You walk into an exam room to a patient you have never seen before. You ask them how they are and what is concerning them at the moment. They explain to you that seemingly out of the blue they began to experience pain in their heel and calf area. You ask them to explain how the pain started, what they do for a living, how much it hurts, and what their symptoms are.
They explain they are a mail carrier and are on their feet most of the day. The pain seems to have started suddenly and no injuries, falls, or accidents occurred recently. You ask for more clarification of their current symptoms and they explain the pain is worse when they stand and walk, their calf feels tight and stiff when they get out of bed in the morning. They seem to be worried about the crunching and cracking of their heel and you can tell the symptom is causing them some anxiety. Upon further examination, you can see the heel and ankle is swollen and tender.
From the patient’s symptoms, concerns, and physical examination you can easily see this is a case of tendon injury or tendinopathy. There are no other red flags and bloodwork or x-rays are not necessary at the moment.
Tendon injuries are rather simple to diagnose. Tendons are tissues that attach muscle to bone. Tendons are strong and can support up to 5 times your body weight. However, sometimes they become injured, especially at the heel, elbow, shoulders, knees, and hands. Often this happens because of the tear in the tendon over time. There are two main tendon injuries:
- Tendonitis: Inflamed tendon.
- Tendinosis: Small tears in and around the tendon.
These two general tendon injuries are commonly known as tendinopathy and are almost always caused by overuse or aging. In particular, the repetitive activity can cause wear and tear of your tendons. This is particularly common in certain jobs, sports or with age.
More often than not, it is easy to diagnose a tendon injury because of symptoms like stiffness, pain in the injured area, and difficulty moving it are trademark signs. The patient may also experience swollenness, bruising and tenderness, or even a grating sound when you use your tendon. Depending on the affected area, they may experience weakness and an inability to use it.
Commonly affected areas
Tendon injuries can happen anywhere, but they’re most common in the following areas:
- Quadriceps (muscles above your knee cap): These muscles are involved in walking, running and jumping as they help extend your leg.
- Achilles (back of your foot above the heel): The Achilles attaches your calf muscles to your heel. It’s involved when you stand on your toes or push off during sports.
- Rotator cuff (shoulder muscles): These muscles are involved in rotating your arm and keeping your shoulder in its socket.
- Biceps (arm muscles): This muscle is involved in flexing your elbow and bending it. Often, it’s used for lifting too.
Depending on the affected area, recovery time and treatment will be slightly different. Be sure to keep in mind specific injured area as treatment and recommendations may be slightly different for each.
A tendon injury can be triggered in different ways. The most common is by far due to overstretching or overusing the tendon, or by the trauma of some kind. This is typical for athletes who engage in intense physical activity before their muscle groups are strong enough, or do a repetitive job activity that requires the same tendon. You can clearly see that your current patient is on their feet all day as a mail carrier and tendon injury to the calf and heel is to be expected.
Tendon injuries can also be caused by:
- Old age
- Strenuous physical activity
- Heavy lifting
- Certain steroids
- Certain antibiotics
Luckily, tendon injuries usually go away with home treatment. You can see there are no red flags with this patient and any further testing is not needed at the time. Therefore, recommending R.I.C.E. guidelines are the best course of action for this patient.
- Rest: Don’t use the injured tendon. Limit use and take a break from sports.
- Ice: Apply ice to the injured area for up to 20 minutes at a time. This will help reduce swelling. Never apply directly to the skin, but use a cloth or plastic bag.
- Compression: Wrap the affected area with compression bandages to support the area, minimize swelling and promote healing. Don’t apply it too tightly, or blood circulation will be cut off.
- Elevation: Prop the affected area to the level of your heart.
Taking painkillers and getting pain relief from home remedies such as essential oils or supplements can often be used as well, especially for patients who are wary of conventional medications.
Tendon injuries take weeks or even months to heal properly. This can be frustrating for patients, but it’s important to take recovery slow and steady. If they try to use their injured tendon without fully healing, they could re-injure it and cause further problems, which is important to ensure the patient understands. Recovery time will be on a case-by-case basis.
It’s important to determine how the tendon injury occurred in the first place. This patient likely developed his injury at work overtime with overuse of the area, even though the pain came on suddenly. If they were injured at work, suggest they talk to their employer about how to improve safety conditions during their job.
In general, to prevent tendon injury, they can use their exercise plan with the following tips:
- Cross train: Develop diverse muscle groups. It’s a good idea to cross train and do different physical activities. For example, during the week, try to run, swim and bike, or create a varied exercise plan that uses different muscle groups.
- Use proper technique: If the patient is new to a sport or workout program, hire a personal trainer to teach proper technique. Not using the correct technique can cause injury.
- Do warm-up and cool-down exercises: Always warm-up and cool-down after every workout. Experts suggest 5 minutes for every 30 minutes. If they have injured their tendon before, it’s key to exercise it so that they prevent stiffness and build strength. Range-of-motion exercises should be done slowly and build over time.
- Avoid repetitive motion: If they do repetitive motion as part of work or a sport they play, it’s important to switch it up. Try changing hands, if possible, and take breaks regularly.
- Wear suitable shoes and gear: A pair of worn-out shoes can place unnecessary pressure on your tendons. Make sure they are using appropriate gear at all times.
- Build intensity level over time: Ensure they don’t do too much, too fast. It’s important to create workouts that build over time, instead of rushing into higher intensity workouts.
As usual, if these simple tips and at-home remedies do not work and the patient is still experiencing symptoms, suggest they come back for a follow-up appointment. Sometimes further intervention is needed, particularly for this patient who will likely continue to walk and be on their feet consistently during the day.
“Basic Biology of Tendon Injury and Healing.” NeuroImage, Academic Press, 19 Nov. 2009, www.sciencedirect.com/science/article/pii/S1479666X0580109X.
“Biomechanics of Tendon Injury and Repair.” NeuroImage, Academic Press, 20 Dec. 2003, www.sciencedirect.com/science/article/pii/S0021929003004068.
NHS Choices, NHS, www.nhs.uk/conditions/tendonitis/.
“Ruptured Tendon: Symptoms, Causes, and Treatments.” WebMD, WebMD, www.webmd.com/fitness-exercise/ruptured-tendon#1.
“Tendinitis and Tendon Injuries: How It’s Diagnosed, Common Treatments, and Prevention.” WebMD, WebMD, www.webmd.com/fitness-exercise/understanding-tendinitis-treatment.
“Tendon Injury (Tendinopathy).” HealthLink BC, www.healthlinkbc.ca/health-topics/uh2113.
“Tendon Injury and Tendinopathy: Healing and Repair: JBJS.” LWW, Oxford University Press, journals.lww.com/jbjsjournal/Abstract/2005/01000/Tendon_Injury_and_Tendinopathy___Healing_and.30.aspx.
About Dr. Brent Wells
Dr. Brent Wells is a graduate of the University of Nevada where he earned his bachelor of science degree before moving on to complete his doctorate from Western States Chiropractic College. He founded Better Health Chiropractor Wasilla in Alaska. He became passionate about being in the chiropractic field after his own experiences with certain hurried, unprofessional healthcare providers. The goal for Dr. Wells is to treat his patients with care and compassion while providing them with a better quality of life through his professional treatment.
Published on 6/6/19