tendon - Dictionary Definition : Vocabulary.com Random Word tendon If you feel the back of your ankle, you will find the tough, ropelike tendon that joins your calf muscle to your heel bone. That's the job of tendons throughout your body: connecting bone and muscle so you can move. Consider that the Latin word tendere means "to stretch." That's an apt beginning for the word tendon, a tough but stretchy fibrous tissue (sinew). A tendon is made of dense bundles of fibrous collagen that form ropelike connectors that allow muscles and bones to work together. Athletes often suffer injuries to tendons, most often to the rotator cuff in the shoulder, the Achilles tendon in the leg, the patellar tendon in the knee, and the biceps muscle in the arm. Achilles Tendon Achilles Tendon Achilles Tendon The Achilles tendon connects the calf muscle to the heel bone. The calf muscle is actually two muscles, the gastrocnemius muscle and the soleus muscle. The soleus lies underneath the gastrocnemius. The Achilles tendon is the largest tendon in the body. It allows you to rise up on your toes and push off while walking or running. Credits Primary Medical ReviewerAnne C.

Poinier, MD - Internal Medicine Specialist Medical ReviewerDavid Bardana, MD, FRCSC - Orthopedic Surgery, Sports Medicine Current as ofMay 22, 2015 WebMD Medical Reference from Healthwise This information is not intended to replace the advice of a doctor. Healthwise disclaims any liability for the decisions you make based on this information.© 1995-2015 Healthwise, Incorporated. Healthwise, Healthwise for every health decision, and the Healthwise logo are trademarks of Healthwise, Incorporated. Top Picks Achilles Tendon treatments and surgery Achilles Tendon What is the Achilles Tendon? Tendons are the links between the muscles and the bones The tendon is the connection between the muscle and the moving part of the body. It may help to think of the tendon as a rope, and the muscle as a motor. Tendons, unlike muscle which is red, are white. They have a poor blood supply. This poor blood supply means that tendons heal slowly. The Achilles tendon is the large tendon that joins the calf muscle to the heel bone (calcaneum). The calf muscle is extremely strong and is responsible for spring and push off during walking and running.

The Achilles tendon is the largest tendon in the body and can be felt just above the heel - it is sometimes known as the "the heel cord." It is named after the mythical Greek warrior Achilles who, as a child, was dipped into the river Styx by his mother. Submersion made him invulnerable to injury, except for the area of his heel by which he was held. This area remained dry. Achilles was mortally wounded during the siege of Troy when he was struck in the heel by an arrow. Problems in the Achilles tendon are relatively common as people get older. There are two main diseases affecting the tendon: • Pain and thickening of the tendon, as a result of degeneration - Achilles tendonosis (or tendinitis). • Achilles tendon rupture. Chronic Achilles tendon pain? Chronic pain and swelling in the Achilles tendon occurs in two locations: • A lump in the substance of the tendon two to six centimetres above its insertion into the heel bone (non-insertional tendinosis). This pain occurs because of age related changes, which cause the tendon to swell and degenerate. This may be associated with a partial rupture of the tendon. Partial ruptures do not necessarily need surgery, or rest.

Sometimes continued stretching is the best option. • Pain at the point of insertion of the tendon onto the heel bone (insertional tendinitis). This is often associated with a hard, bony lump on the point of the heel. This lump of bone is known as a Haglund's deformity. The pain is often most severe on rising in the morning and usually worsens with walking and running. In more severe cases it may occur at rest. Over time, as the symptoms worsen, the pain occurs after less and less activity. The symptoms may start acutely, with symptoms building up over a couple of weeks. Alternatively it may start gradually. Investigations Your doctor may order an X-ray. Often this will show no abnormality but if the tendinitis is lower down at the tendon insertion, the X-ray may show bone spurs. An ultrasound or MRI scan may also be ordered to confirm the diagnosis, and determine how severely the tendon is affected. What is the Treatment of Achilles Tendonosis? Without an operation Most cases of non-insertional Achilles tendonosis are treated successfully without surgery. Usually the longer the symptoms have been present, the longer they will take to settle down.

Treatment includes stretching, and regular paracetamol or anti-inflammatory medication. Physiotherapy is also an important part of the treatment. This includes an intensive program of calf stretches (the eccentric training programme described at the end of this information sheet). Sometimes a medial arch support (or orthosis) may be used. Modifying sporting and training routines can also help. In insertional tendonitis shoes that press less on the heel also help. Injection of the tendon with steroid tends not to be used as it can weaken the tendon. Occasionally there is a small bursa, or bag of fluid secondary to inflammation, which can be injected with steroid. With an operation If non-surgical treatment fails to cure the condition then surgery can be considered. This is more likely to be the case if the pain has been present for six months or more. The nature of the surgery depends if you have insertional, or non-insertional disease. In non-insertional tendonosis the damaged tendon is thinned and cleaned. The damage is then repaired. If there is extensive damage one of the tendons which moves your big toe (the flexor hallucis longus) may be used to reinforce the damaged Achilles tendon.

In insertional tendonosis there is often rubbing of the tendon by a prominent part of the heel bone. This bone is removed. In removing the bone the attachment of the tendon to the bone may be weakened. In these cases the attachment of the tendon to the bone may need to be reinforced with sutures and bone anchors. What can I expect after an operation? For the surgery you will need a general anaesthetic. You will be treated either as a day case, or kept in hospital for one night. Post-operatively it is important to keep the foot elevated. After surgery a plaster splint is usually applied from below the knee to the toes. A prescription for analgesics will be provided. The wound is inspected and the sutures removed after 10 to 14 days. The plaster will be needed for between two and eight weeks, depending on the extent of the surgery to the tendon, and thus the amount of damage present before surgery. Crutches are necessary if you are in plaster. It takes six months for the tendon to fully heal. Are There Any Risks With Surgery? The vast majority of patients who have surgery for Achilles tendonosis recover well, without complication. However, as with any surgery there is always a small chance of problems.

These include: 1. About 85% of patients are satisfied with the results of their surgery, but in some patients the Achilles tendon pain fails to settle despite surgery. In these cases further surgery may be recommended. The surgery is much less successful in smokers. 2. It is uncommon for the tendon swelling to resolve fully. But in the absence of pain the swelling is less of a problem. 3. Tendon rupture or detachment from the heel bone - this can be repaired, but will require a further operation. 4. Infection - this may require intravenous or oral antibiotic treatment. 5. Wound healing problems - this is associated with infection and occasionally requires plastic surgery. Wound healing problems are best avoided by keeping the leg elevated after surgery. Smoking increases the risk of this complication. 6. Nerve damage - causing pain and numbness in the foot. 7. Bleeding. 8. Swelling. The general complications of any surgery and general anaesthesia. Blood clots can occur in the leg (deep venous thrombosis) and in some cases can even go into the lung (pulmonary embolus). What happens if I rupture my Achilles tendon? Achilles tendon rupture means a sudden snapping of the tendon.

This is happening with increasing frequency as a result of people's increasing participation in sport. The rupture is spontaneous and typically occurs in the thirties and forties. The tendon is often weakened because of Achilles tendon degeneration (see Achilles tendonosis above); nevertheless the rupture usually occurs without warning. Partial ruptures usually occur in degenerate tendons, and are often treated with stretching (see above under tendonosis). Often the individual will be playing a sport such as squash, tennis or netball. After a jump or push off there is a sudden snapping sensation in the Achilles tendon area, followed by pain. Sometimes the snap is so loud that it can be heard. The patient often feels that they have been kicked or struck in the heel. This is followed by swelling and bruising. The foot feels weak, with particular weakness pushing off the ground. How can the rupture be diagnosed by my Doctor? The normal site of tendon rupture is just above its insertion onto the heel bone. Often a gap can be felt in the tendon and the foot does not move normally when the calf is squeezed. Sometimes an ultrasound or MRI Scan is used to confirm the diagnosis. What is the Treatment of Achilles tendon ruptures?

It is important that an Achilles tendon rupture is treated adequately; otherwise there will be ongoing weakness. This weakness will interfere with walking and sports activities, and may require later reconstructive surgery. Nevertheless, treatment can be either with or without an operation. Whether you undergo surgery, or not, is a judgement based upon a discussion between you and your surgeon Without an operation Non operative treatment involves casting or bracing the foot and ankle with the foot pointed downwards (plantar flexed or in equinus) for approximately 8 weeks. During this time the position of the foot is changed on several occasions. The advantage of non-operative treatment is that it does not require surgery, reducing the risk of surgical and anaesthetic complications. The disadvantage of non-operative treatment is that the risk of tendon re-rupture at a later date is higher (around 18%). If the tendon re-ruptures surgery will be required. Also, the calf muscle and Achilles tendon may have slightly less power than if the tendon is repaired with an operation. With an operation Operative treatment for Achilles tendon rupture involves making a small incision over the site of rupture. The two ends of the tendon are sewn together with stitches.

On waking from the operation the foot and ankle is in a plaster splint which holds the foot pointing downwards. Typically you will be in hospital overnight and up on crutches the next day. It is important to keep the foot elevated for the first week or two after surgery to reduce the swelling. You will be on crutches with a splint for 6 to 8 weeks. The position of the splint is changed to bring the foot up to square over that period. The advantage of surgical treatment is that the chance of the tendon re-rupturing at a later date is lower (around 2%) and the strength and endurance of the calf muscle and Achilles tendon is slightly greater. Whether the tendon rupture is treated with or without surgery, physiotherapy for strengthening and range of motion may be necessary when the tendon ends have healed together. This strength and range of motion of the foot and ankle will gradually come back over the months afterwards and in general it will be five to six months until there is full recovery and you can return to sport. Gentle running on a flat surface can be undertaken at four months after the rupture. What happens if the diagnosis Achilles tendon rupture is delayed?

Surprisingly missing a rupture is not that rare, and occurs in 1 in 4 cases. If the diagnosis is delayed the damage can usually be repaired with surgery. Although there is likely to be a little more scarring, the functional result is good. Sometime the two ends of the tendon have tightened up, and cannot be sewn together. In these cases the gap may be bridged by lengthening the tendon, or alternatively by using the tendon to the big toe (the flexor hallucis longus) to bridge the gap. Are There Any Risks With Surgery? The vast majority of patients who have surgery for Achilles rupture recover well, without complication. However, as with any surgery there is always a small chance of problems. These include: 1. The main reason for operating is to reduce the risk of re-rupture, or failure of the tendon to heal. Surgery reduces this risk from about 1 in 6, to 1 in 50. 2. Infection - this may require intravenous or oral antibiotic treatment. 3. Wound healing problems - this is occasionally associated with infection and occasionally requires plastic surgery. It is best avoided by keeping the leg elevated after surgery. Smoking increases the risk of wound problems.

4. Nerve damage - causing pain and numbness in the foot. 5. Bleeding. 6. Swelling. 7. The general complications of any surgery and general anaesthesia. Blood clots can occur in the leg (deep venous thrombosis) and in some cases can even go into the lung (pulmonary embolus). Tendo-Achilles Tendinosis - Eccentric Training Programme The exercises should be supervised and progressed by a registered physiotherapist 1. Warm-up • Move ankle up and down X 30. • Walk backwards with toe/heel pattern for 3 mins. 2. Wall Knee Squat • Stand facing close to a wall, feet shoulder width apart. Bend knees so that they lightly touch the wall. Return to the start. Repeat X 10. • Progress by bending knees towards the wall and left, and then repeat to the right. (e.g. skiing position) • Progress further by exercising on one foot only. 3. Balance & Reach Toe/Knee Stretch • Balance on the injured foot facing the wall approximately an arms length away. • Stretch to the skirting-board with the un-injured leg, bending the supporting leg.

• Touch the bottom of the skirting-board/floor and return to the stating position, repeat by now stretching on the left side whilst keeping your balance. Return to the start position and repeat process stretching to the right side. • Repeat whole process X 10 4. Eccentric Lowering • Stand on the edge of a step, keep body upright, knees straight and take body weight into good leg, raise up onto toes, then transfer weight onto injured leg and lower down from tip toes back to horizontal. • Repeat X 10 (h to 15) X 3 sets. • Progress by - i. increasing the range of movement by taking the heel below the step level. ii. increase the load by adding weight e.g. hand weights, multi-gym press or rucksack. Exercise 4 can be repeated with knees bent. Activity - Jogging and walking is allowed if it can be performed with only mild discomfort and no pain. Initially start at a slow pace, for a short distance and on flat ground. Gradually increase the activity if there is NO severe pain in the tendon. No training should be undertaken through disabling pain.

Achilles Tendinitis: Causes, Symptoms, Treatments - Medical News Today Achilles Tendinitis: Causes, Symptoms, Treatments Written by Mike Paddock 4 13 Achilles tendinitis (tendonitis) or Achilles tendon inflammation occurs when the Achilles tendon becomes inflamed, as a result, of the Achilles tendon being put under too much strain. The Achilles tendon joins the calf muscles to the heel bone, and is found at the back of a person's lower leg. It is the largest tendon in the body and can endure great force, but is still susceptible to injury. Achilles tendinitis is usually the result of strenuous, high impact exercise, such as running. If ignored, Achilles tendinitis can lead to the tendon tearing or rupturing, and therefore it is important to seek the necessary treatment. Sometimes, treatment can be as simple as getting rest or changing an exercise routine. However, in more severe cases, surgery may be required. Contents of this article: You will also see introductions at the end of some sections to any recent developments that have been covered by MNT's news stories. Also look out for links to information about related conditions.

Fast facts on Achilles Here are some key points about Achilles tendinitis . More detail and supporting information is in the main article. Achilles tendinitis occurs as a result of the Achilles tendon becoming inflamed. The condition is usually the result of strenuous, high impact exercise. Achilles tendinitis can be caused by using incorrect footwear and not warming up before exercise adequately. Differences in foot, leg or ankle anatomy that put more strain on the tendon can also lead to Achilles tendinitis. Achilles tendinosis is a degenerative condition in which the tendon becomes susceptible to serious damage. If the Achilles tendon has torn, surgery would most likely be performed in order to repair the damage. It is possible to lower the risk of developing Achilles tendinitis, although it is not possible to completely prevent its occurrence. Diagnosis requires that a doctor ask the patient questions about their symptoms and perform a physical examination. Achilles tendinitis treatment aims to relieve pain and reduce swelling. Treatment methods include ice packs, resting, exercising and stretching, pain relief and steroids. What causes achilles tendinitis? There are a number of ways a person can develop Achilles tendinitis.

Some causes are easier to avoid than others, but being aware of them can aid earlier diagnosis and help prevent serious injury. Causes of Achilles tendinitis include: Using incorrect or worn out shoes when running or exercising Not warming up properly before exercise Increasing intensity of exercise too quickly (e.g. running speed or distance covered) Prematurely introducing hill running or stair climbing to exercise routine Running on hard or uneven surfaces Calf muscle is injured or has little flexibility (this puts a lot of strain on the Achilles tendon) Sudden intense physical activity such as sprinting for the finish line. Achilles tendinitis can also be caused by differences in foot, leg or ankle anatomy. For example, some people can have flatness in their foot where there would normally be an arch; this puts more strain on the tendon. The FDA has asked that a boxed warning be added to the prescribing information for fluoroquinolone antibiotics . Patients taking these drugs may experience an increased risk of tendinitis and tendon rupture.

Fluoroquinolones include Cipro (ciprofloxacin), Factive (gemifloxacin), Levaquin (levofloxacin), Avelox (moxifloxacin), Noroxin (norfloxacin), Floxin (ofloxacin) and Proquin (ciprofloxacin hydrochloride). It is important to remember that the risk for injury is not necessarily gone when the drug is stopped. Cases have been reported in which tendon problems occurred up to several months after the drug was discontinued.1 Signs and symptoms of achilles tendinitis A symptom is something the patient feels and reports, while a sign is something other people, such as a doctor, detect. For example, pain is a symptom, while a rash is a sign. The most typical symptom of Achilles tendinitis is a gradual buildup of pain that deteriorates with time. With Achilles tendinitis, the Achilles tendon may feel sore a few centimeters above where it meets the heel bone.

Other possible signs and symptoms of Achilles tendinitis are: The Achilles tendon feels sore a few centimeters above where it meets the heel bone Lower leg feels stiff Lower leg feels slow and weak Slight pain in the back of the leg that appears after running or exercising, and worsens Pain in the Achilles tendon that occurs while running or a couple of hours afterwards Greater pain experienced when running fast (such as sprinting), for a long time (such as cross country), or even when climbing stairs The Achilles tendon swells or forms a bump The Achilles tendon creaks when touched or moved. Please note that these symptoms, and others similar can occur in other conditions, so for an accurate diagnosis, the patient would need to visit their doctor. Potential complications A major complication of Achilles tendinitis is Achilles tendinosis. Achilles tendinosis is a degenerative condition in which the structure of the tendon changes and becomes susceptible to serious damage. This can lead to the tendon tearing and causing great pain. When Achilles tendinosis has occurred, and the tendon has torn, surgery would most likely be performed to repair the tendon damage.

On the next page we look at how achilles tendinitis can be prevented, how it is diagnosed and the available treatments for achilles tendinitis. Heel pain and calcaneal spurs 8 of the best free workouts on YouTube Heel pain and calcaneal spurs A calcaneal spur is a small bony projection that is formed on the calcaneus or heel bone, either at the back of the heel or under the sole of the heel. Find out what causes heel pain and calcaneal spurs. MOST POPULAR Email What is a calcaneal spur? A calcaneal spur is a small bony projection that is formed on the calcaneus or heel bone, either at the back of the heel or under the sole of the heel. It's caused by damage to the bone accumulating over a long period of time as a result of chronic inflammation of the Achilles tendon in the calf or the tough sinewy tissue called the plantar fascia, which is found on the soles of the feet. ADVERTISEMENT - CONTINUE READING BELOW What causes heel pain and calcaneal spurs? Every time you take a step, one of your heels has to support the whole weight of your body.

As you move, the load is equal to 20 times your own body weight. The load is softened by a pillow of fat under the heel and a large sinew or ligament (the fibrous tissue that joins muscle and bone together) under the sole of the foot. This sinew is called the plantar fascia and it pulls the heel bone forward (in opposition to the Achilles tendon, which pulls it backwards). MOST POPULAR If an athlete does not warm up properly or a person with a sedentary job exercises heavily during the weekends, they might overload the muscles of the calf or strain the Achilles tendon, which joins these muscles to the heel bone. When overloaded the tendon becomes tight and painfully inflamed, which places extra strain on the plantar fascia and muscles in the soles of the foot. The strained plantar fascia becomes inflamed and may even develop tiny cracks. This is known as plantar fasciitis. Every time you sit down, sleep or otherwise rest your legs, the muscles of the sole of the foot will contract in an attempt to protect the damaged sinew. The pain in the heel will then no longer be felt.

But when you get up again and put weight on the foot, the foot and ankle may feel stiff (because of the inflammation) and the pain will return either at the back of the heel or on the soles of the feet. When you start to move, the plantar fascia may crack even more causing a vicious cycle of damage and pain. Inflammation at the point where the Achilles tendon (at the back of the heel) or the plantar fascia (under the heel) join the heel bone (a bone known as the Calcaneum) stimulates cells that form bone to deposit bone in this area, eventually leading to the build up of a bony prominence on the heel bone called a calcaneal spur. But it's not the spur itself that causes the pain. The spur is a sign of chronic inflammation in the connective tissues, which is the result of a prolonged overload. It should also be pointed out that heel spurs can occur on their own, without plantar fasciitis or pain, or may be linked to some types of arthritis (inflammation of the joints). And plantar fasciitis or Achilles tendonitis don't necessarily lead to spur formation.

ADVERTISEMENT - CONTINUE READING BELOW What are the symptoms of an overloaded or inflamed sinew or of a calcaneal spur? A sharp, stabbing or dull but intense pain under or on the inside of the heel. The pain is typically relieved during rest, but is worse after getting up again. As a rule of thumb, it is most painful first thing in the morning. The feet or calf muscles may feel very stiff in the morning, making walking difficult. The pain is made worse by walking on a hard surface or carrying something heavy, such as a suitcase. The pain can become so severe that it becomes difficult to continue your daily work. Calcaneal spurs may cause no symptoms at all. Special risk groups Most sufferers are people who are overweight and middle-aged. The excess weight puts additional load on all the muscles, tendons and bones, while with age, the shock-absorbing fat pillow under the foot shrinks and becomes less effective. Weekend athletes whose muscles aren't tuned up for sudden intense activity. People who have feet that are pronated and not corrected. Pronated means that the foot tends to roll inwards when a person walks or runs.

Foot care advice Get advice from a physiotherapist about the right sort of exercises to help the condition. Stretching exercises, which you can begin while still lying flat in bed in the morning can help to loosen the feet and calves and get you going. They should be done several times through the day too. Patients with plantar fasciitis often have tightness of the Achilles tendon and stretching interrupts the vicious cycle in which the two disorders aggravate each other. Up to 90 per cent of people find that their pain eases after 2 to 3 months of stretching exercises. Take time to warm up and stretch before taking part in sport or exercise and cool down afterwards. If you run or jog, it is better to run a short distance several times a week than one long run once a week. Do not overestimate your abilities. If necessary, seek advice about creating a suitable running schedule that will give your body time to adapt. If you experience pain in the heel, you may be overloading your tendons. To help the healing process, follow the RICE principle, which stands for Rest, Ice, Compression and Elevation. If you have an acute flare up of pain, rest the foot and do not run until it has settled again.

Apply an ice pack, such as a packet of frozen peas that has first been wrapped in a towel or cloth. An elasticated support bandage will compress and support the foot. It should be firm, but not so tight that it affects the circulation of blood. Elevate the foot by resting it on a chair or a pillow. However regular low intensity exercise can help to ease the condition, so a balance has to be found between too much and too little exercise. Simply avoiding exercise completely may leave the legs and feet stiff and is not good for your general health. Invest in suitable shoes. The heel can be supported with a small cushioned insole inside the shoe. Arch supports that fit inside shoes will prevent feet from pronating. If you are overweight, losing weight can help resolve foot problems and prevent further trouble. Talk to your doctor about anti-inflammatory painkillers – for example ibuprofen may help if taken regularly but can cause irritation of the stomach lining. How does the doctor make the diagnosis? Calcaneal spurs and plantar fasciitis are usually diagnosed by the symptoms revealed during a clinical examination. To eventually confirm the diagnosis and exclude other possible causes of heel pain like arthritis , the doctor may order other investigations such as X-rays .

Prognosis Plantar fasciitis is a chronic condition that often lasts 12 months or more before eventually subsiding. Once a calcaneal spur develops, it can be a difficult condition to treat. However, many cases involve only minor ligament damage, which is relieved in a matter of weeks or months. Prevention by taking early corrective measures against any predisposing factors will improve the long-term prognosis. How is a painful heel or calcaneal spur treated? In all stages of the condition it is important to use appropriate footwear and adopt footcare habits. Reduce activity during acute pain and rest the heel. Physiotherapy can teach useful non-weight bearing exercises to stretch the tissues and use techniques such as ultrasound to help healing. These help in up to 90 per cent of cases. Your doctor may prescribe anti-inflammatory medicines . injections of steroids will sometimes reduce pain dramatically but the effects will only be temporary. A state-registered chiropodist or podiatrist, particularly one with an interest in biomechanics will be able to offer advice on foot posture and the use of corrective insoles or footwear. If pain persists despite these treatments, your doctor may suggest referring you to an orthopaedic surgeon who can offer treatments such as the following.

Extracorporeal shockwave therapy. This takes just a few minutes. A special machine is used to apply a shockwave to the surface of the foot. Three treatments are usually given, one or two weeks apart. The shockwaves cause microscopic damage to the plantar fascia, which stimulates healing. It may also make the nerves less sensitive to pain. About 80 per cent of patients find this treatment helps them. A course of injections Surgery is often no more than a last resort when pain is hard to deal with, and it may be ineffective. One technique that may help, known as medically as gastrocnemius release, carefully releases some of the tension in the calf muscle, taking the strain off the inflamed heel. It can be done as a minimally invasive technique through a tiny incision. Other people also read: Are you overweight? Find out what your BMI is. Losing weight : if you need to lose weight, what should you do? Arthritis : who is at special risk? X-rays : find out what happens during a test.

Based on a text by Dr Flemming Andersen Last updated Achilles Tendinitis-OrthoInfo - AAOS Copyright 2010 American Academy of Orthopaedic Surgeons Achilles Tendinitis Achilles tendinitis is a common condition that causes pain along the back of the leg near the heel. The Achilles tendon is the largest tendon in the body. It connects your calf muscles to your heel bone and is used when you walk, run, and jump. Although the Achilles tendon can withstand great stresses from running and jumping, it is also prone to tendinitis, a condition associated with overuse and degeneration. Description Simply defined, tendinitis is inflammation of a tendon. Inflammation is the body's natural response to injury or disease, and often causes swelling, pain, or irritation. There are two types of Achilles tendinitis, based upon which part of the tendon is inflamed. Noninsertional Achilles tendinitis Noninsertional Achilles Tendinitis In noninsertional Achilles tendinitis, fibers in the middle portion of the tendon have begun to break down with tiny tears (degenerate), swell, and thicken. Tendinitis of the middle portion of the tendon more commonly affects younger, active people.

Insertional Achilles Tendinitis Insertional Achilles tendinitis involves the lower portion of the heel, where the tendon attaches (inserts) to the heel bone. In both noninsertional and insertional Achilles tendinitis, damaged tendon fibers may also calcify (harden). Bone spurs (extra bone growth) often form with insertional Achilles tendinitis. Tendinitis that affects the insertion of the tendon can occur at any time, even in patients who are not active. Insertional Achilles tendinitis Top of page Cause Achilles tendinitis is typically not related to a specific injury. The problem results from repetitive stress to the tendon. This often happens when we push our bodies to do too much, too soon, but other factors can make it more likely to develop tendinitis, including: A bone spur that has developed where the tendon attaches to the heel bone.

Sudden increase in the amount or intensity of exercise activity—for example, increasing the distance you run every day by a few miles without giving your body a chance to adjust to the new distance Tight calf muscles—Having tight calf muscles and suddenly starting an aggressive exercise program can put extra stress on the Achilles tendon Bone spur—Extra bone growth where the Achilles tendon attaches to the heel bone can rub against the tendon and cause pain Common symptoms of Achilles tendinitis include: Pain and stiffness along the Achilles tendon in the morning Pain along the tendon or back of the heel that worsens with activity Severe pain the day after exercising Thickening of the tendon Bone spur (insertional tendinitis) Swelling that is present all the time and gets worse throughout the day with activity If you have experienced a sudden "pop" in the back of your calf or heel, you may have ruptured (torn) your Achilles tendon. See your doctor immediately if you think you may have torn your tendon. Top of page Doctor Examination After you describe your symptoms and discuss your concerns, the doctor will examine your foot and ankle.

The doctor will look for these signs: Swelling along the Achilles tendon or at the back of your heel Thickening or enlargement of the Achilles tendon Bony spurs at the lower part of the tendon at the back of your heel (insertional tendinitis) The point of maximum tenderness Pain in the middle of the tendon, (noninsertional tendinitis) Pain at the back of your heel at the lower part of the tendon (insertional tendinitis) Limited range of motion in your ankle—specifically, a decreased ability to flex your foot Your doctor may order imaging tests to make sure your symptoms are caused by Achilles tendinitis. X-rays X-ray tests provide clear images of bones. X-rays can show whether the lower part of the Achilles tendon has calcified, or become hardened. This calcification indicates insertional Achilles tendinitis. In cases of severe noninsertional Achilles tendinitis, there can be calcification in the middle portion of the tendon, as well. Magnetic Resonance Imaging (MRI) Although magnetic resonance imaging (MRI) is not necessary to diagnose Achilles tendinitis, it is important for planning surgery. An MRI scan can show how severe the damage is in the tendon.

If surgery is needed, your doctor will select the procedure based on the amount of tendon damage. Treatment Nonsurgical Treatment In most cases, nonsurgical treatment options will provide pain relief, although it may take a few months for symptoms to completely subside. Even with early treatment, the pain may last longer than 3 months. If you have had pain for several months before seeking treatment, it may take 6 months before treatment methods take effect. Rest. The first step in reducing pain is to decrease or even stop the activities that make the pain worse. If you regularly do high-impact exercises (such as running), switching to low-impact activities will put less stress on the Achilles tendon. Cross-training activities such as biking, elliptical exercise, and swimming are low-impact options to help you stay active. Ice. Placing ice on the most painful area of the Achilles tendon is helpful and can be done as needed throughout the day. This can be done for up to 20 minutes and should be stopped earlier if the skin becomes numb. A foam cup filled with water and then frozen creates a simple, reusable ice pack. After the water has frozen in the cup, tear off the rim of the cup. Then rub the ice on the Achilles tendon.

With repeated use, a groove that fits the Achilles tendon will appear, creating a "custom-fit" ice pack. Non-steroidal anti-inflammatory medication. Drugs such as ibuprofen and naproxen reduce pain and swelling. They do not, however, reduce the thickening of the degenerated tendon. Using the medication for more than 1 month should be reviewed with your primary care doctor. Exercise. The following exercise can help to strengthen the calf muscles and reduce stress on the Achilles tendon. Calf stretch Lean forward against a wall with one knee straight and the heel on the ground. Place the other leg in front, with the knee bent. To stretch the calf muscles and the heel cord, push your hips toward the wall in a controlled fashion. Hold the position for 10 seconds and relax. Repeat this exercise 20 times for each foot. A strong pull in the calf should be felt during the stretch. Physical Therapy. Physical therapy is very helpful in treating Achilles tendinitis. It has proven to work better for noninsertional tendinitis than for insertional tendinitis. Eccentric Strengthening Protocol. Eccentric strengthening is defined as contracting (tightening) a muscle while it is getting longer.

Eccentric strengthening exercises can cause damage to the Achilles tendon if they are not done correctly. At first, they should be performed under the supervision of a physical therapist. Once mastered with a therapist, the exercises can then be done at home. These exercises may cause some discomfort, however, it should not be unbearable. Bilateral heel drop Stand at the edge of a stair, or a raised platform that is stable, with just the front half of your foot on the stair. This position will allow your heel to move up and down without hitting the stair. Care must be taken to ensure that you are balanced correctly to prevent falling and injury. Be sure to hold onto a railing to help you balance. Lift your heels off the ground then slowly lower your heels to the lowest point possible. Repeat this step 20 times. This exercise should be done in a slow, controlled fashion. Rapid movement can create the risk of damage to the tendon. As the pain improves, you can increase the difficulty level of the exercise by holding a small weight in each hand. Single leg heel drop This exercise is performed similarly to the bilateral heel drop, except that all your weight is focused on one leg. This should be done only after the bilateral heel drop has been mastered.

Cortisone injections. Cortisone, a type of steroid, is a powerful anti-inflammatory medication. Cortisone injections into the Achilles tendon are rarely recommended because they can cause the tendon to rupture (tear). Supportive shoes and orthotics. Pain from insertional Achilles tendinitis is often helped by certain shoes, as well as orthotic devices. For example, shoes that are softer at the back of the heel can reduce irritation of the tendon. In addition, heel lifts can take some strain off the tendon. Heel lifts are also very helpful for patients with insertional tendinitis because they can move the heel away from the back of the shoe, where rubbing can occur. They also take some strain off the tendon. Like a heel lift, a silicone Achilles sleeve can reduce irritation from the back of a shoe. If your pain is severe, your doctor may recommend a walking boot for a short time. This gives the tendon a chance to rest before any therapy is begun. Extended use of a boot is discouraged, though, because it can weaken your calf muscle. Extracorporeal shockwave therapy (ESWT). During this procedure, high-energy shockwave impulses stimulate the healing process in damaged tendon tissue.

ESWT has not shown consistent results and, therefore, is not commonly performed. ESWT is noninvasive—it does not require a surgical incision. Because of the minimal risk involved, ESWT is sometimes tried before surgery is considered. Surgical Treatment Surgery should be considered to relieve Achilles tendinitis only if the pain does not improve after 6 months of nonsurgical treatment. The specific type of surgery depends on the location of the tendinitis and the amount of damage to the tendon. Gastrocnemius recession. This is a surgical lengthening of the calf (gastrocnemius) muscles. Because tight calf muscles place increased stress on the Achilles tendon, this procedure is useful for patients who still have difficulty flexing their feet, despite consistent stretching. In gastrocnemius recession, one of the two muscles that make up the calf is lengthened to increase the motion of the ankle. The procedure can be performed with a traditional, open incision or with a smaller incision and an endoscope—an instrument that contains a small camera. Your doctor will discuss the procedure that best meets your needs. Complication rates for gastrocnemius recession are low, but can include nerve damage.

Gastrocnemius recession can be performed with or without débridement, which is removal of damaged tissue. Débridement and repair (tendon has less than 50% damage). The goal of this operation is to remove the damaged part of the Achilles tendon. Once the unhealthy portion of the tendon has been removed, the remaining tendon is repaired with sutures, or stitches to complete the repair. In insertional tendinitis, the bone spur is also removed. Repair of the tendon in these instances may require the use of metal or plastic anchors to help hold the Achilles tendon to the heel bone, where it attaches. After débridement and repair, most patients are allowed to walk in a removable boot or cast within 2 weeks, although this period depends upon the amount of damage to the tendon. Débridement with tendon transfer (tendon has greater than 50% damage). In cases where more than 50% of the Achilles tendon is not healthy and requires removal, the remaining portion of the tendon is not strong enough to function alone. To prevent the remaining tendon from rupturing with activity, an Achilles tendon transfer is performed.

The tendon that helps the big toe point down is moved to the heel bone to add strength to the damaged tendon. Although this sounds severe, the big toe will still be able to move, and most patients will not notice a change in the way they walk or run. Depending on the extent of damage to the tendon, some patients may not be able to return to competitive sports or running. Recovery. Most patients have good results from surgery. The main factor in surgical recovery is the amount of damage to the tendon. The greater the amount of tendon involved, the longer the recovery period, and the less likely a patient will be able to return to sports activity. Physical therapy is an important part of recovery. Many patients require 12 months of rehabilitation before they are pain-free. Complications. Moderate to severe pain after surgery is noted in 20% to 30% of patients and is the most common complication. In addition, a wound infection can occur and the infection is very difficult to treat in this location.

Top of page For More Information If you found this article helpful, you may also be interested in Achilles Tendon Rupture (Tear) Achilles Tendon Rupture (Tear) (topic.cfm?topic=AV0003). In order to assist doctors in the diagnosis and treatment of achilles tendon rupture, the American Academy of Orthopaedic Surgeons has done research to provide some useful guidelines. These are recommendations only and may not apply to each and every individual case. For more information: AAOS Clinical Practice Guideline: Diagnosis and Treatment of Acute Achilles Tendon Rupture AAOS Clinical Practice Guideline: Diagnosis and Treatment of Acute Achilles Tendon Rupture ( Chronic Achilles Tendon Problems: An Overview - HSS.edu - HSS Attending Orthopaedic Surgeon, Hospital for Special Surgery Professor of Orthopaedic Surgery, Weill Cornell Medical College Injury Overview The Achilles tendon is the strongest tendon in the body, linking the heel bone to the calf muscle. Problems with the Achilles are some of the most common conditions seen by sports medicine doctors. Chronic, long-lasting Achilles tendon disorders can range from overuse injuries to tearing of the tendon.

Pain in the heel is often caused by a combination of both acute and chronic problems, including inflammation (paratenonitis, insertional tendonitis and retrocalcaneal bursitis) and tendinosis. Anatomy of the lower leg, featuring the Achilles tendon and the muscles of the calf [illustration courtesy of the Journal of Musculoskeletal Medicine . © Steve Oh, CMI 2009] Inflammation What is Paratenonitis? Paratenonitis is an acute Achilles injury caused by overuse. It involves inflammation of the covering of the Achilles tendon. “In really acute cases, the tendon can appear sausage-like, because it is so severely swollen,” says Russell Warren, M.D. , a sports medicine orthopedic surgeon at Hospital for Special Surgery in New York. Marathon runners often experience this type of swelling after long runs. Runners may complain of stiffness and discomfort at the beginning of the run, but push through the discomfort. Symptoms are typically aggravated by running and relieved by rest. If left untreated, paratenonitis may progress to the point that any running becomes difficult. What is Insertional Tendonitis? Insertional tendonitis involves inflammation at the point where the Achilles tendon inserts into the heel bone.

People with this condition often have tenderness directly over the insertion of the Achilles tendon, which is commonly associated with calcium formation or a bone spur forming just above the insertion point. This condition can occur along with retrocalcaneal bursitis (see below) and a bony enlargement of the heel bone, known as Haglund’s deformity , which is referred to as a ‘pump bump.’ “Most cases of Haglund’s deformity occur in women who wear high-heeled shoes or men and women hockey players because of the skate rubbing on the back of the heel,” says Scott Rodeo, M.D. , a sports medicine orthopedic surgeon at Hospital for Special Surgery. What is Retrocalcaneal Bursitis? Retrocalcaneal bursitis is caused by movement-related irritation of the retrocalcaneal bursa, the fluid-filled cushioning sac between the heel bone and the Achilles tendon. This condition involves pain in front of the Achilles tendon, in the area between the tendon and the heel bone. The bursa can become inflamed or thickened and stick to the tendon, as a result of overuse or repetitive loading.

Pain may result from squeezing the tendon itself or the space just in front of the tendon. “Although retrocalcaneal bursitis can be associated with rheumatoid arthritis in 10 percent of people, most occurrences in athletes only involve one side and are not associated with a systemic disease,” says Dr. Warren. Degeneration What is Tendinosis? Most pain within the Achilles tendon may be classified as tendinosis because it involves tendon degeneration, not inflammation. In addition, the tendon may become weakened and lose its structure. Although aging may play a part in this process, repetitive minor trauma, such as playing sports that involve running or jumping, without proper healing can also play a role. Areas of tendinosis may eventually progress to partial or complete ruptures if they experience high loads, as are seen with physically demanding sports such as football and basketball, especially during push-off and landing activities. Treatment Options Doctors commonly use ultrasound and magnetic resonance imaging (MRI) to evaluate heel pain. These diagnostic methods, along with a physical examination and history, can help sports medicine physicians to properly diagnose Achilles tendon conditions and recommend treatment on an individual basis. For the distinct disorders above, treatment depends on the nature of the injury.

Most people who have injuries related to overuse of the tendon undergo non-surgical treatment, which begins with rest and modification of activities. “Sometimes changing to a cross-training program with bicycling and water therapy can be helpful. A small heel lift that can be inserted within the shoe may be useful in reducing the stress on the Achilles tendon,” says Dr. Rodeo. In acute cases of Achilles tendon injury, especially when inflammation is involved, non-steroidal anti-inflammatory medications such as ibuprofen can be beneficial. In addition, treatment involves ice massages, stretching, strengthening exercises and correcting alignment problems under the guidance of a physician, athletic trainer or physical therapist. If these fail to relieve symptoms, injections of cortisone or platelet-rich plasma may be considered, although currently there is little evidence to support their use. A small group of patients who do not benefit from these therapies may require surgery. Prevention According to Dr. Rodeo, athletes should take the following steps to prevent Achilles tendon injury: Don’t take on too much too fast. Increase the intensity and difficulty of an exercise program gradually so as not to strain your Achilles. Use appropriate footwear. The more arch support, the less strain there is on the heel and associated muscles. Stretch.

Make sure to stretch your Achilles tendon and calf muscles before and after exercise, to keep them loose and reduce the risk of injury. Expectation for Recovery Recovery expectations vary based on the particular injury or combination of injuries that are causing the pain. Based on the results of an ultrasound and MRI, sports medicine physicians will discuss the prognosis on an individual basis. The most important components of an expedient recovery are to rest the Achilles and to modify the exercise regimen to accommodate the pain and issues of overuse. Paratenonitis: The recovery time for paratenonitis is highly variable and depends on the extent and severity of symptoms, potentially lasting up to or even exceeding three months. Athletes may be able to return to pre-injury levels of play, but this can require an extended period of recovery. While paratenonitis can be resolved with rest and anti-inflammatory medication, it may recur if there are underlying biomechanical factors that contributed to the development of the problem. Tendinosis: The structural changes that occur in the tendon due to degeneration are largely irreversible, but the symptoms may resolve and thus the athlete may be able to return to play. However, symptoms sometimes recur after activities are resumed.

Insertional Tendonitis: Athletes should recover within six weeks if the cause of pain is a calcium formation or a bone spur forming just above the insertion point of the Achilles tendon to the heel bone, but recurrence is a risk if the bone spur is not removed. Retrocalcaneal Bursitis: Estimated recovery for retrocalcaneal bursitisis is four to six weeks but can be more prolonged, especially if there is an anatomic factor (such as bone spur) that is mechanically irritating the tendon. Posted: 6/1/2011 Plantar Fasciosis - Bone, Joint, and Muscle Disorders - Merck Manuals Consumer Version Bone, Joint, and Muscle Disorders Find information on medical topics, symptoms, drugs, procedures, news and more, written in everyday language. * This is the Consumer Version. * Plantar fasciosis is pain originating from the dense band of tissue called the plantar fascia that extends from the bottom of the heel bone to the base of the toes (ball of the foot). The connective tissue between the heel and ball of the foot may become damaged and painful.

Pain, which is often worse when first bearing weight in the morning and after periods of rest, is felt at the bottom of the heel. The diagnosis is based on an examination of the foot and imaging tests. Stretches, applying ice, changing footwear, wearing devices inside the shoe that cushion, support, and elevate the heel, and sometimes corticosteroid injections can help. The plantar fascia connects the bottom of the heel bone to the ball of the foot and is essential to walking, running, and giving spring to the step. Plantar fasciosis is sometimes referred to as plantar fasciitis. However, the term plantar fasciitis is not correct. The term fasciitis means inflammation of the fascia, but plantar fasciosis is a disorder where the fascia is repeatedly stressed rather than inflamed. Other terms used to describe plantar fasciosis include calcaneal enthesopathy and calcaneal spur syndrome (heel spur―see Figure: What Is a Heel Spur? ). A heel spur is a pointed growth of extra bone on the heel bone. It is caused over time by a combination of increased pull on the fascia and foot dysfunction. However, a heel spur may or may not be present.

Often a small tear results from excessive strain placed on the plantar fascia. Plantar fasciosis is one of the most common causes of heel pain. Plantar fasciosis can develop in people who have a sedentary lifestyle, wear high-heeled shoes, have unusually high or low arches in the feet, or have tight calf muscles or a tight Achilles tendon (the tendon that attaches the calf muscles to the heel bone). Sedentary people are usually affected when they suddenly increase their level of activity or wear less supportive shoes such as sandals or flip-flops. Plantar fasciosis is also common among runners and dancers because of increased stress on the fascia, especially if the person also has poor foot posture. The development of this painful disorder occurs more often in people whose occupations involve standing or walking on hard surfaces for prolonged periods. Disorders that may cause or aggravate plantar fasciosis are obesity, rheumatoid arthritis, and other types of arthritis. Too many corticosteroid injections may contribute to the development of plantar fasciosis by damaging the fascia or the fat pad under the heel.

Symptoms A person with plantar fasciosis may have pain anywhere along the course of the plantar fascia but most commonly where the fascia joins the bottom of the heel bone. The person often feels a great deal of pain with weight bearing, particularly when placing weight on the foot first thing in the morning. The pain temporarily lessens within 5 to 10 minutes but may return later in the day. It is often worse when pushing off of the heel (such as when walking or running) and after periods of rest. In this case, the pain radiates from the bottom of the heel toward the toes. Some people have burning or sticking pain along the inside border of the sole of the foot when walking. What Is a Heel Spur? A heel spur is a pointed growth of extra bone on the heel bone (calcaneus). It may form when the plantar fascia, the connective tissue extending from the bottom of the heel bone to the base of the toes (ball of the foot), pulls excessively on the heel. The spur may be painful as it develops but it may become less painful as the foot adjusts to it. Not all heel spurs cause symptoms.

When heel spurs do cause symptoms, most can be treated without surgery. Diagnosis Achilles Tendon (Human Anatomy): Picture, Definition, Injuries, Pain, and More Next The Achilles tendon is a tough band of fibrous tissue that connects the calf muscles to the heel bone (calcaneus). The Achilles tendon is also called the calcaneal tendon. The gastrocnemius and soleus muscles (calf muscles) unite into one band of tissue, which becomes the Achilles tendon at the low end of the calf. The Achilles tendon then inserts into the calcaneus. Small sacs of fluid called bursae cushion the Achilles tendon at the heel. The Achilles tendon is the largest and strongest tendon in the body. When the calf muscles flex, the Achilles tendon pulls on the heel. This movement allows us to stand on our toes when walking, running, or jumping. Despite its strength, the Achilles tendon is also vulnerable to injury, due to its limited blood supply and the high tensions placed on it. Achilles Tendon Conditions Achilles tendon tear : Tears of the Achilles tendon can be tiny (microtears), or large, causing pain, swelling, and impaired movement. They may occur suddenly during activity, or gradually over time.

Achilles tendon rupture : A complete rupture of the Achilles tendon may make a "pop" sound, followed by pain and swelling of the lower leg. Treating an Achilles tendon rupture requires surgery or long-term immobilization of the ankle. Achilles tendinitis (tendonitis): Frequent activity (running or walking) can gradually inflame the end of the Achilles tendon, causing pain and stiffness at the back of the heel. Rest, ice, and stretching may speed healing, which can take weeks. Achilles peritendonitis: Similar to Achilles tendonitis, but inflammation and pain occur in the tissue surrounding the tendon, often two or more inches above the heel. Achilles tendinosis: Gradual thickening of the Achilles tendon without apparent inflammation, due to aging or overuse. Despite the thickening, the tendon is weakened and prone to further injury or rupture. Achilles tendinopathy : A general term for tendinitis or tendinosis affecting the Achilles tendon. Achilles or heel (calcaneal) bursitis : Low-riding shoes can irritate the bursa, a sac of fluid cushioning the Achilles tendon at the heel.

Pain in the back of the heel, worse with shoes on, is the common symptom. Continued Achilles Tendon Tests Physical examination : To look for Achilles tendon problems, an examiner checks for pain, swelling, warmth, thickening, or discoloration around the heel and leg. A knot on the back of the leg may be present with Achilles tendon rupture. Most cases of tendinopathy without a rupture can be diagnosed by physical exam and often do not need further testing. Thompson test : Lying prone (on one’s stomach) or while kneeling on a chair, an examiner squeezes the calf. The end of the foot should move down in response; if it does not, an Achilles tendon rupture may be present. Knee flexion (Matles) test: A person lies face down and bends the knee slowly to a right angle. During this movement, the toe end of the foot should point away from the leg slightly; if it doesn't, an Achilles tendon rupture may be present. Magnetic resonance imaging ( MRI scan ): An MRI scanner uses a high-powered magnet and a computer to create highly detailed images of the ankle and leg.

An MRI scan is the best test to diagnose an Achilles tendon rupture or other problems but it may not always detect tendinopathy. Achilles tendon ultrasound : A probe on the skin reflects high-frequency sound waves off the ankle, producing images of the Achilles tendon. Ultrasound can often diagnose an Achilles tendon rupture. Computed tomography ( CT scan ): A CT scanner takes multiple X-rays, and a computer constructs detailed images of the ankle and leg. An MRI scan is superior to a CT scan in diagnosing Achilles tendon problems. X-ray film : A plain X-ray film may identify problems with the bones or ankle joint, but it cannot diagnose Achilles tendon problems. Continued Achilles Tendon Treatments RICE therapy : Most Achilles tendon injuries can be treated with RICE: Rest, Ice, Compression with a sports bandage, and Elevation. Pain relievers : Over-the-counter medicines like acetaminophen (Tylenol), ibuprofen (Motrin), and naproxen (Aleve) can lessen the pain of most Achilles tendon problems. For more severe pain, prescription pain relievers may be necessary. Heat : Alternating ice and heat therapy may improve the pain of bursitis near the Achilles tendon.

Footwear: Wearing shoes with good support that are right for your feet may help avoid continual injury to the Achilles tendon. Custom-made orthotics, heel lifts, and certain splints and braces are sometimes helpful. Physical Therapy: Although modifying or decreasing activity is important, particular stretches and exercises may be helpful to rehabilitate tendon problems, especially when they are persistent. Immobilization : Many moderate to severe Achilles tendon conditions require immobilization of the ankle joint. This may require wearing a special boot or a leg cast for several weeks. Achilles tendon surgery : Surgery can often reattach a ruptured Achilles tendon. Following surgery, immobilization of the ankle is necessary for several weeks. WebMD Image Collection Reviewed by Varnada Karriem-Norwood, MD on November 15, 2014 Sources Ruptured Ankle Tendon, Physical Therapy, New Jersey, NJ Ruptured Ankle Tendon Posterior Tendon Rupture Background & Etiology (Cause) The ankle is made up of two joints. These joints need to be strong because they support the weight of the entire body. The ankle is one of the most versatile joint complexes in the body.

It is built for weight bearing, mobility, adaptability and stability. The foot and ankle allow us to walk, stand, run and jump, and serves as our connection to the ground. The ankle must be able to withstand the stress of our body weight, and also be able to adapt to, and react quickly to changes in environment and walking surface. Tendons are connective tissues that attach muscle to bone. They are strong, fibrous structures that are responsible for transferring the forces generated by the muscle to the bone, thus producing movement at the joint. When a tendon becomes irritated or inflamed it becomes painful, causing tendonitis. The tendons in the ankle region are subject to significant stress, and can rupture under extreme pressure. Tendon Rupture When a tendon ruptures it can be extremely painful and cause a disability of the foot that then subsequently causes damage to the ankle joints. The tendons in the ankle include: The peroneals (peroneus brevis, peroneus longus,) anterior tibialis, posterior tibialis, and Achilles tendon. Any of these structures can become ruptured, which is a serious condition that will typically require surgery to fix.

Achilles Tendon The Achilles tendon is the largest tendon in the body. It is formed when the gastrocnemius muscle and soleus muscle of the calf join together. It runs from the calf muscles to the heel bone. The Achilles tendon plays a significant role in the ability to walk, run, and jump. Because the Achilles tendon is used for activities that can put great stress on the tendon, it one of the most often ruptured tendons in the body. Pain from Achilles tendon rupture commonly occurs along the back of the leg in the vicinity of the heel. Posterior Tibialis Tendon The posterior tibialis tendon is located along the inner side of the ankle. It connects the posterior tibial muscle (located at the back of the shin bone) to the foot. Problems with this tendon typically occur underneath the prominence of the medial malleolus (inner ankle bone) because the blood supply to this area can be poor. This makes it easier for overuse injuries to cause a tendon rupture. Pain with this type of injury typically occurs along the inside of the foot and ankle. Peroneal Tendon There are two peroneal tendons, the peroneus longus and the peroneus brevis.

These tendons run along the outside of the ankle and are subject to the repetitive forces from walking and standing. Pain with this condition is typically located along the posterolateral area of the ankle. Anterior Tibialis Tendon The tibialis anterior is a muscle located along the front of the tibia (shin bone). It is attached to the foot by the tibialis anterior tendon. This structure is responsible for the dorsiflextion of the foot and ankle. The anterior tibialis muscle plays a large role in dorsiflextion and deceleration of the foot when walking and running. Stress from a variety of movements including walking, running, kicking, or kneeling can cause the tibialis anterior tendon to rupture. Pain with this condition is typically concentrated along the front of the ankle or foot. Causes Common causes of an ankle tendon rupture include: The progression of or the final result of longstanding tendonitis of the involved tendon or an overuse injury. An injury to the ankle or a direct blow to the tendon. From a fall where an individual lands awkwardly or directly on the ankle Laceration of the tendon Weakness of the associated muscle in people with existing tendonitis places increased stress on the involved tendon.

Steroid use has been linked to tendon weakness Certain systemic diseases have been associated with tendon weakness. A sudden deceleration or stopping motions that cause an acute injury of the ankle. Injection of steroids to the involved tendon or the excessive use of steroids has been known to weaken tendons and make them susceptible to rupture. Symptoms of Ankle Tendon Ruptures Ankle pain and swelling or feeling that the ankle has “given out” after falling or stumbling. Possible audible pop when the ankle is injured. Patient may have a history of prior ankle pain or tendonitis, and may be active in sports. Swelling, tenderness and possible discoloration or ecchymosis in the ankle region. Indentation above the injured tendon where the torn tendon may be present. Difficulty moving around or walking. Individual has difficulty or is unable to move their ankle with full range of motion. MRI can confirm disruption or tear in the tendon. Immediate pain at time of injury. Treatment of Ankle Tendon Rupture Early diagnosis and treatment is the key to a successful outcome for a rupture of any of the tendons in the ankle. If diagnosis or treatment is delayed the integrity of the healing tissue can be compromised as a result of scarring and decreased blood flow.

Surgical repair followed by structured and aggressive physical therapy is the treatment of choice for complete ruptures. In the case of a small partial tendon tear conservative treatment without surgery is an option. Partial (small) Tendon Tear Immobilization of the ankle for 3-6 weeks to rest and promote healing. Individual will be placed in an immobilizer or brace and will move around with crutches to keep weight off of the leg. Physical Therapy: following the period of immobilization your physician will decide when you are ready for physical therapy. Treatment will emphasize gradual weaning off the immobilizing device, increasing weight bearing, restoration of ankle range of motion and strengthening of the associated muscles. It is important that the physician and therapist communicate during the early stages and progress your recovery program based on the principles of healing so as not to compromise the injured tendon. Patient will be progressed to more functional activities as normal ankle range of motion and strength is restored. Treatment of Complete Tendon Ruptures Immediate surgical repair of the tendon is indicated in complete tears. Delaying surgery can lead to shortening of the tendon, formation of scar tissue and decreased blood flow, which can lead to a poor outcome.

Following surgery your ankle will be put in an immobilizing device and you will be instructed to use crutches to limit weight bearing and protect the joint. Over the next 2-4 weeks weight bearing will be increased and physical therapy will be initiated. The surgeon will determine the physical therapy timeline and program. Physical Therapy: treatment will emphasize gradual weaning off the immobilizing device, increasing weight bearing, restoration of ankle range of motion and strengthening of the associated muscles. It is important that the physician and therapist communicate during the early stages and progress your program based on the principles of healing so as not to compromise the involved tendon. Patient will be progressed to more functional activities as normal ankle range of motion and strength is restored. Physical therapy for a tendon rupture must remain conservative at the onset in order to protect the repair. Emphasis will be on rest, tendon protection, reducing the inflammation and increasing the blood circulation for healing. Following the surgeon’s timeline and protocol, a program of progressive weight bearing, stretching and strengthening will be initiated.

Physical Therapy Interventions Common Physical Therapy interventions in the treatment of Ankle Tendon Rupture include: Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, stretching and joint mobilization of the ankle by a physical therapist to improve joint mobility and range of motion of the ankle. Use of mobilization techniques also helps to modulate pain. Therapeutic Exercises (TE) including stretching and strengthening exercises to regain range of motion and strengthen the muscles of the ankle and lower extremity. Neuromuscular Reeducation (NMR) to restore stability, retrain the lower extremity and improve movement techniques and mechanics (for example, running, kneeling, squatting and jumping) of the involved lower extremity to reduce stress on the tendons in daily activities. Taping, strapping or bracing may be indicated to rest the tendon and promote healing. Modalities including the use of ultrasound, electrical stimulation, ice, cold, laser and others to decrease pain and inflammation of the involved tendon and bursa. Prognosis If repair and treatment are initiated immediately, individuals with a rupture or tear of any of the tendons in the ankle generally do well.

Delay can result in the formation of scar tissue and retraction of the tendons. Other factors that can affect recovery are: Age: Older individuals are generally weaker and take longer to heal affecting the functional outcome. Strength: Individuals who are strong and in good condition prior to the injury generally do better following surgical repair. Tissue: Tissue quality prior to the surgical repair will effect healing and recovery following surgery. Poor circulation and presence of scar tissue will interfere with the healing process. The healing time for a tendon repair will take up to 8-12 weeks but restoration of function and ability to accept full activity, load and stress can take up to one year.

Question: Which tendon joins the calf muscle to the heel bone
Answer: Achilles