Subject: Achilles tendon problems

From: [email-masked] (Dr Gnu)
Date: 20 Jan 95 17:13:17

Achilles Tendon Problems

[1] TENDINITIS Tendinitis is an irritation of the tendon, the
structure which connects a muscle to bone.  It may an irritation of
the tendon or the structures which surround and nourish the tendon.
It may also be an irritation of the tendon at the point where it
attaches to the bone.

[2] SHORTNESS There may be shortness of the tendon.  This may have
come about from birth [congenital] or may have been caused by wearing
high shoes or from an accident [acquired]

[3] RUPTURE The tendon may have ruptured.  The tendon can rupture as a
result of trauma or overuse.

[4] LACK OF MOVEMENT Some arthritic conditions of the foot may cause
real or apparent shortening of the tendon.

                  WHAT ARE THE SYMPTOMS OF THIS CONDITION

The most common symptom of this condition is the gradual appearance of
a lump behind the foot or ankle, just above the heel bone.  Sometimes
this may occur suddenly with an inability to push the foot against the
floor or pain while trying to push off against the floor. Another
symptom of short achilles tendons is flatfoot.  The stress of trying
to keep the foot off the ground while the whole body weight is on the
foot may cause a flat foot. A third symptom may be pain in the back of
the heel related to a short tendon or from trauma.  Occasionally the
pain goes along the tendon and up into the leg.

                          WHAT GENERALLY HAPPENS

Disease of the achilles tendon can be an extremely disabling condition
with long term consequences if not treated at the outset.  Since the
achilles tendon is responsible for stability of the heel and lifting
the heel off ground [in fact lifting the body over the foot], it is
constantly under load while walking.   With tightness, the tendon is
shifts support to the arch and the arch gradually lowers.

Fracture or rupture of the tendon can be likewise very disabling.  It
is impossible to walk without shuffling.  The body cannot be lifted
over the foot and walking becomes difficult.

Some patients have a history of an exacerbating remitting [gets better
then gets worse] tendinitis treated with a variety of methods but
rarely followed for long periods of time.  Usually the mechanism
responsible is hypertrophic synovium around the tendon which creates a
weakness in the tendon.  The tendon may go on to rupture.

With many children, the shortness can make walking difficult and shoe
fit very hard.  Most toe walking children will become plantigrade
[walk on the heel]. Those who do not may need surgical intervention.

                     WHAT DIAGNOSTIC TESTS CAN BE USED

Usually conventional xrays are taken to determine changes in the bony
structure of the foot.  Regular xray usually will not show tendon
changes.  If the condition progresses or fails to respond to therapy,
then usually an MRI [Magnetic Resonance Imaging Study] is ordered.
This allows good visualization of the tendon. Frequently gait
[walking] and biomechanical [measurement of joints] exams are done to
better assess the condition.

                        ACHILLES TENDON TREATMENTS

                             EARLY TREATMENTS

Early treatment may consist of:
      Ultrasound therapy
      Oral anti-inflammatory agents
      Muscle stimulation and manual therapy
      Stretching programs.
      Support therapy [tape]
      Long term support [orthotic devices]

These treatments decrease the inflammation around the tendon and make
healing possible.  Frequently one or more of these therapies may stop
the progression of the tendinitis.

Cortisone injections are used only with great care.

                          MIDDLE LEVEL TREATMENTS

Usually these treatments are used when the foot begins to collapse or
swelling or dysfunction interferes with normal shoe wear, walking or
development.

      -Change in shoe gear
      -Aggressive stretching programs including lower back and hamstring
         stretching
      -Aggressive orthotic therapy including the use of foot
          stabilizing devices and shoe modifications

      -Aggressive physical therapy including muscle stimulation and work
              programs

                            SURGICAL TREATMENTS

There are several surgical approaches to this disease.  Depending on
the degree of destruction of the tendon as well as arthritis created
in the surrounding joints, different surgical procedures may be
elected.

SHORTNESS WHICH CANNOT BE STRETCHED OUT
   The tendon can be lengthened
   The muscle [calf] can be lengthened

PARTIAL TENDON TEAR
   The tendon can be repaired
   The tendon can be reinforced
   Another tendon can be transferred to the area to assist function

TOTAL TENDON RUPTURE
   The tendon can be repaired or reinforced.  This can include the
   transfer of other tendons to the area as well as the use of other
   materials to reinforce the tendon.

   Affected joints can be fused

TENDON RUPTURE WITH ARTHRITIC JOINT CHANGES

   Usually several joints in the rear part of the foot need to be fused