Overview
Achilles tendinopathy is not only one of the most commonly seen injuries in running and sporting populations, but it is also extremely prevalent within the general population. The achilles tendon connects your calf muscles (the Gastrocnemius and Soleus) to your heel bone (Calcaneus). It’s role is plantar flexion of the foot and ankle, which is crucial in walking and running.
What is a Tendinopathy?
A tendinopathy is normally the result of a tendon becoming overloaded, and comes under the umbrella of what is commonly referred to as an “overuse injury”. Normally when a tendon is strengthened, it becomes more stiff and is then able to respond to higher levels of load. However, if activity is increased too quickly, the tendon becomes more thick rather than more stiff. This results in inflammation, pain, and decreased tissue health in the long term. Achilles tendinopathies often occur when athletes are returning to play after the off-season, or a runner increases their distance or frequency. Recovery from tendinopathy can be slow, and typically takes longer if the injury has been causing symptoms for an extended period of time. Thus it is important to seek appropriate treatment as early as possible.
Common Symptoms of Achilles Tendinopathy
- Localised pain in the middle of the achilles or over the posterior heel bone (calcaneus).
- Initial gradual onset of pain during or after activity.
- Morning pain/stiffness.
- Pain in the beginning of activity, which decreases as the body warms up.
- Pain when walking or running.
- Increased thickness or tenderness of the Achilles tendon.
Contributing Factors
Rapid Increase in Load:
As previously mentioned, the main driving factor in tendinopathy is an increase in load that is too fast for the tendon to respond appropriately. There are a variety of ways that this can occur, some common examples include increasing the total distance you are running each week, increasing the frequency of your walking or beginning a new activity.
Footwear:
Poor footwear can play a large role in the way our joints, muscles and tendons react to and absorb load. If the shoe you exercise in does not have sufficient arch support, cushioning or a raised heel, the tendons surrounding the foot and ankle are forced to take more load than they would otherwise.
Decreased Ankle Range of Motion and Calf Tightness:
A decreased range of dorsiflexion has been associated with increased risk of developing an achilles tendinopathy. Decreased range is normally a result of a stiff joint, or tight calf muscles, and can be improved through exercise and manual therapy.
Weakness
Not only does a weak tendon increase the likelihood of developing an Achilles tendinopathy, weakness of muscles further up the chain can alter the amount of energy the Achilles absorbs. Weakness of the calf muscles (Gastrocnemius and Soleus) means more force has to produced by the achilles in order to help us push off when walking/running. Other muscles such as hamstrings and the gluteal muscles have also been shown to influence the biomechanics of the achilles tendon.
Biomechanics and Foot Posture:
Biomechanics is how the body and it’s muscles, tendons, joints and ligaments work together to aborb, distribute and produce energy. Biomechanics influencing the achilles tendon include foot posture, such as decreased range of motion as discussed earlier, but also over-pronation. Pronation is rolling of the foot outwards, typically resulting in a flat foot posture. Whilst flat feet and over-pronation are not always an issue, it can lead to more stretch on the achilles tendon and increase the likelihood of microtears, leading to achilles tendinopathy.
Common Treatment Options
Load Management:
- Load management is the cornerstone of Achilles tendinopathy management.
- Aggravated activities are minimised to allow time for the tendon to heal and for pain to decrease, then gradually increased until normal function is restored.
Strengthening Exercises Prescribed by Physiotherapist:
- Along with load management, strengthening is a core part of Achilles tendinopathy treatment.
- Initially exercises may be isometric, meaning the muscle is contracted, but not lengthened or shortened. Research has shown that not only do isometric exercises increase tendon strength, they also have analgesic effects, and thus are useful in the early, painful stages of tendinopathy.
- Exercises then progress to a combination of isometric, heavy-slow resistance and eccentric exercises. Research has shown that heavy-slow resistance and eccentric exercises increase tendon stiffness and promote realignment of tendon collagen fibres.
- Once these exercises are pain-free, then faster, more activity-related exercises are slowly introduced, and gradually progressed to plyometrics. This prepares the tendon to deal with a similar amount of energy that it faces when walking, running, or jumping.
- Strengthening may also be done in areas further up the kinetic chain, in order to improve the distribution of load, or within the foot to correct postural differences such as over-pronation.
Heat or ice:
- Ice may be used in initial stages and after activity in order to decrease pain. Normally ice is only used in the initial stages of treatment (24-72 hours).
- After this, heat can be used before activity and exercise to improve blood-flow and muscle activation.
Massage:
- Massage directly over the tendon is not indicated, and may increase pain.
- However massage can be done further up the chain in the Gastrocnemius or Soleus, in order to take load off the Achilles.
Dry Needling:
- Similar to massage, dry needling the tendon directly may not result in great outcomes.
- Dry needling further up the chain is indicated and can be helpful in conjunction with exercise therapy and load management.
Shockwave:
- Shockwave therapy may be used in conjunction with load-management and exercise therapy.
- Shockwave therapy may improve synthesis of collagen fibres and promote tendon healing.
Heel-Lifts and Orthotics:
- Heel-lifts can be placed in shoes in order to reduce the amount of stretch placed on the achilles tendon during activity.
- Orthotics and heel-lifts may also be used to correct postural imbalances such as decreased range of motion and over-pronation.
Return to Activity:
Graduated return to activity is an important part of recovery from Achilles tendinopathy. Returning to activity too quickly is likely to disrupt the tendon again, resulting in increased time before returning to normal function. Your Physiotherapist can discuss an appropriate plan with you, and decide on the best and safest approach for return to activity.
References:
- Cardoso, T. B., Pizzari, T., Kinsella, R., Hope, D., & Cook, J. L. (2019). Current trends in tendinopathy management. Best Practice & Research. Clinical Rheumatology, 33(1), 122–140. https://doi.org/10.1016/j.berh.2019.02.001
- van der Vlist, A. C., Winters, M., Weir, A., Ardern, C. L., Welton, N. J., Caldwell, D. M., Verhaar, J. A. N., & de Vos, R.-J. (2021). Which treatment is most effective for patients with Achilles tendinopathy? A living systematic review with network meta-analysis of 29 randomised controlled trials. British Journal of Sports Medicine, 55(5), 249–256. https://doi.org/10.1136/bjsports-2019-101872