Why does the Back of my Heel Hurt?

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The achilles tendon is the largest tendon in the body that stretches from calf muscles to the heel bone. Achilles tendinitis is an injury that is caused by overuse of this tendon, and it occurs most commonly in runners who increase the intensity and duration of their runs suddenly without proper build-up. In addition, middle-aged people who play sports might also experience this condition, since the structure of the tendon often becomes weaker as people age, making it more susceptible to injuries.

There are two main types of achilles tendinitis:

  • Insertional achilles tendinitis
    • This form of achilles tendinitis involves the lower part of the heel where the tendon attaches itself to the heel bone
    • Results most often from overuse (eg: runners)
    • However, can occur any time, even in patients who are not active
  • Non-insertional achilles tendinitis
    • This form of achilles tendinitis occurs when the fibers in the middle part of the tendon have started to degenerate and swell, causing it to become thickened
    • Occurs in younger and active patients.

Symptoms of achilles tendinitis include:

  • Mild aches in the back of the leg / above the heel after engaging in sports
  • Tenderness or stiffness in the area
  • Pain when stretching ankle or standing on toes
  • Trouble pointing toes and pushing off toes when taking a step
  • Bruising and swelling
  • A snapping or popping noise (occurs when your Achilles tendon tears)

If you hear a sudden snapping or popping sound, you may have ruptured or torn your tendon. In this case, please see your doctor immediately for medical attention.

What causes Achilles Tendinitis?

Achilles tendinitis is often not related to trauma, but is instead caused by the repetitive overuse and stress placed on the tendon. More specifically, the following situations might cause achilles tendinitis:

  • A sudden increase in intensity and duration of physical activity

  • Tight calf muscles (engaging in vigorous physical activity without stretching first)
  • Bone spur (Extra growth of bone occurring where the tendon attaches to the heel bone may rub on the tendon and cause discomfort)

What are the Implications of Achilles Tendinitis?

While the pain experienced at first may be bearable, if achilles tendinitis goes untreated, the patient is likely to experience chronic pain and the tendon might rupture. This might cause the range of motion of the ankle and foot to be significantly reduced.

How is Achilles Tendinitis Diagnosed?

If your doctor suspects that you might have achilles tendinitis, he or she might use diagnostic imaging such as X-rays and MRI scans to confirm the diagnosis.

Using X-rays, your doctor will be able to identify if the lower area of the tendon has calcified (become hardened), as the presence of this calcification would indicate achilles tendinitis.

MRI scans are typically used only when confirming the precise location and extent of the tendon damage in preparation for surgery.

How is Achilles Tendinitis Treated?

If you suspect yourself or someone you know might have achilles tendinitis, it is important to seek treatment as soon as possible to avoid any serious and severe injuries. There are several treatment methods for achilles tendinitis, which can be largely divided into non-surgical treatment options and surgical treatment options.

Non-surgical treatment options

  • Rest, Ice, Compress, Elevate (RICE)

    • Rest your leg and avoid putting any weight on it as much as possible. Athletes might want to consider switching to lower-impact exercises, such as biking and elliptical exercise.
    • Ice your affected heel for around 20 minutes at a time.
    • Compress the leg by using an elastic bandage to reduce swelling
    • Elevate the leg by propping it up using a pillow
  • Pain medication
    • Nonsteroidal anti-inflammatory drugs (NSAIDs) might help with pain relief.
    • However, please consult your doctor for specific information about the dosage and frequency. In addition, be sure to communicate any drug allergies with your doctor.
  • Use of a heel lift
    • Your doctor may recommend that you use a heel lift, an insert in the shoe, as this will help to protect the achilles tendon from stretching further.
    • Other similar treatment options include wearing a cast, walking boot, or heel cups, which aid in reducing pressure on the tendon and minimising movement of the tendon.
  • Physiotherapy
    • Your doctor might recommend physiotherapy or other stretching and strengthening exercises in order to increase the mobility of the foot and reduce injuries due to lack of stretching.
    • One potential stretching exercise that can be considered is the calf stretch. To do this stretch, lean forward against a wall with knee straight and the heel flat on the floor. Position the other leg in front, with the knee bent. Push your hips towards the wall in a slow and controlled manner. Hold the stretch for around 10 seconds before relaxing and changing feet. If done effectively, a pull in the calf should be felt while attempting the stretch. *Do consult your doctor before attempting this stretch.
  • Extracorporeal shockwave therapy (ESWT)
    • During this non-invasive procedure, shockwave impulses of high energy will be sent to the tendon tissue to stimulate healing.

Surgical treatment options

In the event that the achilles tendon is torn or ruptured, or the pain does not improve even after six months of treatment, your doctor might recommend surgery. There are various forms and surgical procedures used, which typically depend on the extent and location of tendon damage, as well as the age of the patient. The various surgical options can be summarised below:

  • Gastrocnemius recession

    • This procedure is used for patients who continue to have difficulty in flexing their feet, even with consistent stretching and physiotherapy.
    • During this procedure, your doctor will lengthen the calf (gastrocnemius) muscle. This procedure is performed either through a usual-sized incision, or a smaller incision and an endoscope.
    • Depending on your condition, your doctor might also remove the damaged tendon tissue (d├ębridement) during the surgery.
  • Debridement and repair
    • This surgery is used in patients whose tendon has degenerated. Your doctor will simply remove the damaged portion of the tendon and then repair the other parts of the tendon.
    • If the patient has insertional tendinitis, the bone spur will also be removed, and the doctor may use metal or plastic anchors to help hold the achilles tendon and heel bone together.
  • Debridement with tendon transfer
    • This procedure is used in patients whose tendon has suffered significant and severe damage, as the remaining portion of the tendon is no longer strong enough to function properly. Hence, your doctor might transfer the tendon from another place in the foot to the back of the heel during the procedure.
    • Depending on the damage to the tendon, it is possible that some patients may be unable to return to the same level of vigorous physical activity as before.

What can I Expect after Treatment?

The duration of recovery needed by a patient would largely depend on the extent of damage to the tendon. The greater the extent of tendon damage, the longer the time the patient would require to recover from the surgery. Your doctor might refer you to a physiotherapist for physical therapy, which is a vital part of recovery. Through regular physiotherapy for around 3 to 6 months after the surgery or treatment, the range of mobility of the ankle will be slowly increased, and the pain experienced by the patient will also gradually subside.

For assessment of your condition, please book an appointment with Dr Yong Ren.

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Sarah Taylor

Obstetrics & Gynaecology