What is Achilles Tendinopathy?
Achilles tendinopathy is an umbrella term which covers ‘insertional achilles’ and ‘mid portion achilles’ injuries. The term Achilles tendinitis has been superseded by the term tendinopathy as the tendon disorder has been shown to be a degenerative issues rather than a typical inflammatory issue, or simply put an ‘overuse injury’ to the tendon.
What does my Achilles Do?
The Achilles tendon is the combined tendon of the gastrocnemius and soleus muscles, and is the thickest and strongest tendon in the human body. Our Achilles tendon is one of the most unique tendons in our body, as it acts similar to a spring enabling us to walk, run and jump. As the achilles absorbs our body weight it stores energy and as we take off it releases energy, giving us forward momentum (like a spring).
So why do Achilles cause pain?
Tendons love exercise, but they need the right dose, too much and they get angry too little and they get weak. Similar too muscles, tendons need a rest period after exercise to adapt and recover and become stronger, when this balance is out the rate of work is above the rate of repair and this can start the tissue in a degenerative overload process, if this occurs for too long it will likely trigger pain. There are other risk factors that contribute to this pathway and these will be explained further.
Whats the difference between Insertional achilles tendinopathy and Mid portion achilles tendinopathy?
Insertional achilles tendinopathy common symptoms are pain on or near the back of the calcaneus (heel bone) and pain symptoms are replicated when the foot is moved into dorsiflexion (toes pushed up towards shin) usually due to compression of the tendon on the heel, where as Mid-portion achilles tendinopathy usually presents with pain 2-7cm above the heel bone and usually occur from increase in load, volume or intensity.
There are stages of tendon pathology, understanding these helps the clinician to understand what treatment modalities will be most suited.
Reactive/early stage tendinopathy – a non inflammatory phase where the tendon acutely becomes overloaded and may have a thickened appearance, in this case the patient may have a sudden onset of symptoms.
Tendon dysrepair – describes a decline in the tendon pathology, in this stage the tendons collagen matrix becomes disorganised, this is often seen in chronically overloaded tendons. There is marked evidence under microscope of ingrowth of vessels and nerves.
Degenerative tendinopathy – in this stage large areas of are disordered and filled with vascular and nerve cells, the collagen fibres are disorganised. The tendon may have focal nodular areas with or without general thickening. Typically seen in patients with long term tendon overloading. This tendon is at a high risk of rupture.
- Pain is generally felt at the back of the heel and/or on the tendon.
- Pain after exercise or the following day particularly the morning.
- Pain free at rest and increases with activity.
- Often pain symptoms improve once warmed up, only to return when they cool down.
- Maybe local tenderness and/or thickening
Causes of Achilles Tendinopathy
Extrinsic (External) risk factors
- Sudden Increase in activity level. This can be an increase in: duration, distance, speed, type of activity, jumping, skipping, burpees
- Not enough recovery time between activity/training.
- De conditioning – Long period of inactivity e.g. holidays, return from injury, sedentary.
- Sudden change in terrain, for example running on soft surfaces, sand running, possibly even grass. Increase in hill/stairs running or walking.
- Footwear – can play a role, new or old footwear that is no longer supportive enough, too flexible and for some a low heel to toe difference can aggravate some tendons.
- Intrinsic (Internal) risk factors
- Previous history of Lower limb Tendinopathy can increase the risk of reoccurrence.
- Recent Injuries that affect strength, mobility and function of the lower limb may elevate the risk of AT
- Increase in Age
- High BMI
- Reduced Muscle Strength and endurance of the posterior leg muscles particularly the gastrocs and soleus.
- Reduced ankle Range of motion – reduced Dorsiflexion, tight gastrocs and soleus.
- Poor foot mechanics – an unstable foot can quickly overload the achilles.
Managing Achilles tendinopathy
Management is highly dependent on the individual, there presentation of symptoms and the factors that need to be addressed varies between patients, below is a general outline of some strategies:
- Reduce or cease training loads
- Increase recovery days between exercise – 48-72hrs dependent)
- Therapeutic exercise – depending on severity and stage. Isometric calf holds have been found to be effective in reducing and moderating pain receptors to the CNS.
- Addressing patients risk factors for example if wearing poor footwear, has poor mobility at the ankle joint and strength deficits treatment would be specific to these risk factors.
- Other treatment modalities may include: Shockwave therapy, Dry needling of the gastroc/soleus muscles, orthotics, massage of the gastroc and soleus, heel lifts.
If you have any enquiries regarding Achilles tendinopathy or are currently suffering foot and ankle pain please contact Rhys Whittaker for an initial assessment, Rhys has a particular interest in tendinopathy injuries and works at both of our Casey Allied Health and Patterson Allied Health clinics.