of stem cells to transform into different cell types to renew damaged tissue. Cells can be harvested from bone marrow in the pelvis, concentrated and then injected into the tendon. This may create a healing response. The effectiveness of stem cell therapy is still being studied, and the procedure usually is not covered by insurance.

If nothing else works, surgery to remove damaged tendon tissue is a possibility.

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