Achilles Tendinopathy

The Achilles tendon is a strong tissue which is formed from our 2 main calf muscles – the gastrocnemius and soleus, which attaches to the heel bone. It is the biggest and strongest tendon in the human body (Physiopedia, 2019).

What is it?

Physiopedia (2019), defined achilles tendinopathy is a, “common overuse injury caused by repetitive energy storage and release with excessive compression.” This can lead to pain in the tendon, and worst case, a rupture of the Achilles tendon.

What are the risk factors?

• Changes in loading activities (O’Neill 2019)
• Obesity – increased load and potentially increased inflammatory mediators (Castro et al, 2016)
• Reduced ankle dorsiflexion (Cook, 2011, O’Neill 2019)
• Taking certain medicines, a group called fluoroquinolones e.g. ciprofloxacin and ofloxacin antibiotics can also increase your risk of developing Achilles tendinopathy (Payne, J. 2016)
• Inflammatory conditions such as rheumatoid arthritis, gout, psoriatic arthritis and thyroid disorders (WebMD, 2018)

If the tendon is ruptured, it requires immediate medical attention. This article discusses management of Achilles tendinopathy, rather than ruptures.

What are the symptoms?

• Pain at the insertion or middle portion of the Achilles tendon (distal part of the calf where the tendon begins to the heel bone)
• Increased pain with increased load, during or after activity (O’Neill 2019)
• Reduced pain after warming up (O’Neill 2019)
• Swelling of the tendon
• Pain with high impact activities – running, jumping, hopping.

Red flags:

Seek immediate medical attention if you have any of the following symptoms:

• Significant calf redness, swelling and pain, or shortness of breath
• Palpable dent in the area of the tendon
• Sudden trauma and not able to weight bear

What can Physio do?

Achilles tendon rehabilitation can take 3-6 months. Times are different for everyone. It is worth seeing a Physiotherapist for rehabilitation and treatment of the symptoms, as there is no fixed programme that works for everyone due to varying goals and pain severity.

When symptoms are flared up, resting from aggravating activities (running, jumping) can allow the flare up to settle.

Put ice wrapped in a layer on to and around the tendon for 15-20 minutes. This can provide short term relief. If you are struggling with pain management, speak to a pharmacist or doctor regarding pain relief.

Wear supportive footwear such as trainers.

Strengthening – holding on to something for support e.g. kitchen worktop or stable chair – rise up on your toes, keeping your knees straight. You can do this around 10 times to warm up the calf.

You can also try the following strengthening exercise. It is ok to do these with some discomfort in the calf muscle, but if you are flaring up, leave these for now to allow symptoms to settle a little. Repetitions depend on comfort. You could do 3 sets of 6 to 8 repetitions if tolerated. You may need to start at e.g. 3 sets of 3 repetitions.

https://www.youtube.com/watch?v=J8y7RBM0s00

Strengthening and power is generally more of the focus of Achilles tendon rehabilitation. However, stiffness in to dorsiflexion is a risk factor for Achilles tendinopathy (Cook, 2011).

Along with exercise to help the symptoms, the physio can do their own assessment to see if there is anything else that may assist your recovery, such as taping, dry needling, acupuncture, electrotherapy, or manual therapy for stiffness in the ankle. These would be as an adjunct to a home rehab programme.

Notes for physios:

Differential Diagnoses include (from Physiopedia, 2019):

• Haglund’s Deformity
• Plantar fasciopathy
• Calcaneal stress fracture
• Heel fat pad syndrome
• Sever’s Disease
• Posterior ankle impingement
• Medial tendinopathy
• Sural nerve
• Lumbar radiculopathy
• Ankle OA
• DVT

Cook and Purdum (2015) proposed that there is a tendon continuum as an approach to tendon pain. The model describes 3 stages known as reactive tendinopathy, tendon disrepair and degenerative tendinopathy. The article is within the reference list for more information.

Clinical Edge Podcast notes for objective tests, (O’Neill 2019):

• London Hospital Test – push tendon at painful site, passively dorsiflex the food and push on tendon again – reduction of pain in dorsiflexion is positive
• Painful arc sign – grip swollen area and dorsiflex the ankle. If swelling is within the tendon swelling would move with fingers, if within the sheath the swelling would not move
• Functional testing – pain with 10 single leg heel raises and stretching over step
• Strength testing – handheld dynamometer

Physiopedia summarise the current evidence base for treatment on this link: https://www.physio-pedia.com/Achilles_Tendinopathy

Treatment notes from Clinical Edge Podcast (O’Neill 2019):

• Variable responses to isometric exercise
• Patient education – why management involves progressive loading (as aggravated by loading). Can explain the pathology by describing the imbalance between wear and repair process
• Use symptoms to determine load rather than standard reps – can go to muscle soreness, not flare ups
• Heel raises – consider motor control
• Consider soleus

References:

Castro, A; Skare, T; Nassif, P; Sakuma, A; Barros, W. 2016. Tendinopathy and Obesity. 29. Pp. 107-110. Arquivox Brasileiros De Cirurgia Digestiva. 29. pp. 107-110. [online]. [Accessed 29^th April 2019]. Available from: http://www.ncbi.nlm.nih.gov

Cook, J. 2011. Tendons and Tendinopathy. Physio Edge Podcast. [online]. [Accessed 6^th May 2019]. Available from: http://www.physioedge.com.au

O’Neill, S. 2019. Achilles Tendinopathy Treatment – the Latest Research. [online]. [Viewed 29^th April 2019]. Available from: http://www.clinicaledge.co

Payne, J. 2016. Achilles Tendinopathy. [online]. [Accessed 28^th April 2019]. Available from: http://www.patient.info

Physiopedia. 2019. Achilles Tendinopathy. [online]. [Accessed 28^th April 2019]. Available from: http://www.physio-pedia.com

WebMD, 2018. Tendinitis. [online]. Accessed 6^th May 2019]. Available from: http://www.webmd.com