The most common overuse injury seen in Podiatric Sports Medicine is Achilles Tendonitis. It is caused by the direct overloading of the tendon or the accumulative repetitive result of micro-trauma to the substance of the tendon. Running, soccer, basketball, and dance are activities often associated with the cause of this malady. Treatments for Achilles Tendonitis vary, as do the results of these treatments.

Anatomical Considerations

The Tendo-Achilles (heel cord) is comprised of fibrous extensions from the gastrocnemius and soleus muscle bellies in the back of the calf. This tendon inserts into the posterior 1/3 of the calcaneus, and is the strongest and the thickest tendon in the body. Amazingly, the Tendo-Achilles can handle up to ten times the body's weight during sport activity.

Approximately 2-6 cm above the insertion of the Tendo-Achilles is an area of decreased blood flow. This hypovascular area has been deemed the "watershed area" and is the most common location for tendonitis and ruptures.

Function of the Tendo-Achilles

The triceps surae (the two heads of the gastrocnemius and the singular head of the soleus) cause the feet to plantar flex at the ankle joint. This downward motion of the foot resists the ground reactive forces imposed upon the foot. Once the Tibia moves over the foot, maximum position of the foot is achieved and the forward momentum of the body causes the heel to "lift off" the ground. The foot has thus become a lever for propulsion.

Conditions that lead to excessive forces onto the Tendo-Achilles include a hypermobile (flat) foot, a contracted heel cord (Gastroc Soleus Equinus), and a high arched (Pes Cavus) foot. These are but a few examples of contributing factors that cause undo micro-trauma to the watershed area. Nutritional deficiency and certain medications may also lead to the development of tendonitis.

Clinical Picture

Common indications of Achilles Tendonitis include the patient's experience of pain at the watershed area, swelling warmth with localized tenderness, and possibly, crepitus (crackling sensation). While the physician stretches the heel cord through dorsiflexion of the foot at the ankle joint with the knee extended and flexed, the patient is often in a guarded condition. Depending on the degree of severity, the examiner is typically able to feel uneven and nodular presentation. When Achilles Tendonitis exists, the Thompson's test (squeezing the calf to contract the muscle tendon unit) is negative.

Imaging

MRI has become the main stay of the assessment of the tendon for irregularity, thickening, thinning, inflammation, and degeneration. X-Rays assess any bone aberration such as a "pump bump," spurring, and soft tissue swelling. Ultrasonography has been used as well; however, the results are dependent upon the skill of the technician.

Conservative Treatment

Modified rest is typically recommended when Achilles Tendonitis is diagnosed. This conservative treatment includes the reduction of aggravating activity through movement to a non-aggravating activity such as swimming or bicycling. Another treatment involves the use of non-steroidal medications (used more so for the acute, rather than chronically injured heel cord). Although corticosteroids provide merely some relief, injection of steroids into the tendon is considered risky and avoided. Physical Therapy may be employed to improve healing. Passive stretching and range of motion will help prevent adhesions. Electrical stimulation and pulsed ultrasound will help increase collagen synthesis. Dexamethazone with Iontophoreses will reduce the inflammation.

Surgical

After three months of conservative therapy with resistant tendonitis of the Tendo Achilles, surgery may be considered. The focus of the surgery should be on either the tendon proper or the insertion of the tendon. If more than 20% of the tendon is scarred with adhesions or partially ruptured, then reconstruction and/or side to side repair (after excision of defective tissue) should be employed. If bone spurring or bursal sac inflammation is noted, then excision of either is indicated. Often the tendon may need to be "re-anchored" with a tendon anchor screw. Weight bearing after surgery will be restricted, although varied depending on the severity the foot. It is possible that the patient may be placed in a cast and limited to non-weight bearing status.

Improper stretching prior to athletic activity, hormonal, nutritional and mechanical imbalances, as well as traumatic events might all lead to Achilles Tendonitis. Activity level and expectation to return to a desired sport must be guided carefully for the success of the concurrent treatment regimen. Too often, patients re-injure the tendon due to early return to an aggravating activity. Chronic inflammation will prolong the healing process and lead to a surgical route of relief. Early recognition with proper treatment, therefore, will lead to a better success and return to the activity level desired.

Dr. Graham has been in private practice in Effingham since 1989 and is on staff at St. Anthony's Memorial Hospital and Effingham Ambulatory Surgical Treatment Center. He is Board Certified by the American Board of Podiatric Surgery and American Board of Podiatric Orthopaedics and Primary Podiatric Medicine. Dr. Graham is a Fellow of the American College of Foot and Ankle Surgeons, the American College of Foot and Ankle Orthopaedics and Medicine, and American Professional Wound Care Association. He is also a member of the American Podiatric Medical Association and the Illinois Podiatric Medical Association.

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