Achilles Tendinopathy

Achilles tendinopathy is a common cause of heel pain and is seen often with running or jumping sports. We also see it regularly in walkers, hikers and the general population.

The most common pathology is Midportion Achilles Tendinopathy, with pain and tenderness in the middle of the tendon. However the Achilles Insertion, the paratenon, sural nerve, bursas and, or the Plantaris Tendon can also be a source of symptoms. It’s important to get the diagnosis correct and thus the management right.

Anatomy

Most people know of this strong, thick, fibrous band that connects the calf muscle to the calcaneus (heel bone).

The gastrocnemius muscle and the deeper soleus muscles both combine into the Achilles tendon. Running along the inside border of the calf is the plantaris tendon and overlying the calcaneus is the superficial calcaneal bursa. Along the outside border of the Achilles tendon is the sural nerve. Each of these structures can present slightly differently and need a different approach.

Common Causes of Achilles Tendinitis include:

• Over-training or unaccustomed use – “too much too soon.”
• An excessive intensity or distance increase
• Change in training surface – e.g. grass to bitumen
• Lack of training variation
• Poorly supportive footwear.
• Hill running.

Achilles Tendinopathy Risk Factors

• Gender: Men > Women
• Age: >30 most common
• Weight: Higher body weight increases the risk
• Diabetes
• Calf Muscle: weakness, poor endurance &/or tightness
• Poor Lower Limb Muscle Control: e.g. Poor hip and knee muscle control
• Stiff Ankle/Foot Joints

What happens

The most common presentation is the Mid portion Achilles tendinopathy and it is a continuum of pathological processes.

The tendon gets overloaded over a period of time and the tissue fibres get disrupted. In the early stages, symptoms are mild, such as localised pain or stiffness first starting to exercise, but then eases off. As the condition worsens pain becomes more apparent, and the tendon may appear to be “lumpy” or swollen.Management will be determined by the stage of the process

Management

The main management of tendinopathy is LOAD MANAGEMENT. Complete rest will worsen the condition and make it harder to return to function later on. In an acutely sore tendon, cutting back on load is essential and allows pain to go away and the tendon to heal. It will involve change in the aggravating activities while commencing a graduated rehabilitation programme.

Simple pain killers and ice may help if the pain is quite severe, and given that there is very little inflammation in overload tendinopathy, anti-inflammatories are not usually very effective. However If the paratendon is involved it will often be aggravated by traditional strength based rehabilitation and management may first need to focus on settling the localised inflammation.

What we start with

Isometric heel raises are “Panadol exercises” which can load the tendon in a healthy way, and build up the healthy tendon structure around the disrupted tendon. Then a graduated rehabilitation program to increase load and types of load to the tendon.

There are many rehabilitation protocols all involving graded adaption to compressive and tensile loading through a variety of exercise choices. These can be isometric, eccentric, concentric or combined. The program will vary and take into consideration other factors in each individuals presentation such as maximum load, range of exercise, speed of contraction and frequency of sessions. It is not a one size fits all as all tendinopathies are different.

Beware

Calf stretching or massaging the tendon may aggravate symptoms. When a tendon is unhappy, direct stretch or compression on the tendon will aggravate it. Increased compressive loads in dorsiflexion can particularly flare up insertional and bursa related pain. If tight calf muscles are contributing to the problem, massage or foam roll the calf muscle to release.Wearing shoes with a higher heel or external wedge can often be helpful for these cases as well.

How our Physiotherapists can help

Apart from excessive external loading, the Achilles tendon can be overloaded due to other issues. Stiffness in the foot or ankle may lead to load being distributed unevenly within the tendon, causing one part of the tendon to get overloaded and hence disrupted. Stiffness or weakness in the hip can also put unequal load on the tendon.

• Pain management using therapeutic modalities and appropriate taping and unloading techniques
• Manual therapy to mobilize joints, neural structures and soft tissues
• Range of motion and when appropriate, stretching exercises
• Strengthening exercises of the ankle, foot and proximal stabilizing muscles.
• Functional training and sport specific exercises
• Patient education and prevention.

Our Physios are experienced in treating Achilles tendinopathy with clinical expertise in diagnosing the contributing biomechanical factors that can predispose this debilitating overuse condition. Early treatment results in a quicker resolution, better outcomes and less recurrence. Please speak to us now if you are enduring his common problem.