Ankle Issues

  • Achilles Tendon Rupture

    The Achilles tendon is the large cord like structure on the back of the leg just above the heel. It is the largest tendon in the body and has a tremendous amount of force transmitted through it during walking, running and jumping activities. The Achilles tendon is prone to injury, including rupture during periods of increased stress and activity. Common activities causing injury include running, basketball, baseball, football, soccer, volleyball and tennis. These activities require jumping and pushing forces that are possible due to the strength of the calf musculature and the ability of the Achilles tendon to endure this stress. Men from the ages of 30-50 are the most commonly injured during weekend athletic activities.

    Anatomy

    The Achilles tendon is the extension from the two large muscles in the calf region, the gastrocnemius and the soleus. These two muscles combine to form the Achilles tendon. The tendon forms in the lower one third of the leg and extends to the back of the heel bone (calcaneus). When the muscles of the calf contract this produces tension on the Achilles tendon pulling on the back of heel causing the heel to rise and the foot to point downward. It is during this motion that high-tension force is transmitted through the Achilles tendon during pushing and jumping activity. This high tension force can cause the Achilles tendon to tear or rupture. This happens in 3 common locations. The most common location for a tendon tear is within the tendon substance just above the heel. The second and third most common locations are where the Achilles tendon attaches into the heel bone and higher in the leg, where the tendon begins.

    Symptoms and Diagnosis

    Patients often describe a feeling of being kicked or hit with a baseball bat in the back of the heel during athletic activity. They are unable to continue the activity and have an extreme loss of strength with the inability to effectively walk. On physical examination there is often a defect that can be felt in the tendon just above the heel. A diagnosis of an Achilles tendon rupture is commonly made on physical exam. A MRI may be ordered to confirm the suspicion of a tear or to determine the extent of the tear.

    Treatment

    Early treatment is imperative for the best long-term outcome. Surgical repair is the most common treatment producing the greatest return to function and activity level. The goal of surgery is to realign the two ends of the ruptured tendon to allow healing. There are multiple techniques to accomplish this goal that will vary from surgeon to surgeon. Recovery from this injury is usually very successful with return to full function in approximately 6 months. Post operatively casting is required with the use of crutches or other means to remain non-weightbearing for 4-8 weeks. This is followed by a course of physical therapy. Partial rupture may or may not require surgical intervention depending on the extent of injury but cast immobilization is a common requirement.

  • Achilles Tendonitis

     

    The Achilles tendon is the largest tendon in the human body. It is located at the back of the ankle joint and can be felt as a large, cord-like structure attaching to the back of the foot. Since tendons serve to attach muscles to bone, the Achilles tendon also attaches the large calf muscles, the gastrocnemius and soleus, to the back of the heel bone, the calcaneus.

    Achilles tendonitis tends to occur more frequently in older athletes than in younger athletes. As a person ages into their thirties and especially into their forties and fifties, the ligaments and tendons of the body tend to lose some of their stretchiness and are not as strong as before. This predisposes older individuals who are active in running and jumping activities, to tendon injuries such as Achilles tendonitis. However, Achilles tendonitis can also occur in teenagers who are very active in running and jumping sports.

    Diagnosis

    Achilles tendonitis is diagnosed by a history and physical examination of the patient who describes pain at the back of the ankle with walking and/or running activities. The pain generally will be associated with an increase in running or jumping intensity or frequency. It is also often associated with a change from running in a thick heeled shoe to a thin heeled shoe, such as going from training shoes to racing flats and/or racing spikes in cross-country and/or track. The pain from Achilles tendonitis is often so severe that running is impossible and even walking is uncomfortable.

    During the physical examination, the podiatrist will feel and push lightly around the Achilles tendon to see if it is tender or has any irregularities in its surface. Achilles tendonitis may cause the tendon to be thickened in areas, may cause swelling of the area around the tendon, and can even feel like the tendon has a painful bump on it. In addition, the person with Achilles tendonitis will limp while barefoot, but walk more normally with heeled shoes on. X-rays are not helpful in diagnosing Achilles tendonitis but may be taken to rule-out other pathology. MRI scans are only indicated if a partial or complete rupture of the Achilles tendon is suspected by the podiatrist.

    Treatment

    Achilles tendonitis generally responds very well to conservative treatment as long as it is diagnosed and treated early. Surgery is rarely indicated unless the Achilles tendonitis is particularly severe and chronic, or if the tendon has ruptured completely.

    The Achilles tendon is a band of tissue that connects the calf muscle to the heel bone. Sometimes referred to as the “heel cord” this tissue raises the heel from the ground when walking. There are two common disorders of the Achilles tendon – Achilles Tendonitis and Achilles Tendonosis.

    The two disorders are related and Achilles Tendonosis is a result of untreated Achilles Tendonitis. Achilles tendonitis is common is recreational athletes but can happen to anyone. If the Achilles tendon is overused, it can become inflamed, which can lead to pain and swelling of the ankle. 

    Symptoms of Achilles tendonitis

    • Pain behind the heel

    • Pain after a period of inactivity

    • Pain while running or jumping

    • Stiffness, soreness or tenderness in the tendon (directly above the heel to just below the calf muscle)

    • Tender to the touch in the same region

    • Enlarged tendon, nodules may develop on the tendon increasing the size

    Causes: 
    Achilles tendonitis is an overuse disorder typically caused by a sudden increase of activity (commonly with repetitive movements). Microscopic tears occur and if the activity causing the injury is continued the tears will not heal. Most commonly people with supination, tend to walk on the outside of their foot, are prone to these conditions. Also, people with a flattening of the arch or excessive pronation are more likely to develop Achilles tendonitis and tendonosis. This is because there is a greater demand on the Achilles tendon when walking. Wearing proper supportive footwear is important to promote healing and avoid future injuries. There are two main causes of Achilles tendonitis: lack of flexibility and over-pronation, but it can be caused by other factors as well. 

    Recent changes in footwear and changes in exercise routines can contribute to the development of Achilles tendonitis.  Achilles tendonitis is most commonly found in middle-aged individuals because as we age, our tendons become less flexible and in turn, more susceptible to injury. Sometimes degeneration involves the location where the tendon connects to the heel bone. In rare, chronic degeneration, cases it is possible that a rupture of the tendon will result.

    Diagnosis:
    A doctor will evaluate the condition and range of motion of the tendon. Other imaging devices may be used to evaluate the condition of the tendon such as ultrasound imaging and x-rays.

    Treatment:
    Based on the degree of damage and the length of time the patient has been experiencing these conditions different treatments are used. In the early stages or during a sudden inflammation treatment may include:

    • Rest and immobilization - The use of a cast or temporary device may be used to promote healing

    • Ice - Used to reduce the swelling due to inflammation

    • Pain relievers/anti-inflammatory drugs - Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen

    • Proper footwear

    • Custom orthotics - If over-pronation/supination or an abnormal gait is an issue, an evaluation or examination should be performed and prescription orthotics may be necessary

    • Night splints - These can assist by preventing the tendon from becoming stiff over night or long periods of rest

    • Physical therapy - Some exercises, stretching and massage may be beneficial in recovery

    • A special brace may help to protect and promote healing with this disorder

    Surgery:
    When non-surgical techniques do not restore the tendon surgery may be required. Based on the extent of the injury and age of the patient the surgeon will select the appropriate procedure to repair the tendon.

    Prevention:
    Proper stretching and footwear will help prevent injury/re-injury. If you have an abnormal gait, or walking pattern, custom orthotics may be necessary.

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