Achilles Tendonitis (tendinopathy) is a broad term referring to a range of conditions describing injury to the Achilles tendon. It is caused by an acute or chronic tendon overload, usually leading to a rapid onset of pain, stiffness and loss of function. This can occur at the heel where the tendon attaches (insertional Achilles tendinopathy), or higher in the tendon on the lower aspect of the calf (midportion Achilles tendinopathy). There are several stages involved in the progression of this condition:
Reactive tendinopathy – refers to the early non-inflammatory phase of injury where cells react to increased tendon loads and release chemicals that cause pain. It is an adaptive change resulting in tendon thickening, however these changes are not permanent
Tendon dysrepair – occurs when the tendon is not healing correctly, where the tendon matrix breaks down and cells become disorganised – picture fibres of a rope starting to fray.
Degenerative tendinopathy – results in permanent changes to the tendon structure, with thickening and formation of nodules (lumps), and large areas of the tendon matrix are broken down.
The first two stages are reversible if managed early and correctly. However, once it progresses further, it can be much more challenging to rehabilitate, hence the importance of seeking early treatment.
The Achilles tendon is an important structure that helps you walk, run, jump and stand on your toes. The tendon connects the calf muscle to the heel bone, and assists with transmitting force, acting like a spring when you push your foot off the floor. It is the largest tendon in the body and is therefore capable of withstanding a considerable amount of stress, up to 8 times your body weight. Achilles tendinopathy generally occurs when the tendon is excessively loaded with more force than it is used to, resulting in cellular changes to the tendon’s structure. Here are some of the risk factors that can contribute to tendon overload:
– Sudden increase in intensity, frequency or duration of activity
– Excessive training and inadequate rest periods
– High impact activities that require rapid directional change
– Inadequate warm up, stretching and cool down
– Poor footwear or ill fitting shoes (eg. high heels)
– Tight and or weak calf muscles
– Altered biomechanics contributing to increased Achilles strain (eg. excessive pronation)
– Being overweight
– Underlying medical conditions (eg. diabetes, high cholesterol, inflammatory arthritis)
– Certain medications (steroids and fluoroquinolone antibiotics have been associated with Achilles tendon ruptures)
Symptoms of Achilles Tendonitis
Classic features of Achilles Tendinopathy include:
– Pain and stiffness at the back of the heel, or 2-6 cm above from the base of the Achilles
– Pain in the Achilles before and after exercise. It may increase or flare up when activity stops. In some cases pain in the Achilles may prevent you from participating in activity altogether.
– Stiffness around the area of the back of the heel in the morning which may subside after exercise and movement
– The affected area can be swollen, warm and tender to touch
– Bony spurs at back of the heel – this is usually painless but can cause irritation from footwear
At Erko Podiatry, we can diagnose Achilles tendinopathy through a biomechanical assessment, where we take a detailed medical history, look at muscle strength and function, footwear and gait. We may use further imaging such as x-ray, ultrasound or MRI to determine the exact location and pathology of the tendon, and may want to assess surrounding structures.
Treatment of Achilles Tendinopathy
Treatment of Achilles tendinopathy is focussed on reducing aggravating factors to the tendon through offloading and controlling the foot biomechanics. This will be followed by rehabilitation to improve the tendon’s pain free load capacity through exercise, with the goal to prevent future injury. This will involve:
– Modified activity, avoiding activities which may cause the tendon to flare up
– Strapping for short term relief
– Heel raises applied to insoles to reduce tension off the Achilles tendon, usually required for short term
– Exercises: Stretching, strengthening and functional exercises for calf muscle/tendon complex. We would usually provide you with a progressive loading program.
– Custom foot orthotics to address any biomechanical issues that can contribute to Achilles tendon strain
– Footwear education and advice
– Manual therapies (ie. dry needling, soft tissue and deep tissue massage), to release calf muscle tightness
– Shockwave therapy to accelerate and facilitate healing
Frequently asked questions about Achilles Tendonitis
Achilles tendinopathy is common in athletes, with observational data suggesting that competitive athletes have a lifetime incidence of Achilles tendinopathy of 24 percent, with 18 percent sustained by athletes younger than 45 years. Amongst competitive runners, the lifetime incidence of Achilles tendinopathy may be as high as 40-50%. However, this condition can affect anyone regardless of physical activity levels, from elite athletes, to weekend warriors, and to those with a more sedentary lifestyle.
Achilles tendinopathy is an umbrella term which encompasses all conditions affecting the Achilles. You may have heard of some of these terms being used interchangeably. Most of us are familiar with the term Achilles tendinitis, with ‘itis’ being inflammation. This term is generally referring to the early stage (reactive phase) of tendinopathy, and is perhaps incorrectly used, as the inflammation is not the source of Achilles pain. For this reason, it is more widely accepted to use the term tendinopathy to describe the condition.
While it may seem instinctive to rest to protect the tendon from further injury, research suggests complete rest is not all that good for the long term. Too much rest can cause weakening of the tendon, enabling a slower recovery. Relative rest and modified activity may be needed to settle flare ups of the Achilles, followed by an early start to a progressive heavy load strength training program.