Achilles Tendinopathy explained...
Achilles tendinopathy historically was called Achilles tendinitis, but we now know more about the condition which can be acute (reactive) or chronic (degenerative) or somewhere in between. There is little or no inflammation that occurs within the tendon as previously thought. It is a degenerative condition, caused most probably by poor biomechanics and therefore over-loading.
The Achilles tendon is a strong structure and is a continuation of your calf muscles - joining directly into the back of your heel bone. Achilles tendinopathy is common in runners and can occur on just one or on both sides simultaneously. Diagnosis is important to ensure that you have not sustained a more significant injury such as a partial or total rupture to the structure. These tendons can take a long time to repair due to their poor local blood supply so be patient as you are looking at up to six months for resolution.
What are the symptoms of Achilles Tendinopathy?
The most common signs are local dull or sharp pain, tenderness, swelling around or thickening of the tendon itself. Weakness can also be associated. The pain is usually worse first thing in the morning, after activity and as the condition progresses, it can become painful during activity as well.
What are the causes of Achilles Tendinopathy?
This is another condition that is now thought to be due to repetitive microtrauma, and is common in runners. As with many injuries, these cases are multi-factoral and require a multi-faceted approach to treatment and rehabilitation. What you need to do is address the underlying factors and not just try and make the pain go away – that is how you will get long term resolution from this and any other biomechanical issue.
The structure of the Achilles tendon should be strong and linear. Chronic tendinopathy occurs over time when the arrangement of the collagen fibres that make up the tendon becomes more haphazard. Because the tendon has a poor blood supply, it doesn’t heal well on its own and this is why you have to try and identify and remove all the aggravating factors and causes. We most commonly see this in runners 40+ and more in men than women. We also see it in jumping sports such as tennis, squash or netball so bear this in mind if you do these sports or anything similar in addition to your running.
Inadequate shock absorption, excessive rear foot pronation and a heavy heel strike can be risk factors for Achilles tendinopathy. Check your running shoes haven’t done more miles than they should! If you suddenly start hill training, this can also increase the load on your Achilles and also be associated with the onset of symptoms.
How is Achilles Tendinopathy diagnosed?
Our diagnosis is made from the signs and symptoms your present with as well as your case history and our own assessment including palpation of the tendon itself and tests such as getting you to stand on your tip toes.
An x-ray won’t show any soft tissue damage or degeneration. We would choose to refer for diagnostic ultrasound but this is not usually necessary unless your symptoms are not settling with conservative treatment and management.
How is Achilles Tendinopathy Treated?
Historically patients with Achilles tendinopathy were given anti-inflammatory medication but we know now that this is of very little use.
It can take a while for AT to settle even if you are religious about your treatment and management approach to it. This is because our bodies have a cyclical regeneration/repair process which takes around 12 weeks and so you should start to see some real improvement after this time. If running is what makes your pain worse, whilst you many not want to hear this, it may be that rest is what is needed. However we will likely give you lots of things to be doing in the meantime to keep you busy as complete rest is not usually advised. I will often recommend using a cross trainer as a non-impact alternative together with swimming and cycling and we will normally get you back running as soon as you can do so within certain limits.
There is some evidence to show that stretching a reactive Achilles tendon will irritate it so don’t think that stretching madly all day every day is what you need to be doing and listen to the advice that is given.
A typical treatment program here at our clinic after initial consultation would be soft tissue massage to the calf and hamstrings in the first instance all aimed at de-loading the tendon. We will look at your strength, flexibility and function all the way from your feet up to your hips and pelvis. We may use kinesiotape to the Achilles and calf. We will provide a stretching and strengthening program which is unique to you but will usually include the proven 12 week progressive eccentric loading protocol described by Prof Hasan Alfredson. Some therapists use acupuncture to try and increase local blood supply and healing.
We will also look at what you spend your days doing, and what your wear on your feet during this time. We might recommend a basic over the counter orthotic to support your rear foot motion and provide some support for your foot arches. Sometimes we will also use heel lifts for a short time to once again de-load the tendon itself and provide it with some rest to recover.
Should conservative treatment fail, there are a number of options now for the treatment of Achilles tendinopathy. Cortisone injections are no longer recommended. Shockwave therapy is a more recent option and is showing some promising positive research. PRP injections have limited research driven results. Surgical intervention is a last resort.