Expert: Achilles Tendon Injuries Are on the Rise

The Achilles tendon is mythical, and not just because of its Greek-inspired name. Connecting the calf muscles to the heel bone, it is considered the strongest and longest tendon in the body, with the ability to withstand up to four times a person’s weight. It also plays an essential role in walking, jumping, and running, as well as in our ability to point our toes downward.

But orthopedists, podiatrists, and emergency room doctors have noticed a worrisome trend. More people are suffering Achilles tendon injuries, particularly ruptures.

Research supports that clinical observation, says Jennifer Horawski, M.D., an orthopedic sports medicine specialist at the University of Miami Health System. The Achilles tendon now wears the unwanted title of being the most frequently ruptured tendon in the human body.

“We’re seeing more cases not just among elite athletes, but also among recreational exercisers and weekend warriors,” she adds.

While these injuries are still uncommon, the uptick is real and affecting a broader demographic.

Historically, Dr. Horawski says, Achilles ruptures have been most prevalent in men, usually between the ages of 30 and 50. But now doctors are seeing more older adults.

The most comprehensive data, the National Electronic Injury Surveillance System (NEISS) National Epidemiology Study, reports that the incidence rate rose from 1.8 to 2.5 cases per 100,00 between 2012 to 2016.  A more recent study estimated 18 ruptures per 100,000. Another retrospective look by an online medical encyclopedia used by physicians, nurses, and medical students puts the rate at 5 to 10 ruptures per 100,00 people.

In all these studies, men with a ruptured Achilles tendon outnumbered women, accounting for up to 83% of those injuries.  And while younger men (20 to 39 years of age) made up the majority of these injuries, the fastest growth of injury cases has been in the 40-to 59-year-old set, with a 78% increase in a five-year study period.

As many as 80% of Achilles injuries are sports-related, with basketball being the number one offender.

Soccer and tennis share in those numbers, too — “and increasingly, pickleball, which has exploded in popularity among older adults,” Dr. Horawski says. However, participating in any sport that requires sudden acceleration and deceleration, jumping, quick changes of direction, or rapid push-off from the ground increases an athlete’s risk of injury.

There are several reasons for the increase in Achilles tendon injuries. More people are playing sports well into middle age and beyond, and adult participation in recreational athletics has grown. Keeping physically active later in life is both laudable and important for our health, but many don’t condition their older bodies well enough for high-intensity movements. What’s more, as we age, tendons become less resilient. Dr. Horawski cites studies in The Journal of Orthopaedic Research and Sports Health that show “older tendons tolerate sudden load less well, especially without progressive conditioning.”

While the population of people who suffer these injuries has changed over the years, the injuries themselves remain the same.

There are three main categories:

• chronic tendinopathy (degenerative overuse)
• partial tears
• complete ruptures

In most cases of complete rupture, the individual is likely to have experienced some prior degenerative overuse.

Symptoms of an Achilles tendon rupture include:

• pain and tenderness in the area, with a worsening of intensity during or after physical activity
• stiffness
• weakness
• reduced range of motion and swelling or thickening

Treatment depends on the type and severity of the injury. For instance, chronic tendinopathy is typically treated with physical therapy, focusing on increasing tendon load capacity. A partial tear requires temporary immobilization or some protection for a period of time so the affected foot does not bear weight. Rehabilitation is also part of the treatment. In the case of a complete rupture — the most serious of the Achilles injuries — surgical repair may be needed and/or functional rehabilitation. The recovery timeline is long: It can take up to a year for a full return to previous activity.

Dr. Horawski suggests ways to prevent these painful injuries:

• Build up your calf and tendon strength by doing calf raises and standing on tiptoes for 30 to 45 seconds. Also, practice eccentric heel drops.
• Always warm up before an activity. Try calf stretches, ankle circles, marching on your toes, and walking lunges with heel lifts. Some athletes also like to foam roll their calves.
• Wear the right shoes. Shoes that are too stiff or too flat increase your tendon load, so use a shoe with a higher heel-to-toe ratio. Also, remember to replace your running shoes every 300 to 500 miles.
• Train gradually. You should increase your running or jumping volume by about 10% per week — at most. “Gradual progression of activity is key, especially when returning after time off,” she explains.
• Keep track of your medications. Some, such as fluoroquinolone antibiotics, certain corticosteroids and oral bisphosphonates (for osteoporosis and other bone conditions) can affect your tendons. Discuss side effects with your prescribing clinician.
• Keep your body weight in check. Extra pounds increase the load your Achilles tendon has to bear.
• Don’t ignore warning signs. If you feel stiffness, tenderness, or any kind of pain in the area, stop the activity and consult a doctor. “You want early intervention when pain or stiffness appears, not pushing through symptoms,” Dr. Horawski says.

Written by Ana Veciana-Suarez. Medically reviewed by Jennifer Horawski, M.D.

Tags: Dr. Jennifer Horawski, Foot and ankle care, Lower leg injury rehabilitation, Muscle-tendon connection, Tendon rupture recovery tips