Achilles Tendon injury, What is it?
The Achilles tendon injury is quite common, and is the largest tendon in the body. Located on the back of the lower leg, it starts in the middle of the calf and attaches to the back side of the heel. The job of this tendon is to point the toes downward, and is therefore important for pushing off in walking, running, hopping, jumping, and climbing stairs. It also helps control the return of all those same motions as well. Two muscles contribute to the Achilles tendon, the gastrocnemius and the soleus.
The name Achilles comes from Greek mythology. The great warrior Achilles, as an infant, was dipped in the River Styx by his mother to make him immortal. However, she held him by his heel, and that part never touched the water, making that area of his leg vulnerable. The phrase “Achilles heel” is often used to describe vulnerability or weakness.
Despite the namesake, the Achilles tendon is very strong and can withstand great forces. However, with overuse or a traumatic event, it can be injured.
Most Achilles tendon injuries occur just a few inches above the heel. But there are some cases where the injury occurs at the insertion, where the tendon attaches to bone, which is approximately one inch above the bottom of the foot.
What causes an Achilles Tendon injury?
Problems with the Achilles tendon can stem from any of the following, including:
- Altered or abnormal foot mechanics or walking pattern
- Bone spurs
- Calf muscle tightness
- Flat arches of the feet
- Improper training (e.g. significant changes in exercise routine, ramping up too fast and too soon, or insufficient warm-up before exercise)
- Running on uneven ground
- Quick start-and-stop sports (e.g. tennis, basketball, gymnastics, volleyball, etc.)
- Stiffness in the ankle joint
- Unsupportive or poorly-fitting footwear
- Wearing high heels
Symptoms of Achilles Tendon injury
Symptoms will vary depending on the severity and type of the injury.
With overuse injuries, the symptoms progress over time, pain in the heel will typically worsen after activity or the following day.
Strains to the tendon occur when there has been trauma and are graded as the following:
- Grade I-is considered a mild strain; symptoms may include pain, swelling, and tenderness. It is responsive to conservative treatment like physical therapy (PT).
- Grade II-is considered a moderate strain; symptoms may include pain, swelling, tenderness and difficulty with walking. It is also responsive to conservative treatment like PT.
- Grade III – occurs when the tendon completely tears, often pulling away from the bone; symptoms include severe pain and swelling. A “popping” noise is often heard at the time of the injury. People who have this injury will not be able to put weight on the injured leg. Bruising may be present as well. Surgical intervention is likely needed.
How is an Achilles Tendon injury diagnosed?
For an injury at grades I and II, typically an Achilles tendon injury can be diagnosed through a physical exam either by a physician or a physical therapist (PT). The health care provider will check for tenderness, swelling, range of motion, gait quality, balance, and strength of the lower leg muscles.
For a traumatic grade III injury, immediate medical attention is recommended. A physical exam of the calf, ankle, and foot will be performed. Also, the physician may also order an X-Ray or MRI (magnetic resonance imaging) to evaluate the soft tissue and bones of the lower leg.
Treatment of Achilles Tendon injury
Achilles tendon injuries can be slow to recover, and people must carefully follow medical advice when returning to activity as this area is sensitive to re-injury. Because blood supply to the tendon is limited and because the physical demands placed on the tendon in normal activity are intense, the best way to manage an injury is under the guidance of a physical therapist.
For strains of grades I and II, a recovery time of 12-18 weeks is common, but some can take 24 weeks. Grade III strains that require surgery may need 9-12 months to fully recover. Much of the expected healing time depends on the severity of the injury and type of procedure that was done. While people often begin feeling better sooner and are eager to resume activity, returning too quickly can result in re-injury or inflamed tissue and slow the recovery further.
For conservative treatment of non-surgical Achilles injuries, the PT and patient work together to develop an appropriate plan of care and goals for rehabilitation. Managing symptoms of pain and swelling is very important, so the recovery process initially includes modifying activities, resting the injured leg, and icing the area.
As the swelling and pain symptoms improve, the PT will instruct the patient on appropriate therapeutic exercises for restoring range of motion, strength, and balance. Following the guidance of the PT is very important. The PT will know when the proper time is to introduce a new exercise, as well as the correct number of repetitions and frequency for safe rehabilitation, and when to progress weightbearing activity.
In some cases, when conservative care alone does not help with symptom management, medication or injection therapy may be needed. Risks, benefits, and expected outcomes associated with those treatments are best discussed with a medical provider who is adding those to the care plan.
Proper footwear and inserts can make a significant impact on symptoms and recovery. The PT and/or medical provider may discuss the different types of shoes and support provided by each type, as well as custom-fit inserts (also called orthotics), or recommend off-the-shelf options or heel wedges if needed. Not every patient will require inserts, but good quality footwear is important for everyone. Those who do need special inserts should be custom fit by a physical therapist or a medical provider who is skilled in this practice.
Surgical cases require a longer duration of recovery, often 9-12 months. All surgeries have a specific protocol, or guidelines to follow, after surgery and it is critical to adhere to the guidelines for the best outcome.
Post-surgical patients are often issued a walking boot or cast to immobilize the ankle joint and reduce stress on the repaired tissues. Weightbearing post-operatively is dependent on the surgical protocol, and physical therapy is introduced when the patient has recovered enough to begin. The PT program will consist of a thorough evaluation and development of treatment plan and goals, with adherence to the surgical guidelines, and often consists of therapeutic exercises, hands-on techniques, balance activities, instruction in recovering a normal walking pattern, and other interventions as determined by the PT and patient.
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