Achilles tendinopathy is a tendon disorder that has been shown to be a degenerative in nature rather than a typical inflammatory process, similar to an ‘overuse injury’ to the tendon. Achilles tendinopathy is a term which covers ‘insertional achilles’ and ‘midportion achilles’ injuries.
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. This unique tendon 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).
What is the cause of Achilles tendinopathy?
Tendons love exercise, but they need the right dose, too much and they get angry too little and they get weak. Similar to 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 pain pathway, and these will be explained further.
There are two main types of Achilles Tendinopathy: Insertional Achilles Tendinopathy and Mid portion Achilles Tendinopathy
Insertional achilles tendinopathy symptoms are generally 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). This usually occurs due to compression of the tendon on the heel, in this injury there can sometimes be involvement of a bursa called the retro-calc bursa.
Mid-portion achilles tendinopathy usually presents with pain 2-7cm above the heel bone in the thick portion of the tendon. This type is the most common and usually occurs from a sudden increase in load over what the tendon has adapted to, this can include an increase in frequency, duration or intensity of activity. This is important to recognize as the treatment of both slightly differ.
Symptoms
- 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
Stages of Achilles Tendinopathy
It is important for the clinician to understand which stage of pathology your tendon is in as this will guide treatment. This is gained at the beginning of the consult with a thorough history and also during the assessment.
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 tendon collagen matrix becomes disorganised with vessels and nerves. This is often seen in chronically overloaded tendons.
Degenerative tendinopathy – in this stage large areas of collagen are disordered and filled with vascular and nerve cells, the collagen fibers are disorganized. 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.
This diagram shows neatly how tendons either adapt to load and remain healthy or move down the continuum if excessive load exceeds what the tendon can tolerate.
NB – tendons love exercise within its capabilities. There tolerance to an increase in exercise needs to be gradually increased to allow the tendon to adapt.
Risk factors of Achilles Tendinopathy
External 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, for example return from holidays, injury, sedentary lifestyle.
- Sudden change in terrain, for example running on soft surfaces, sand running, 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 people have a low heel to toe difference can aggravate some tendons.
Internal factors
- Previous history of Lower limb Tendinopathy.
- Recent Injuries that affect strength, mobility and function of the lower limb.
- Increase in Age
- Reduced Muscle Strength and endurance of the posterior leg muscles particularly the gastrocs and soleus.
- Reduced ankle flexibility.
- Poor foot mechanics.
Managing Achilles tendinopathy
- Reduce or cease offending activity.
- Increase recovery days between activity.
- Therapeutic exercise – depending on severity and stage.
- Address identified 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 are currently suffering foot and ankle pain or have any enquiries regarding Achilles tendinopathy or 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.