Platelet-rich plasma (PRP) (also known as blood injection therapy) is a medical treatment being used in Singapore for a wide range of musculoskeletal problems. Platelet-rich plasma refers to a sample of serum (blood) plasma that has as much as four times more than the normal amount of platelets. This [...]]]>

Double Spin Platelet Rich Plasma

Platelet-rich plasma (PRP) (also known as blood injection therapy) is a medical treatment being used in Singapore for a wide range of musculoskeletal problems. Platelet-rich plasma refers to a sample of serum (blood) plasma that has as much as four times more than the normal amount of platelets. This treatment enhances the body’s natural ability to heal itself and is used to improve healing and shorten recovery time from acute and chronic soft tissue injuries.

Platelets are part of the blood that circulate around the body ready to help with blood clotting should you have a cut, broken bone, injury that bleeds internally, or any other type of injury. Besides containing clotting factors, the platelets release growth factors that help start the healing sequence. With a concentrated amount of platelets, larger quantities of these growth factors are released to stimulate a natural healing response. Plasma is the clear portion of the blood in which all the other blood particles such as platelets, red blood cells, and white blood cells travel.

Blood injection therapy of this type has been used for knee osteoarthritis, degenerative cartilage, spinal fusion, bone fractures that don’t heal, and poor wound healing. This treatment technique is fairly new in the sports medicine treatment of musculoskeletal problems in Singapore, but gaining popularity quickly.

In theory, blood injection therapy could be used in any area where a rapid healing response is desired such as the tendon-muscle junction, muscle injuries, torn ligaments, damaged joints, or inflamed tissue (e.g., plantar fasciitis).

Torn tendons and ligaments don’t always heal well because they have a poor blood supply. Connective tissues such as ligaments and tendons heal by filling in with scar tissue that doesn’t bear the brunt of large loads well. This increases the risk of re-injury. Other available treatments for chronic tendon problems do not necessarily improve the tendon’s ability to heal in the same way that PRP does. And injections of PRP don’t have the side effects that can occur with steroid injections or long-term use of non-steroidal anti-inflammatory drugs (NSAIDs).

The platelet-rich plasma therapy has been around long enough now to start studying it more carefully. Researchers have found that the platelet-rich plasma preparation varies significantly from sample to sample. That means patients aren’t always getting the same amount of platelets and growth factors. This has been shown to be true from one treatment to the next and even from one patient to the next. The question comes up: why the differences?

To find out, researchers sampled blood from eight people on three separate occasions (baseline or first blood draw, fourteen days later, one month later). Each sample was analyzed for each patient at each of those time periods.

They used three different lab techniques to harvest the platelets: 1) a single-spin technique (referred to as LP), 2) an alternative single-spin method (the HP method, and 3) a double-spin (DS) technique. Each technique is carefully described for the reader including the number of minutes spun and the revolutions per minute.

In all cases, the HP (alternative single-spin separation method) gave the best results with the highest percentage of white blood cells and platelets. The one-step LP method far outperformed the other two methods.

There were clear differences in outcomes not only with the differing techniques used but also for the different times the samples were taken for each individual. The question naturally arises: why would platelet levels and white blood cell levels vary over time for the same person? The authors suggest age could make a difference. Or there could be a physiologic reason why these variations exist that we just don’t know about yet.

What the study does show is that the method of separation when obtaining platelet-rich plasma makes a difference in the number of white blood cells and platelets collected. Physicians may want to take this fact into consideration when selecting the method used.

For example, it might be helpful to choose the method that matches the intended use of the plasma. One thing to keep in mind is the fact that too many white blood cells can actually cause an overreaction in the tissues. And too much inflammation at certain points in the healing process may not be a good idea.

Perhaps the double spin method (yields lower levels of platelets and white blood cells) would work best when a mild healing response is needed. Likewise, there may be times and situations where increased antibacterial and an increased immune response would be helpful. In those cases, the single-spin method might be the most useful.

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What is in-toeing?

Most people’s feet point straight ahead or slightly outward. Some people’s feet, however, point inward a musculoskeletal condition referred to as in-toeing. In-toeing affects infants and children and is characterized by an inwardly rotated foot or feet, or, less often, an outwardly rotated foot or feet (sometimes [...]]]>

In-Toeing and Out-Toeing

What is in-toeing?

Most people’s feet point straight ahead or slightly outward. Some people’s feet, however, point inward a musculoskeletal condition referred to as in-toeing. In-toeing affects infants and children and is characterized by an inwardly rotated foot or feet, or, less often, an outwardly rotated foot or feet (sometimes called out-toeing ). Doctors may also refer to this as a rotational problem’ of the lower extremity, which can arise from abnormalities in the growth or alignment of the upper legs, lower legs, or feet. The vast majority of such problems, however, represent simply a physiological variation during a normal stage of development. As a result, a child may be pigeon-toed,’ or, alternatively, one or both feet appear splayed outwards. Depending on the specific cause of the condition, in-toeing may appear at different ages, from birth to adolescence.

There are three common causes of in-toeing: (1) medial femoral torsion (also called femoral anteversion ), in which the femur, or thighbone, is rotated inward; (2) medial tibial torsion (also called internal tibial torsion ), which is marked by an inwardly rotated tibia or shinbone in the lower leg; and (3) metatarsus adductus, in which the foot is bent inward like a kidney bean.

Out-toeing is much less common than in-toeing, but is caused by similar problems.

Some basic facts about in-toeing

• Generally, children with in-toeing are otherwise completely healthy and do not suffer from other congenital abnormalities or diseases.
• In-toeing does not cause arthritis or clumsiness.
• In-toeing is significantly more common than out-toeing and occurs in about 2 out of every 1000 children.
• Rotational problems are much more common in infants and young children than in adolescents.
• The most common overall cause of in-toeing is tibial torsion, which usually becomes apparent when infants begin to walk. Tibial torsion :
• Affects boys and girls to an equal degree
• Is bilateral about two-thirds of the time, meaning that both legs are affected, but in most cases is asymmetrical (i.e. the legs are not affected equally, with one leg rotated more than the other)
• Occurs more frequently in the left leg than the right leg when the condition is unilateral
• Metatarsus adductus , another frequent cause of in-toeing, is the most common congenital foot deformity.
• When the onset of in-toeing occurs in early childhood, it is most frequently due to medial femoral torsion. Femoral torsion :
• Is usually diagnosed before 3 years of age, but the resulting in-toeing becomes most pronounced between 4 and 6 years of age
• Is twice as common in girls than boys
• Almost always presents symmetrically (i.e. affects both legs equally)
• Is believed to be inherited, to some degree, because of the disproportionate number of cases that occur in siblings or offsprings of people who themselves had femoral torsion
• Sometimes causes affected children to have an abnormal gait and difficulty running
• Out-toeing is most often caused by lateral tibial torsion
• Out-toeing caused by lateral tibial torsion is most often first seen during late childhood or adolescence. Lateral tibial torsion :
• Unlike medial tibial torsion, is frequently unilateral and affects the right side more than the left side
• When bilateral, is usually symmetrical
• Can produce pain around the knee, called patellofemoral pain , which is not uncommon in adolescents (for a variety of reasons)

The normal leg and the normal foot

The upper portion of the leg consists of a single bone called the femur , or thighbone. The top of the femur inserts into the pelvis to form the hip joint, which is a ball-and-socket joint. The bottom of the femur connects to the lower portion of the leg at the knee joint, which is a hinge joint. The lower leg consists of two bones, the tibia and the fibula . The tibia is the shin bone, which is the larger of the two bones, bears most of the weight placed on the lower leg, and is located to the inside of the fibula. The other leg bone is the fibula , which is a thinner bone located to the outside of the tibia and runs parallel to it.

The foot has a complex musculoskeletal structure, consisting of 7 bones in the base of the foot, known as tarsal bones , 5 bones in the middle portion of the foot, called metatarsal bones , and a series of 14 small bones, or phalanges , which comprise the toes. The bones are attached to each other and to the lower leg bones by an integrated meshwork of thick, fibrous structures known as ligaments . The areas in which two bones make contact with each other are lined with smooth cartilage coated with a natural lubricating material known as synovial fluid , allowing them to slide past each other with minimal friction. These areas are the joints , and there are many joints in the foot, which collectively allow for movement in the foot and ankle.

When a fetus is developing in the womb, the lower limbs initially point outward, then begin rotating inward around the seventh week. However, this rotation causes the toes to point towards each other. During the rest of fetal development, the legs gradually rotate laterally again. This lateral rotational growth continues slightly during childhood, but by the time of birth, the feet are approximately pointed straight forward. A small amount of rotation in infant legs is considered within the range of normal growth variation and is referred to as version. An abnormal amount of rotation is termed torsion .

What causes in-toeing

In healthy children, in-toeing is caused by three conditions. They are metatarsus adductus, internal tibial torsion, and increased femoral anteversion:

• Metatarsus Adductus : Metatarsus adductus is an inward curve of the forefoot. The hindfoot, or heel, is normal. It is usually caused before the baby is born due to the way the baby was packed inside the uterus or womb. Generally, the curve is very flexible and the foot can be straightened by gently pushing it in the opposite direction. In 90% of infants, this bend will resolve on its own. If, after 3-4 months, the curve persists, the foot may benefit from gentle stretching exercises in order to straighten it. If the foot is more rigid, casting is sometimes performed. The goal of treatment is to have a foot that will fit comfortably in a shoe. A little residual inward bending will not cause pain or functional problems. Surgery is very rarely necessary.
• Internal Tibial Torsion : Internal tibial torsion is a twist in the tibia or the large bone in the lower leg. It is typically first noticed by parents when their child begins walking. It usually affects both legs equally. Most infants have some internal twist of the tibia that disappears by one year of age. If it persists, it is called internal tibial torsion. The cause is unknown but is believed to be related to the way the baby was positioned inside the uterus. In some cases, it may run in families. Typically, the child will stand or walk with the knees pointing forwards, but the feet turning in. In the past, tibial torsion was treated with boots connected by bars that held the feet turned outward. Many children have been treated this way and most of them have developed perfectly straight legs. The problem is that many children who were not treated with the boots and bars also developed straight legs. It turns out that most children correct their twist on their own without any treatment at all. In very rare instances, the child may still have internal tibial torsion as a young adolescent. If this becomes a cosmetic problem for the patient, the bone may be cut and rotated outward to improve the appearance. Internal tibial torsion does not lead to arthritis.
• Increased Femoral Anterversion : Increased femoral anteversion is an inward twisting of the thigh bone or femur. Many children are born with a small twist of their femur, however this generally improves within the first few years of life. If it persists, the condition is called increased femoral anteversion. Typically, a 3-8 year old child is brought to the physician because the parents have noted in-toeing. The child will stand with the kneecaps and toes pointing inward. It is diagnosed by measuring and comparing the degree of inward and outward rotation of the child’s hips. Recent studies examining many children over time have confirmed that femoral anterversion corrects on its own. Special braces, shoes, and exercises are not needed. Even when it does not resolve completely, it does not cause any functional problems. Very rarely, an adolescent will be unhappy with the appearance of their legs. In this uncommon circumstance, an operation may be necessary to correct the rotation.

How is in-toeing diagnosed?

As described above, in-toeing or out-toeing may begin to manifest itself at different ages, depending on the underlying musculoskeletal cause of the condition. When a rotational problem of the lower extremities is suspected, a complete physical examination will be performed to evaluate the severity of the condition and its cause, and to ensure that no other deformities or orthopaedic conditions are present. An assessment known as the rotational profile (also called the torsional profile ) will also be performed, which involves taking six different measurements of the angles of the feet, legs, and hips when the child is in various positions and when walking or running. This allows for detection of isolated abnormal angles and facilitates identification of the cause of the rotational problem. X-rays of the legs and feet will also be taken to assist with definitive diagnosis and treatment planning. More sophisticated radiographic imaging techniques, such as a CT (computed tomography) scan and MRI (magnetic resonance imaging), are sometimes performed as well.

Coping with in-toeing or out-toeing

Rotational problems are common in infants and children. However, the majority of deformities are minor, will not cause functional deficiencies, and will resolve on their own. Operative treatment is rarely necessary. Children with in-toeing or out-toeing go on to have no limitations in their activities, from simple outdoor games to competitive sports. Therefore, although rotational problems may present some early challenges for children and parents alike, parents can expect their child to live a normal, active, and healthy life.

Other questions

Naturally, you may have other questions about in-toeing or out-toeing that are not answered in the above summary. As your orthopaedic surgeon, we welcome any and all questions you may have, which we urge you to pose during your next office visit. Do give us a call at +65 6471 2694 or email us at kevin@orthopaedicclinic.com.sg if you have any further queries.

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What is leg length discrepancy?

Leg length discrepancy is an orthopaedic problem that usually appears in childhood, in which one’s two legs are of unequal lengths.  Often abbreviated as ‘LLD,’ leg length discrepancy may be caused by or associated with a number of other orthopaedic or medical conditions, but is [...]]]>

Leg Length Discrepancy

What is leg length discrepancy?

Leg length discrepancy is an orthopaedic problem that usually appears in childhood, in which one’s two legs are of unequal lengths.  Often abbreviated as ‘LLD,’ leg length discrepancy may be caused by or associated with a number of other orthopaedic or medical conditions, but is generally treated in a similar fashion, regardless of cause and depending on severity.   Leg length discrepancy is sometimes divided up into ‘true LLD’ and ‘functional LLD.’  Functional LLD occurs when the legs are actually equal in length, but some other condition, such as pelvic obliquity (a tilt in the position of the pelvis), creates the appearance of legs of different lengths.  True LLD will be the focus of this website and its causes are more fully described in the below section (?What causes leg length discrepancy?’).

As patients develop LLD, they will naturally and even unknowingly attempt to compensate for the difference between their two legs by either bending the longer leg excessively or standing on the toes of the short leg.   When walking, they are forced to step down on one side and thrust upwards on the other side, which leads to a gait pattern with an abnormal up and down motion.   For many patients, especially adolescents, the appearance of their gait may be more personally troublesome than any symptoms that arise or any true functional deficiency.   Over time, standing on one’s toes can create a contracture at the ankle, in which the calf muscle becomes abnormally contracted, a condition that can help an LLD patient with walking, but may later require surgical repair.

If substantial enough, LLD left untreated can contribute to other serious orthopaedic problems, such as degenerative arthritis, scoliosis, or lower back pain.   However, with proper treatment, children with leg length discrepancy generally do quite well, without lingering functional or cosmetic deficiencies.

Some basic facts about leg length discrepancy

• The majority of people in the world actually have some degree of leg length discrepancy, up to 2cm.   One study found that only around 1/4 of people have legs of equal lengths. LLD of greater than 2cm is relatively rare, however, and the greater the discrepancy, the greater the chances of having a clinical problem down the road.
• A limp generally begins when LLD exceeds 2cm and becomes extremely noticeable above 3cm.
• When patients with LLD develop an abnormal gait, one of the debilitating clinical features can be fatigue because of the relatively high amount of energy needed to walk in the new, inefficient way.
• Poliomyelitis, or polio, as it is more commonly known, used to account for around 1/3 of all cases of LLD, but due to the effectiveness of polio vaccines, it now represents a negligible cause of the condition.
• Functional LLD, described above, usually involves treatment focused on the hip, pelvis, and/or lower back, rather than the leg.   If you have been diagnosed with functional LLD or pelvic obliquity, please ask your orthopaedic surgeon for more information about treatment of these conditions.

The normal leg

The upper portionof the leg consists of a single bone called the femur, or thighbone.  The top of the femur inserts into the pelvis to form the hip joint, which is a ball-and-socket joint.  The bottom of the femur connects to the lower portion of the leg at the knee joint, which is a hinge joint.  The lower leg consists of two bones, the tibia and the fibular.  The tibia is the shin bone, which is the larger of the two bones and bears most of the weight placed on the lower leg, and is located to the inside of the fibular, closer to the other leg.  The other leg bone is the fibular, which is a thinner bone located to the outside of the tibia and runs parallel to it.

Like all long bones in the human body, the tibia does most of its growing not in the middle, but at the end of the bone during childhood, in a region known as the epiphysis .   The epiphysis is responsible for the rapid production of bone and cartilage cells and the gradual lengthening of the leg.

What causes leg length discrepancy?

The causes of LLD may be divided into those that shorten a limb versus those that lengthen a limb, or they may be classified as affecting the length versus the rate of growth in a limb.   For example, a fracture that heals poorly may shorten a leg slightly, but does not affect its growth rate.   Radiation, on the other hand, can affect a leg’s long-term ability to expand, but does not acutely affect its length.

Causes that shorten the leg are more common than those that lengthen it and include congenital growth deficiencies (seen in hemiatrophy and skeletal dysplasias ), infections that infiltrate the epiphysis (e.g. osteomyelitis ), tumors, fractures that occur through the growth plate or have overriding ends, Legg-Calve-Perthes disease, slipped capital femoral epiphysis (SCFE), and radiation.   Lengthening can result from unique conditions, such as hemihypertrophy , in which one or more structures on one side of the body become larger than the other side, vascular malformations or tumors (such as hemangioma ), which cause blood flow on one side to exceed that of the other, Wilm’s tumor (of the kidney), septic arthritis, healed fractures, or orthopaedic surgery.

Leg length discrepancy may arise from a problem in almost any portion of the femur or tibia. For example, fractures can occur at virtually all levels of the two bones.   Fractures or other problems of the fibula do not lead to LLD, as long as the more central, weight-bearing tibia is unaffected.   Because many cases of LLD are due to decreased rate of growth, the femoral or tibial epiphyses are commonly affected regions.

How is it diagnosed?

Leg length discrepancy may be diagnosed during infancy or later in childhood, depending on the cause.   Conditions such as hemihypertrophy or hemiatrophy are often diagnosed following standard newborn or infant examinations by a pediatrician, or anatomical asymmetries may be noticed by a child’s parents.   For young children with hemihypertophy as the cause of their LLD, it is important that they receive an abdominal ultrasound of the kidneys to insure that Wilm’s tumor, which can lead to hypertrophy in the leg on the same side, is not present.

In older children, LLD is frequently first suspected due to the emergence of a progressive limp, warranting a referral to a pediatric orthopaedic surgeon.   The standard workup for LLD is a thorough physical examination, including a series of measurements of the different portions of the lower extremities with the child in various positions, such as sitting and standing.   The orthopaedic surgeon will observe the child while walking and performing other simple movements or tasks, such as stepping onto a block.   In addition, a number of x-rays of the legs will be taken, so as to make a definitive diagnosis and to assist with identification of the possible etiology (cause) of LLD.   Orthopaedic surgeons will compare x-rays of the two legs to the child’s age, so as to assess his/her skeletal age and to obtain a baseline for the possibility of excessive growth rate as a cause.   A growth chart, which compares leg length to skeletal age, is a simple but essential tool used over time to track the progress of the condition, both before and after treatment.   Occasionally, a CT scan or MRI is required to further investigate suspected causes or to get more sophisticated radiological pictures of bone or soft tissue.

How is it treated?

The treatment of LLD depends primarily on the diagnosed cause, the age of the patient, and the severity of the discrepancy.   Non-operative treatment is usually the first step in management and, in many cases, LLD is mild or is predicted to lessen in the future, based on growth rate estimates in the two legs.   In such cases, no treatment may be necessary or can be delayed until a later stage of physical maturity that allows for clearer prognostic approximation.   For LLD of 2cm to 2.5cm, treatment may be as simple as insertion of a heel lift or other shoe insert that evens out leg lengths, so to speak.   For more severe cases, heel lifts can affect patient comfort when walking, decrease ankle stability, and greatly increase the risk of sprains.   For infants with congenital shortening of the limb, a prosthetic ? often a custom-fit splint made of polypropylene ? may be successful in treating more severe LLD without surgery.

In many instances, however, a surgical operation is the best treatment for LLD.   Surgeries for LLD are designed to do one of three general things ? shorten the long leg, stop or slow the growth of the longer or more rapidly growing leg, or lengthen the short leg.

Stopping the growth of the longer leg is the most commonly utilized of the three approaches and involves an operation known as an epiphysiodesis , in which the growth plate of either the lower femur or upper tibia is visualized in the operating room using fluoroscopy (a type of real-time radiographic imaging) and ablated , which involves drilling into the region several times, such that the tissue is no longer capable of bone growth.   Because the epiphyseal growth capabilities cannot be restored following the surgery, proper timing is crucial.   Usually the operation is planned for the last 2 to 3 years of growth and has excellent results, with children leaving the hospital within a few days with good mobility.   However, it is only appropriate for LLD of under 5cm.

Leg shortening is employed when LLD is severe and when a patient has already reached skeletal maturity.   The actual surgery is called an osteotomy , which entails the removal of a small section of bone in the tibia (shinbone) and sometimes the fibula as well, resulting in the loss of around an inch in total height.

Leg lengthening is a difficult third option that has traditionally had a high complication rate.   Recently, results have improved somewhat with the emergence of a technique known as callotasis , in which only the outer portion of the bone (the cortex ) is cut, (i.e. a corticotomy ).   This allows the bone to be more easily lengthened by an external fixation device that is attached to either side of the cut bone with pins through the skin.   The ?ex-fix,’ as it is sometimes called, is gradually adjusted by an orthopaedic surgeon, and healing can occur at the same time that the leg is being distracted , or lengthened over time.   Unlike epiphysiodesis, leg lengthening procedures can be performed at almost any skeletal or chronological age.

Coping with leg length discrepancy

For some cases of leg length discrepancy, real adjustments may be required for parents and their child with the condition.   Frequent visits to the doctor or a surgical operation at a young age can represent an emotional and physical challenge for children and parents alike.   However, almost all patients respond tremendously well to treatment and the condition does not present any lingering deformities.   Moreover, the vast majority of children with LLD have no future restrictions on their activities and abilities following treatment, from everyday walking to demanding, competitive sports.

Other questions

Naturally, you may have other questions about leg length discrepancy that are not answered in the above summary. As your orthopaedic surgeons, we welcome any and all questions you may have, which we urge you to pose during your next office visit. Do call us at +65 6471 2694 if you have any queries.

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In case of significant arthritic changes of the facet joints with hypertrophy of the capsule, hypertrophied facet osteophytes, incomplete spontaneous fusion of the facet joints, and air inclusion, the patients may profit from a facet joint infiltration. If a temporary pain release can be reached, a direct fusion or screw fixation [...]]]>

Lumbar Joint Arthritis

In case of significant arthritic changes of the facet joints with hypertrophy of the capsule, hypertrophied facet osteophytes, incomplete spontaneous fusion of the facet joints, and air inclusion, the patients may profit from a facet joint infiltration. If a temporary pain release can be reached, a direct fusion or screw fixation of the arthritic joint may be quite helpful. The so-called “facet joint syndrome” which is radiologically difficult to identify, even with MRI, is a diagnosis which rarely goes along with long-lasting periods of pain relief after
surgical treatment. Even if the facet joint infiltration may be suggestive for a facet joint syndrome, the pain relief through fusion may only be temporarily. In a recent study it has been demonstrated that cases where there is fluid in the lumbar facet joints, detected on MRI, as well as instability in flexion lumbar radiographs, in patients with L4/5 degenerative disease,
pain correlates well with the morphological findings. Therefore, fluid on MRI in the facet joints should raise suspicion of lumbar instability and qualifies for fusion
surgery.

The X-rays, respectively the MRI, of significant facet arthritis should be done supine as well as standing to demonstrate the fluid in the joint. When standing, the fluid is pressed out and the facet joints are almost locked. When the patient is supine, the joints may open and air inclusion can be demonstrated on the conventional X-rays as well as fluid in the joints. These
patients often indicate typical pain in the night when turning in bed which wakes them up and pain in the morning while getting up until the facet joints have “settled” under the axial load. True facet joint arthritis, as the relevant pain source, can usually be stabilized with simple translaminar or transfacetal screws. In case of a still significantly good disk, a combination with an
anterior interbody fusion through a TLIF or PLIF may be mandatory to get the patient pain-free.

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Lordosis is an increased curving of the spine.

The spine has three types of curves:

Achilles tendonitis is a condition of irritation and inflammation of the large tendon in the back of the ankle. Achilles tendonitis is a common injury that tends to occur in recreational athletes. Overuse of the Achilles tendon can cause inflammation that can lead to pain and swelling. Achilles tendonitis is differentiated from another common [...]]]>

Achilles tendonitis is a condition of irritation and inflammation of the large tendon in the back of the ankle. Achilles tendonitis is a common injury that tends to occur in recreational athletes. Overuse of the Achilles tendon can cause inflammation that can lead to pain and swelling. Achilles tendonitis is differentiated from another common Achilles tendon condition called Achilles tendinosis. Patients with Achilles tendinosis have chronic Achilles swelling and pain as a result of degenerative, microscopic tears within the tendon.

Causes of Achilles Tendonitis

The two most common causes of Achilles tendonitis are:

• Lack of flexibility
• Overpronation

Other factors associated with Achilles tendonitis are recent changes in footwear, and changes in exercise training schedules. Often long distance runners will have symptoms of Achilles tendonitis after increasing their mileage or increasing the amount of hill training they are doing.

As people age, tendons, like other tissues in the body, become less flexible, more rigid, and more susceptible to injury. Therefore, middle-age recreational athletes are most susceptible to Achilles tendonitis.

Symptoms of Achilles Tendonitis

The main complaint associated with Achilles tendonitis is pain behind the heel. The pain is often most prominent in an area about 2-4 centimeters above where the tendon attaches to the heel. In this location, called the watershed zone of the tendon, the blood supply to the tendon makes this area particularly susceptible. Patients with Achilles tendonitis usually experience the most significant pain after periods of inactivity. Therefore patients tend to experience pain after first walking in the morning and when getting up after sitting for long periods of time. Patients will also experience pain while participating in activities, such as when running or jumping. Achilles tendonitis pain associated with exercise is most significant when pushing off or jumping.

X-rays are usually normal in patients with Achilles tendonitis, but are performed to evaluate for other possible conditions. Occasionally, an MRI is needed to evaluate a patient for tears within the tendon. If there is a thought of surgical treatment an MRI may be helpful for preoperative evaluation and planning.

Treatment of Achilles Tendonitis

Treatment of Achilles tendonitis begins with resting the tendon to allow the inflammation to settle down. In more serious situations, adequate rest may require crutches or immobilization of the ankle. Learn more about different treatments for Achilles tendonitis, including ice, medications, injections, and surgery

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