Non-insertional Achilles tendinopathy (also known as tendinosis, tendonitis, and paratendonitis) is a condition in which the Achilles tendon degenerates or breaks down over time. The Achilles tendon is the cord-like structure along the back of your leg that connects your calf muscle to your heel bone (calcaneus). Achilles tendinopathy is a chronic overuse injury that causes pain in the back of your leg.
Symptoms start gradually and spontaneously. You may experience aching and burning pain, especially with morning activity, which gets worse with exercise. Often the tendon gets larger. A bump can form within the tendon that can be painful to touch. You may have weakness in push-off strength with walking.
Non-insertional Achilles tendinopathy is common in people who have recently increased the intensity of running or jumping workouts. It can be associated with repetitive activities, problems such as flatfoot or high-arched feet, or running on slanted surfaces. Age, diabetes, and high blood pressure are also risk factors.
Your tendon may feel enlarged and warm 1-4 inches above your heel. Gently squeezing the tendon between your thumb and forefinger while you move your ankle may cause pain and sometimes a “scratching” feeling in early stages.
A foot and ankle orthopaedic surgeon will evaluate your symptoms and history to make a diagnosis. An MRI may be used to define the extent of the degeneration but is not required for diagnosis.
Many cases of non-insertional Achilles tendinopathy are treated successfully without surgery. This treatment may include nonsteroidal anti-inflammatory drugs (NSAIDs), rest, immobilization, limitation of activity, ice, contrast baths, stretching, and/or heel lifts. It takes time for symptoms to improve, which may be frustrating if you are used to being active. Treatment is less likely to be successful if your symptoms have been present for more than 6 months.
Exercise-based treatments such as physical therapy are an effective first-line treatment for the majority of patients. This treatment usually includes eccentric strengthening exercises.
An example of an eccentric strengthening exercise is shown in the photo below:
This exercise may cause pain initially; however, when done properly and regularly, the pain should gradually improve. This type of strengthening program is best started under the care of a physical therapist.
Other options that may help include night splints, arch supports, extracorporeal shockwave therapy (ESWT), or the use of a temporary brace or boot for patients who have difficulty walking. Shock wave therapy involves the use of a probe that delivers waves of energy to the tendon to help it heal.
Steroid/cortisone injections and sclerosing agents near the Achilles are not recommended due to the risk of a tendon tear.
Other injections such as platelet-rich plasma (PRP) are low risk, but the effectiveness of these injections remains unknown. Platelet-rich plasma involves taking your blood and separating a part of it that has growth factors or substances that can help your tendon heal. These growth factors are then directly injected into the area of pain.
At least 3-6 months of non-surgical treatment is recommended before considering surgery . In this procedure, your surgeon will cut out areas of unhealthy tendon and repair any tears within the tendon. Your surgeon may also lengthen your calf muscle to reduce tension on the tendon. This is called a gastrocnemius release.
If the Achilles is badly diseased, a tendon transfer may be required to replace it. The most commonly transferred tendon is the flexor hallucis longus (FHL), the tendon that bends the big toe. You may have some weakness in your big toe after the transfer, but the effect on gait and function is usually minimal.
After surgery, your surgeon will advise when you can put weight on your foot. You will need to wear a cast, splint, or brace for 4-8 weeks following surgery, although you will start doing range-of-motion exercises before that. Return to competitive activity takes 6-9 months. It may take up to two years for symptoms to go away completely.
All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves, bleeding, and blood clots.
While most patients will achieve lasting relief after both non-surgical and surgical treatment for Achilles tendinopathy, symptoms may return. Athletes and runners in particular are at a slightly higher risk for recurrence because of the high demands they put on the Achilles. These patients should pay close attention to stretching and shoe choice to prevent recurrence.
It is very likely that you will be able to return to activity after surgery. Success rates for Achilles tendinopathy surgery are 80-90%. Some of the variability depends on the amount of tendon that is diseased at the time of surgery, as well as differences between individual patients.
Contributors/Reviewers: Mark Drakos, MD; Paul Peters, MD; Sudheer Reddy, MD; David Garras, MD; Paul Ryan, MD; Elizabeth Cody, MD
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