Achilles Tendinitis

Overview

Achilles tendinitis is inflammation and irritation of the Achilles tendon behind the heel. The Achilles tendon is the largest and strongest tendon in the body. A tendon is a tough and fibrous connective tissue that attaches muscles to bones. The Achilles tendon specifically connects the calf muscles to the heel bone. This tendon works during every movement such as walking, running, jumping, and standing on tiptoes.

With each step you take, several times your body weight in force is placed on the Achilles tendon. For this reason, it can easily become irritated and inflamed with overuse or sudden movements. It is especially common in runners, basketball players, tennis players, and dancers.

Achilles tendinitis can occur in two areas.

• The first type occurs where the tendon attaches to the heel bone and sometimes bone spurs also develop here. This is called insertional tendinitis.
• The second type is more common and occurs in the middle portion of the tendon closer to the calf. This type is usually seen in young and active people. This is called non-insertional tendinitis.

The disease usually begins gradually. At first it is felt as a mild discomfort. If not treated, it worsens over time and begins to affect daily life. The most important risk when left untreated is the possibility of the tendon tearing completely (rupture). This is a very serious condition and requires emergency surgery.

Most people completely recover with early diagnosis and appropriate treatment. Achilles tendinitis treatment is usually simple. Rest, ice application, special exercises, and physical therapy are usually sufficient. Surgery may be needed in rare cases.

Symptoms

Achilles tendinitis symptoms develop slowly. They usually do not occur suddenly but gradually increase over several weeks or months.

Achilles tendinitis symptoms include the following:

• Pain behind the heel. This is the most pronounced and most common symptom. Pain is felt just above the heel bone, along the tendon. The first few steps when you get out of bed in the morning are usually the most painful. Similar pain occurs when you stand up after sitting for a long time. Pain increases during activity. It is more pronounced when running, climbing stairs, or standing on tiptoes. Interestingly, in some people the pain lessens as they move, but increases again after activity ends.
• Stiffness and tightness sensation. Especially in the mornings, the Achilles tendon feels tight and stiff. You have difficulty trying to bend your foot upward. There is a feeling as if the tendon has shortened. This stiffness lessens after walking for a few minutes.
• Swelling. There may be a slight bulge along the tendon. The tendon appears thicker than normal. Swelling usually increases throughout the day and is more pronounced in the evenings. It may decrease slightly in the mornings.
• Tenderness to touch. You feel pain when you press on the tendon with your finger. You are uncomfortable when the back of the shoe rubs against the tendon. Some people therefore prefer to wear backless slippers.
• Tendon thickening. If the problem becomes chronic, the tendon thickens over time. When you hold the tendon with your hand, you feel it is more swollen than normal. Sometimes small lumps (nodules) form on the tendon. These indicate the tendon has been damaged.
• Sound and sensation. Sometimes you hear a crackling or creaking sound when the tendon moves. When you hold the tendon with your hand and move your foot, you can feel this sound and movement. This sound is a sign of inflammation.
• Weakness. Standing on tiptoes becomes difficult. You do not feel as strong as before when climbing stairs or running. Your pushing power has decreased.

Symptoms are mild at the beginning and are usually ignored. You wait thinking "it will pass." However, if not treated, they worsen over time. If you feel sudden and severe pain, cannot stand on tiptoes at all, or there is pronounced swelling in the heel, you should see a doctor immediately.

When to See a Doctor

Mild Achilles pains usually improve with a few days of rest. However, in some cases you should definitely see a doctor.

See a doctor in the following situations:

• If you have persistent pain behind the heel (if it has been continuing for several weeks)
• If pain has begun to affect your daily tasks (if walking and climbing stairs have become difficult)
• If rest, ice, and pain relievers at home do not work after one or two weeks
• If your first steps in the morning are very painful and this condition does not improve
• If you have felt sudden and very severe pain in the heel (the tendon may have ruptured)
• If you cannot stand on tiptoes at all
• If there is pronounced swelling, redness, or heat increase in the heel
• If you have a fever (infection is possible but rare)

Especially people who exercise regularly should see a doctor even when symptoms are mild. Early treatment prevents chronic problems and tendon rupture. Once the tendon ruptures, surgery is mandatory and recovery takes much longer.

Causes

Achilles tendinitis usually occurs due to excessive load on the tendon or repetitive movements. When the tendon is constantly under stress, small tears accumulate and inflammation begins.

Causes leading to Achilles tendinitis are as follows:

• Overuse and sudden activity increase. This is the most common cause. For example, you were running two days a week and suddenly started running every day. Or you were running on flat roads and switched to hilly terrain. Your body cannot adapt to this sudden change. The tendon cannot rest sufficiently and gets damaged. The condition known as "Monday syndrome" is also an example of this (doing excessive sports on the weekend and resting during the week).
• Inadequate warm-up. Cold muscles and tendons are stiff and inflexible. Starting activity without warming up means catching the tendon unprepared for sudden tension. Warming up stretches muscles and tendons, increases blood flow, and reduces injury risk.
• Tight and short calf muscles. If your calf muscles are tight (the back of your leg is tight), your Achilles tendon stretches more with each movement. When muscles lose their flexibility, the tendon has to carry extra load. This is common in people who do not do regular stretching exercises.
• Bone spurs. Sometimes bone spurs form where the tendon attaches to the heel bone. These spurs constantly irritate the tendon and create friction. This condition is rare but should be considered especially if there is pain in the part of the tendon close to the heel.
• Inappropriate footwear. Shoes without adequate support in the heel area place extra load on the Achilles tendon. Worn-out sports shoes also create problems. High-heeled shoes shorten the tendon and with continuous use the tendon adapts to this shortening. Then when you switch to flat shoes, the tendon suddenly stretches and becomes irritated.
• Foot structure problems. Flat feet (inward rolling foot) or having a very high arch affects your walking style. When the foot moves abnormally with each step, force is applied to the Achilles tendon from wrong angles. This condition tires the tendon over time.
• Running on hard surfaces. Running on very hard surfaces like asphalt or concrete creates a shock effect on the tendon with each step. Running on dirt or a track surface places less stress on the tendon. Also, constantly running uphill or downhill stresses the tendon at different angles.

Risk Factors

Some factors increase the likelihood of developing Achilles tendinitis.

Risk factors for Achilles tendinitis are as follows:

• Age. After age 30, tendons gradually begin to lose their flexibility. Risk is highest in the 40-50 age range. With age, the structure of tendon fibers changes and they become more easily damaged.
• Sex. It is slightly more common in men compared to women. However, in women who constantly wear high-heeled shoes, problems in the part of the tendon close to the heel may be more common.
• Certain sports. Sports requiring jumping, sudden stopping, and acceleration such as running (especially long distance like marathons), basketball, tennis, soccer, volleyball, and dance are high risk. Those who do intense sports more than 5 days a week are in a riskier group.
• Sudden changes. Suddenly changing your sports routine is dangerous. For example, doubling your running distance in one week, switching from flat to hills, or starting a new sport. The body needs time to adapt.
• Muscle tightness. If your calf muscles are tight (stretching the back of your leg is difficult), you are at risk. In people who do not do regular stretching, muscles shorten. Also, weakness in the hamstring (back thigh) and hip muscles increases risk.
• Excess weight. Every extra kilogram places extra load on your Achilles tendon. In obese people, the tendon constantly carries extra weight. Losing weight reduces stress on the tendon.
• Certain diseases. Psoriasis, high blood pressure, and diabetes increase the risk of tendon problems. Gout rarely can affect the Achilles tendon. Some antibiotics (fluoroquinolone group) can cause tendon damage, tell your doctor if you are using these medications.
• Past injuries. If you have had Achilles tendinitis before, your risk of re-injury is high. Especially if you returned to sports without full recovery, the problem can recur.

Diagnosis

Achilles tendinitis diagnosis is usually made by examination. The doctor listens to your symptoms and checks your tendon.

The methods used in Achilles tendinitis diagnosis are as follows:

• Physical examination. The doctor checks your tendon with their hands. Looks for tender points. Presses on the tendon and checks whether there is pain. Checks if there is swelling or thickening. Asks you to move your ankle. Measures how flexible your calf muscles are (how much they open when you stretch your leg). May ask you to stand on your tiptoes. May do a test, squeezes your calf muscle and sees if your foot moves (this test is to understand tendon rupture).
• Your medical history. The doctor asks you questions. When did the pain start, in which movements does it worsen, is it more painful in the mornings or after activity, have you had a similar problem before, what sports do you do, what kind of shoes do you wear, what medications are you using.
• X-ray. This is usually the first imaging done. X-ray does not show the tendon itself but shows bone problems. Especially if there is pain in the part of the tendon close to the heel, it checks whether there are bone spurs or calcification. X-ray is a cheap and easily accessible test.
• Ultrasound (US). This is the most practical method for imaging the tendon. Ultrasound shows tears, thickening, and inflammation in the tendon. It does real-time imaging, meaning the doctor watches on the screen while you move your tendon. It is a painless test. It shows soft tissue problems that cannot be seen with x-ray.
• MRI (Magnetic resonance). It provides the most detailed imaging but is not needed in every case. It is usually used in chronic cases where surgery is being considered or diagnosis is not clear. MRI shows how serious the tendon damage is, exactly which area is affected, and the condition of surrounding tissues. It is an expensive test and may not be available at every hospital.

In most Achilles tendinitis cases, examination and ultrasound are sufficient. MRI is usually not needed. Your doctor will choose the most appropriate test according to your condition.

Treatment

The goal of Achilles tendinitis treatment is to reduce pain, stop inflammation, and allow the tendon to heal. Treatment usually starts with simple methods and most people recover without surgery.

The methods used in Achilles tendinitis treatment are as follows:

• Rest and activity modification. This is the first and most important step. Stop the activity causing pain. This does not mean staying completely immobile. Just avoid painful movements. For example, stop running but you can walk. Or instead of running you can ride a bicycle or swim. This way you maintain your fitness but do not place extra load on the tendon.
• Ice application. Especially beneficial in the first days. Ice reduces inflammation and swelling, relieves pain. Apply ice 3-4 times a day, 15-20 minutes each time. Always wrap the ice in a cloth or towel, do not put it directly on the skin (cold burn can occur). Applying ice after activity is especially effective.
• Compression and elevation. An elastic bandage or compression sock can reduce swelling. Do not tighten too much, you should not block blood circulation. While resting or sleeping, place your foot on a pillow and elevate it. This reduces swelling.
• Pain relievers. Medications like ibuprofen (such as Advil, Motrin) or naproxen both relieve pain and reduce inflammation. Use at the dose written on the medication box. If you have stomach discomfort, take on a full stomach. If you need to use for a long time (more than a few weeks), consult your doctor.
• Physical therapy and special exercises. This is the most important part of treatment. A physiotherapist teaches you special exercises. The most effective exercise type is called "eccentric exercise" (strengthening exercises while the muscle lengthens). Simply explained, you stand on your tiptoes, then slowly lower down. The lowering part works your muscles while they lengthen and strengthens the tendon. It may be a bit painful at the beginning but be patient, it is very effective. You also do stretching exercises for your calf muscles. Stretching exercises lengthen muscles and reduce the load on the tendon.
• Heel lifts and supports. Small heel pads placed inside your shoe reduce stress on the tendon. They slightly elevate your heel and the tendon stretches less. Night splints are sometimes recommended, keeping the ankle in a stretched position throughout the night. Ankle supports (elastic bandage or brace) can also be used.
• Shock wave therapy. Used in some chronic cases. Tendon healing is stimulated with sound waves. It is a painless method. Usually 3-5 sessions are done. May not be available at every hospital. It is moderately effective.
• Plasma therapy (PRP injection). A special substance prepared from your own blood is injected into the tendon. This is a new treatment method. Its effectiveness is controversial, not every doctor recommends it. It is expensive and usually not covered by insurance.
• Cortisone injections. Generally not recommended and rarely done. Cortisone reduces inflammation but weakens the tendon. The risk of tendon rupture increases. For this reason, most doctors avoid injecting cortisone into the Achilles tendon.
• Achilles tendinitis surgery. Considered only if there is no response to all other treatments for a period like 6-12 months. In surgery, damaged tendon tissue is cleaned, bone spurs are removed if present. In serious cases the tendon is repaired. The recovery process is longer than non-surgical treatment, taking 3-6 months.

Most people recover with physical therapy and exercises. Being patient is important, treatment can take several months.

Complications

If Achilles tendinitis is not treated or is neglected, some problems can develop.

Complications of Achilles tendinitis are as follows:

• Chronic (long-term) tendon problem. Untreated tendinitis becomes chronic. The tendon structure permanently changes and weakens. In this case, treatment becomes much more difficult and complete recovery can take months or even years. You experience constant pain and discomfort.
• Tendon rupture. This is the most serious complication. The weakened tendon suddenly ruptures completely. It usually happens during a sudden movement (jumping, starting to run). At the moment of rupture, you usually hear a "pop" in the heel, as if someone hit your heel. Severe pain occurs and you cannot stand on tiptoes at all. Tendon rupture requires emergency surgery. If there is untreated tendinitis, the risk of rupture is very high.
• Persistent pain. If the tendon does not fully heal, permanent pain may remain. You have difficulty doing your daily tasks. You cannot do sports. Even walking can become painful. Your quality of life decreases.
• Muscle wasting. If you do not use your leg for a long time due to pain, your calf muscles weaken and shrink (atrophy). Muscle loss can be permanent. For this reason, doing pain-free activities instead of complete rest is important.
• Walking disorders. Constant pain or tendon weakness changes your walking style. You begin to walk with a limp. This can also lead to knee, hip, or back pain over time.
• Treatment-resistant tendinitis. Rarely, some cases do not fully respond to any treatment. Even surgery may not help. In these situations, it is necessary to learn to live with pain management and lifestyle changes.

Living with Achilles Tendinitis

Living with Achilles tendinitis may seem difficult at first, but with the right approach most people completely recover and return to their former activities.

Continue Exercises Regularly

Do the exercises your physiotherapist gave you regularly every day. Do not skip. It may be a bit painful at the beginning but this is normal. Exercises must be done correctly, show the technique to the physiotherapist.

Do not return to sports too early. Rushing restarts the problem. Usually you can gradually return to sports after 6-12 weeks. Do not increase the activity you do by more than 10 percent each week.

Choose the Right Shoes

Good shoes are very important. Buy shoes with adequate support in the heel area and good cushioning. Running shoes lose their cushioning properties after 500-600 km, replace them. Avoid high-heeled shoes or use very little. Wear comfortable, supportive shoes in daily life.

Warm Up and Stretch

Always warm up before each activity. Walk at a slow pace for 5-10 minutes or do light jogging. After activity ends, stretch your calf muscles. Repeat stretching exercises several times a day, not just after sports.

Watch Your Weight

If you have excess weight, try to lose it. Every extra kilo places extra load on your Achilles tendon. Eat healthy and exercise regularly.

Try Other Sports

While the tendon is healing, use swimming, cycling, or elliptical machine instead of running. These activities protect your heart health but place little load on the tendon. Especially swimming is very good, you work your calf muscles in water but the tendon rests.

Listen to Your Body

Pain is a warning, do not ignore it. If there is pain, slow down or stop. "Continuing despite pain" deepens the damage. Mild discomfort is acceptable but severe pain is never normal.

Protect from Cold

Keep your legs warm in winter months. Cold weather stiffens tendons. Do longer warm-up in the cold.

Continue Prevention

Continue preventive measures even after tendinitis heals. Do stretching and strengthening exercises several times a week. Use appropriate shoes. Increase your activities gradually. The problem can recur, be careful.

Preparing for Your Appointment

What you can do:

• Note when your pain started
• Write in which movements pain increases and in which it decreases
• Take a photo of the shoes you use to show the doctor
• Write treatments you tried before (ice, rest, medication) and their effects
• Explain how often and what type of sports you do
• List medications you use
• Write your questions in advance

Questions you can ask your doctor are as follows:

• How serious is my tendinitis?
• How long will it take to heal?
• What exercises should I do?
• When can I return to my sport?
• What should I not do?
• Will I need surgery?
• How do I prevent it from recurring?
• Do I need to go to physical therapy?

Questions your doctor may ask you are as follows:

• When did the pain start?
• Does it hurt more in the mornings or after sports?
• Have you recently increased the amount of sports you do?
• What sports do you do?
• Have you had a similar problem before?
• What kind of shoes do you wear?
• Do you have other health problems?
• What medications are you using?
• How does pain affect your daily tasks?