What To Expect If You Have An Achilles Tendon Injury

Dr. James - Orthopaedic Surgeon in Singapore

Medically reviewed by Dr. James Tan

An achilles tendon injury is one of the common causes of pain around the heel area, back of the ankle, and the lower calf region of the leg. Achilles tendon injuries can tend to become quite painful and cause discomfort in performing daily activities of one’s life. This article discusses everything you need to know about Achilles tendon injuries, how and why they occur, their symptoms and diagnosis, and the various treatment options available in Singapore for these conditions. 

What are Achilles Tendon Injuries?

To understand about the Achilles tendon injuries, it is important to first understand the anatomy of the leg and foot. The Achilles tendon is the largest tendon in the body that connects the calf muscles with the heel bone behind your leg. This tendon is used in many different activities like walking, running, jumping, climbing stairs, and standing on your tiptoes. If this tendon gets damaged, inflamed, or torn, it can cause severe pain and stiffness in the adjoining areas. Here are 4 problems when you injure your achilles tendon.

  1. Limited blood supply: The achilles tendon has a low blood supply which slow down the process of oxygen and nutrients delivery that is essential for healing.
  2. Microtears and Inflammation: Microtears and inflammation are common in achilles tendon injuries, triggering complex cellular response that takes time to repair.
  3. Constant stress during weight-bearing: Constant stress impedes the tendon’s ability to rest and fully heal.
  4. Incomplete rehabilitation: Rushed or incomplete rehabilitation increases the risk of re-injury.

There are primarily two types of Achilles tendon injuries: tendonitis and rupture.

Achilles Tendonitis

Achilles tendonitis is the condition that occurs when this Achilles tendon becomes inflamed or irritated. When a body part is injured because of an acute trauma or overuse, the body’s natural response is to create inflammation which results in pain, stiffness, and irritation. Tendonitis is also closely related to tendinopathy which refers to the microscopic degeneration of the tendon because of chronic damage over time. Depending on the location where the tendon gets inflamed, we can divide this condition into two sub-categories.

Noninsertional Achilles Tendonitis

In noninsertional Achilles tendonitis, the middle part of the tendon above the heel gets inflamed or irritated. The fibres of the tendon may degenerate over time and tear that further cause swelling and heel pain in the area. This type of tendonitis is most common in young individuals and athletes.

Insertional Achilles Tendonitis

Insertional Achilles tendonitis refers to the inflammation of the tendon at the point where it attaches to the heel bone. This type of tendonitis can result in the forming of bone spurs on the heel. This condition is most common in runners but can happen to anyone. One of the main causes of insertional Achilles tendonitis is tightness in the calf muscles that places increased stress on the tendon at the point where it attaches to the heel.

Achilles Rupture

An Achilles rupture is the condition that occurs when the Achilles tendon gets separated from the heel bone completely or the tendon gets torn in half from any other place. This kind of rupture occurs in case of an acute injury or trauma and can result in severe pain and an inability to walk. You may hear a popping sound when the tendon ruptures followed by extreme pain. Achilles rupture is a debilitating condition that must be examined by a qualified orthopaedic doctor. The doctor will suggest surgery to repair the ruptured tendon in most of the cases.

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Signs and Symptoms of Achilles Tendon Injury

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The most common symptoms of Achilles tendon injury are:

  • Difficulty with foot movement such as pointing your toes downwards or tiptoe.
  • Audible snapping or popping sounds, especially in a sudden tear that causes a partial or complete rupture.
  • Difficulty walking as weight on the leg will become painful and uncomfortable.

Some other symptoms include:

  • Pain and stiffness in the area behind the leg along the tendon
  • Pain in the back of the heel that worsens with activity
  • Pain in the Achilles tendon after exercising.
  • Pain in the tendon when touched or put pressure on.
  • Formation of bone spurs in some cases near the heel
  • Pain in the heel or back of the ankle when you wear shoes.
  • Inflammation and warm feeling along the tendon or the heel.
  • Thickening of the tendon.
  • Difficulty and increased pain while flexing the foot.
  • A decrease in the range of motion of the foot.

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Test for Achilles Tendon Injury

  1. Range of motion test
    – Point your toes downwards and then upwards while seated
    – Pay attention to any pain or limitations in your range of movement.
  2. Strength test
    – Stand up and rise up on your tiptoes using your uninjured leg.
    – Do the same on your injured leg and spot the difference.

Causes of Achilles Tendon Injury

Although the Achilles tendon is quite strong and can withstand a lot of stress as you perform different activities, there are certain factors that cause it to become damaged. These causes include:

  • Overuse of the tendon during exercise or daily high impact activities.
  • Gradual wear and tear of the tendon as one gets older.
  • Sports such as tennis, football, and rugby that cause you to stop abruptly and put strain on your calf.
  • Doing exercises without warming up first.
  • Switching to more aggressive activities or exercise without giving the body enough time to adjust
  • Straining the calf muscles during various activities.
  • Repeated motion of the leg that strains the calf muscles.
  • Running a lot and walking or running uphill.
  • Wearing ill-fitted or unsupportive shoes.
  • Wearing high heels for long periods of time.
  • Having a condition called Haglund’s deformity where the bone at the back of the heel becomes enlarged and pushes or rubs the Achilles tendon. This causes the tendon to become inflamed and causes pain.

Who is at risk of developing an Achilles Tendon Injury?

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Although anyone can develop an Achilles tendon injury, there are certain risk factors that may increase your chances of injuring your Achilles tendon. These include doing repetitive motions that strain the calf muscles, overuse of the tendon, doing high impact activities and exercise without warming up first, and treatment with an antibiotic called fluoroquinolone. Moreover, people who have tight calf muscles and flat arches in the foot are more at risk to get these conditions. Plantar Fasciitis is another condition with similar causes so it is best to visit an orthopaedic doctor for a diagnosis.

Diagnosis

To treat your Achilles tendon injury, it is crucial that the proper diagnosis be made in the first place. This is because sometimes, an Achilles tendon injury is misdiagnosed as an ankle sprain. A qualified orthopaedic doctor in Singapore can diagnose your Achilles tendon injury by the following steps:

  • By taking your medical history and asking about your symptoms.
  • By carrying out a physical exam to check for inflammation, pain, bone spurs, and other related symptoms.
  • By moving your foot and ankle at various angles to check for the range of motion.
  • The doctor may sometimes carry out imaging tests such as x-rays, MRIs, and CT scans to see the extent of damage to the tendon as well as determine if there are any bone spurs or if the tendon has thickened and become calcified.

Management and Treatment

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If you leave your achilles tendon injury untreated, here are 3 things that can happen:

  • Chronic pain and discomfort: If you continue to strain your damaged achilles tendon, you will get persistent pain in your daily activities such as walking and standing. Ignoring it can result in long-term discomfort.
  • Increased risk of rupture: A partially damaged achilles tendon, if left untreated becomes more vulnerable to a complete rupture. This is a severe condition that often requires surgical intervention.
  • Development of Tendinosis: Tendinosis involves chronic changes in tendon structures, leading to weakness and increased vulnerability to further injuries. Treatment is crucial to reduce the further tendon damage and its complications.

Once your orthopaedic doctor has diagnosed your Achilles tendon injury, he/she will devise a treatment plan according to the extent of damage to the tendon. This heel pain treatment may comprise non-surgical treatment options or include surgery as a viable option. Let’s look at these treatment modalities to get an idea of what treatment to expect if you have an Achilles tendon injury.

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Treatment Options for Mild Achilles Tendon Injuries

The first line of treatment for an Achilles tendon injury is the conservative measures used for mild achilles tendon injuries. Depending on your unique condition, it may comprise the following modalities.

RICE Protocol

Doing the RICE protocol is the most effective thing that a patient can do on his own that will help with the pain and swelling. Rest, Ice, Compression, and Elevation are important conservative measures that can prove to be effective for managing pain. Giving your leg and foot adequate rest by avoiding activities that put strain on them is the first step. Applying ice on the affected area for 15-20 minutes several times a day can help bring down the swelling, consequently reducing pain. Putting a pressure bandage or surgical wrap on the affected leg and heel is also effective in managing pain and inflammation. Finally, propping your foot up by placing pillows or cushions underneath your leg while lying down so that the foot is elevated above the heart level can also bring down swelling.

Non-Steroidal Anti-Inflammatory Medication

To control the pain and swelling, your doctor may prescribe over-the-counter painkillers like acetaminophen, ibuprofen, and naproxen. In some severe cases, the doctor may prescribe stronger painkillers like opiates to help manage the pain. It is important that whatever medication has been prescribed to you, you take it exactly as the doctor has recommended and do not alter the dose, frequency, or duration of taking the medication without your doctor’s advice.

Physical Therapy and Strengthing Exercises

Physical therapy is one of the most effective techniques for treating Achilles tendon injuries. Your physical therapist can guide you in doing certain exercises and stretches that reduce tension in the calf muscles and strengthen the Achilles tendon. These include calf stretches, eccentric strengthening, bilateral heel drop, and single-leg heel drop.

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Treatment Options for Severe Achilles Tendon Injuries

Extracorporeal Shockwave Therapy (ESWT)

Extracorporeal Shockwave Therapy (ESWT) refers to the treatment method in which low or high intensity shockwaves are administered to the Achilles tendon to promote healing. It is a non-invasive method which has very low risks. Hence, it is often recommended by doctors in combination with other non-surgical treatment options before considering surgery as the last option. Low intensity ESWT can be carried out without anaesthesia and is a simple, quick procedure. However, high-intensity ESWT may require local anaesthesia but is still considered low risk.

PRP Injections

Platelet-rich plasma injections are sometimes used to reduce pain caused by Achilles tendon injuries. The PRP injection is administered directly into the tendon where it can promote healing and consequently reduce pain. However, more research is needed in this field to gauge its effectiveness in Achilles-related conditions. Moreover, other injections such as cortisone injections are not recommended for these conditions as a steroid injection in the Achilles tendon can cause it to tear or rupture.

Night Splints

Your doctor may recommend wearing a night splint while sleeping at night. These are removable braces that can help hold your foot in place while you sleep. One of the reasons for experiencing pain in the heel and Achilles tendon in the morning is the way the toes of the foot drop forward while you sleep. By wearing a night splint, the foot is held in place with the toes pointing upwards, thus maintaining calf flexibility and reducing tension in the tendon on your heel. Night splinting can significantly reduce morning pain associated with Achilles tendon issues.

Supportive Shoes

Wearing supporting shoes and using other orthotic devices can also help greatly with Achilles tendonitis. Soft, comfortable shoes that are open from the back are helpful as they reduce the chance of irritation of the tendon at the back of the ankle and heel. Similarly, placing heel pads can help put off the strain on the tendon. Sometimes, the doctor may recommend wearing a walking boot for some time as it gives the tendon enough time to rest and heal. However, wearing of the boot for longer periods is not recommended as it can weaken the calf muscle which, in turn, will be counterproductive.

Achilles Tendon Surgical Treatment Options In Singapore

If the Achilles tendon injury is too severe that cannot be treated with conservative measures or if all conservative measures have been exhausted without significant pain reduction or healing of the Achilles tendon, the doctor may recommend surgery. Non-surgical treatment methods are given a chance for at least 6 months before considering surgical intervention. Depending on the location and severity of damage done to the tendon, your orthopaedic doctor in Singapore may recommend one or more of the following surgical procedures.

Debridement

Debridement is a surgical procedure that refers to the removal or cleaning up of damaged tissues of the Achilles tendon. This procedure may be performed for insertional Achilles tendonitis in which bone spurs formed in the heel are removed. Moreover, any damaged part of the tendon is removed and the remaining part of the tendon is reattached to the heel bone through stitches or anchors. This procedure has shown positive outcomes where the patients are able to walk after a few weeks of surgery while wearing a specialised boot or cast.

However, in some cases, the amount of damaged tissue of the tendon may be too much and removing them results in a weak Achilles tendon that cannot function on its own. In such cases, some other tendon from the body is attached with the Achilles tendon to give it enough strength to help you walk and carry out your activities. Usually, the tendon beneath the big toe that helps to flex it down is removed and attached to the heel with the Achilles tendon. This strengthens the Achilles tendon while patients hardly feel any change in the way they walk or run after the removal of their big toe tendon.

Gastrocnemius Recession

One of the main reasons for Achilles tendon injuries is the tight calf muscles (the gastrocnemius muscles) that put added stress on the tendon. Gastrocnemius recession is a surgical procedure that refers to the lengthening of the calf muscle in order to reduce stress on the Achilles tendon. This procedure may be recommended for patients who have tight calf muscles in spite of doing calf stretches. 

During this procedure, one of the two calf muscles is surgically lengthened to lessen the strain on the heel and increase the range of motion of the ankle. This surgical procedure may be performed through a standard open incision or through an endoscope where tiny incisions are made and a camera guides the surgeon and the surgical instruments in carrying out the surgery. The surgeon either removes a small part of the muscle from it attaches to the Achilles tendon at the heel or makes small incisions in the muscle to lengthen it. Depending on your unique condition and the extent of damage to the tendon, the doctor will recommend whether to go for an endoscopic surgery or a standard open procedure.

Achilles Tendon Rupture Repair Surgery

In case the Achilles tendon has been ruptured, the surgeon will carry out a tendon repair surgery. There are three different types of Achilles tendon rupture repair surgeries:

  • Percutaneous Achilles Repair — During a Percutaneous Achilles repair procedure, the surgeon makes tiny incisions along the length of the calf and insert thin surgical instruments through these incisions. He then removes any damaged tissues of the Achilles tendon before attempting to repair the torn or ruptured parts. Using thin needles and sutures, the surgeon stitches the torn parts of the tendon together or attaches the ruptured tendon back with the heel bone. If needed, he may use screws and anchors to attach the tendon with the heel bone. In the end, the incisions are closed up with sutures. This procedure is minimally invasive and results in faster healing and recovery.
  • Open Achilles Repair — In an open Achilles repair procedure, the surgeon makes a relatively big incision at the back of the calf and tries to repair the torn parts of the Achilles tendon. Any damaged tissues of the tendon are first removed followed by stitching the torn parts of the tendon together through sutures. In case the tendon has ruptured completely from the heel bone, high strength sutures and surgical screws may be used to attach the tendon back with the heel bone. In the end, the incision on the leg is stitched together. Since in this procedure, a large incision is made, it can result in relatively slower healing and recovery.
  • Tendon Transfer — If the damage to the Achilles tendon is too severe and the rupture has caused the tendon to become too short that it cannot be stitched together, the surgeon may transfer some other tendon from the body and attach it with the Achilles tendon. The flexor hallucis longus tendon which is present underneath the big toe is often used for this tendon transfer. The surgeon removes this tendon and attaches it with the Achilles tendon at one end and the heel bone at the other end. Sutures and screws are used to anchor the tendon in place. The incisions are closed at the end after which the ankle and calf start to heal.

Surgical Biologics

Your surgeon may place a collagen patch on the Achilles tendon during your surgical procedure to further promote healing and help with recovery. Collagen is a protein that is present in our bodies and is a vital element of tendons and ligaments. When a collagen patch is put directly on the Achilles tendon, it promotes repair and healing at a cellular level. These collagen patches are quite effective in tendon repair, however they cannot rejuvenate the damaged tissues. With time, these patches dissolve and there is no need to remove them.

Hydrocision TenJet

This is a minimally invasive technique in which ultrasound-guided high-velocity saline is used to break up the damaged or scar tissue in the tendon. The unhealthy tissue is then removed through tiny incisions in the calf.

Living With Achilles Tendon Injuries

Achilles tendon injuries are mostly treated through non-surgical methods but the healing and recovery can be quite slow. It is important to follow your healthcare provider and surgeon’s advice to stay on the track of recovery and prevent the worsening of your symptoms. For more severe cases of Achilles tendon injuries like rupture, it is important that you contact your healthcare provider at the earliest and get evaluated. The longer you wait to get evaluated and start treatment for an Achilles tendon injury, the longer it will take to heal and recover.

Ray of Health is a comprehensive musculoskeletal health service provider that offers a wide range of diagnosis and treatment options including foot pain treatment, meniscal injuries, ACL tears, shoulder pain, and many other orthopaedic conditions. By getting in touch with their qualified specialists, you can start your journey towards a pain-free life. Contact Ray of Health today for any queries about Achilles tendon injuries or other orthopaedic conditions. 

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Dr. James - Orthopaedic Surgeon in Singapore

About the Author

Dr James Tan is a highly skilled orthopaedic surgeon who has more than 10 years of experience in sports surgery and exercise medicine. He is a member of the elite Asian Shoulder and Elbow Group and a founding member of the Singapore Shoulder and Elbow Surgery Society.

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