Injuries that affect the Achilles tendon are common among active adolescents and young athletes. The Achilles tendon is the largest and strongest tendon in the body, connecting the calf muscles to the heel bone. Insertional Achilles tendinopathy (or tendonitis) refers to inflammation, compression and pain that occurs at the back of the heel, at the point where the Achilles tendon inserts onto the heel bone.
Adjacent to the Achilles tendon insertion onto the heel bone are some protective fluid-filled sacs, called bursae. These protective bursae assist the gliding movement of the Achilles tendon against the heel bone. Insertional Achilles tendinopathy can involve compression and inflammation of the bursa, known as ‘retrocalcaneal bursitis’.
What causes Insertional Achilles Tendonitis in adolescents?
There are several factors that may contribute to the development of Achilles tendon problems:
- Excessive hill running/walking – this puts the tendon on maximum stretch and compression
- Change in exercise routine: a sudden increase in the intensity, frequency or duration of sports training
- Unsupportive footwear (eg: minimalist shoes, low or negative heels)
- Poor muscle flexibility or strength (eg: tight or weak calf muscles)
- Decreased joint range of motion (eg stiff ankle joint)
- Abnormal foot posture – a high arched foot with restricted ankle joint flexibility can place excessive load on the tendon insertion. A pronated foot may have a smaller tendon volume, making the tendon less able to cope with increased tendon load
- Bony heel deformity (eg; Haglunds deformity) – an abnormal bony prominence that may cause compressive loads on the Achilles tendon or bursa
- Inadequate warm up, stretching, or cool down after sport
What are the symptoms of Insertional Achilles Tendinopathy?
The pain caused by insertional Achilles tendinopathy develops gradually and may initially be experienced only after exercise or when first arising in the mornings. As the injury worsens, pain is often felt during exercise activities and may also be present during normal daily activities. The pain is often worse when walking or running uphill or on uneven terrain. Some children experience pain if they have pressure on their heel from firm school shoes.
The most common symptoms of insertional Achilles tendinopathy include:
- Pain and tenderness at the back of the heel
- Swelling or mild redness at the heel, sometimes a bony lump (Haglunds deformity)
- Stiffness and pain most noticeable in the morning on first arising
- Weakness when hopping, jumping or skipping on the affected leg
How is Insertional Achilles Tendinopathy diagnosed?
Your Podiatrist will take a comprehensive medical history and perform a physical examination and gait analysis. The assessment will include:
- Pain provocation tests (eg: tendon palpation, heel raise, skipping, hopping)
- Foot posture assessment
- Joint range of motion (flexibility)
- Foot and leg muscle strength testing – looking for any muscle imbalance or weakness
- Footwear assessment
- Gait analysis & biomechanical assessment – to look for any abnormalities in the way the feet and legs move during gait
- A soft tissue ultrasound scan or a plain xray may be required
How is Insertional Achilles Tendinopathy treated?
Treatment for insertional Achilles tendinopathy is most effective when this condition is treated early and may include a combination of the following:
- Rest – from aggravating activities (eg: running, jumping, skipping) until your child is able to walk comfortably
- Home Exercise Program – exercises are prescribed to strengthen and repair the Achilles tendon and form an integral part of your child’s treatment plan
- Heel Raise – a raise placed inside the child’s shoe to elevate the heel can be very helpful in the initial stages of recovery
- Footwear – changing to a supportive, stable shoe will help to absorb shock and support the foot and ankle
- Foot Orthotics – to improve your child’s foot posture and reduce strain on the Achilles tendon insertion
- Massage Therapy
- Ice massage – to reduce any local inflammation
- Medication – sometimes a short course of non-steroidal anti-inflammatory medications (eg. Voltaren, Nurofen) can be a helpful adjunct in reducing pain, especially if there is an associated bursitis
Return to sports training should be gradual and guided by your Podiatrist.
What should I do if my child has Insertional Achilles Tendinopathy?
If your child is experiencing Achilles tendon pain, or you are concerned about their gait or foot posture, don’t hesitate to consult with our experienced paediatric podiatrists for a comprehensive walking assessment and professional advice.