Achilles tendinopathy

--Tell me more about Achilles tendinopathy

In the early stages, Achilles tendinopathy is caused by increased numbers of cells in the tendon that try and account for the excessive load. This cellular reaction causes pain when the tendon is loaded (but not at rest). In chronic cases, the cellular reaction may lead to structural disorganisation of fibres of a small part of the tendon.

Though commonly thought to be due to inflammation (and previously widely known as ‘tendinitis’), research evidence does not support inflammatory cells as a cause of tendinopathy.

Achilles tendinopathy is seen either at the insertion (right where it attaches on to the heel), or at the mid-portion (in-between the muscles and the heel bone). It is important to distinguish between the two as they have slightly different treatment methods.

--What causes Achilles tendinopathy?

Achilles tendinopathy is caused by an acute change in load or activity. This change may be due to a sudden increase in training loads in athletes or beginning an exercise program for sedentary individuals. Compression of the tendon is also an important factor in the development of pain. The Achilles insertion is compressed in positions where the foot is bent up (dorsiflexion). These positions combined with high energy storage tendon loads (running and jumping) may lead to the development of symptoms. A variety of other factors are proposed to contribute to this condition:

• obesity (causes systemic changes in circulating cytokines that increase the risk of tendinopathy)
• type 2 diabetes
• fluoroquinolone antibiotics and statin medications
• genetic factors
• poor function of the lower limb muscles.

The following, however, are not linked with the development of Achilles tendinopathy:

• poor flexibility
• foot pronation (flat foot)
• age (though tendinopathy is more common in older adults, it is a result of lifetime exposure to load).

--How do I know if I have Achilles tendinopathy?

Achilles tendinopathy causes very localised pain where the Achilles attaches to the heel in insertional cases, or between the heel bone and muscle in mid-portion cases.

Importantly, this pain is specific, and does not cover a large area. If pain covers an area larger than a coin, or is vague in nature, alternate diagnoses should be considered. Achilles tendinopathy causes pain with loading activities—running, jumping or sport. Classically, it affects both young and older distance runners. It is characterised by stiffness and pain first thing in the morning. It does not usually cause pain at rest but can be sore when walking after sitting for a period. Often the tendon may appear thicker; however, this is a sign of your body trying to adapt and overcome the problem by creating more tendon tissue.

Your physiotherapist will be able to diagnose Achilles tendinopathy. They will need to carefully ask about your history and any changes to your activity and loading. They will perform tests, such as a single leg calf raise or hop, to assess your tendon’s response to load. It is also important to look at the strength of your leg as a whole. Importantly, a number of other conditions cause pain in a similar area to this condition, and careful assessment will be necessary to differentiate these based on the behaviour of your symptoms.

It is not necessary to have scans ordered for this condition, and there is a poor link between findings on ultrasound imaging and pain. Scanning should only be contemplated when considering alternate diagnoses.

--How can physiotherapy help with Achilles tendinopathy?

It will be important for your physiotherapist to construct a treatment plan tailored to your individual findings. In the early stages, treatment will focus on reducing your pain. It will be important to modify and temporarily reduce any high load activities (such as running or jumping). Positions where the tendon is compressed (foot bent up) should be avoided, such as stretching. Holding without movement (isometric) exercises are effective at reducing pain in this condition, and should be considered.

Once your pain is more settled, it's important to begin heavy and slow strengthening of the entire leg, depending on identified deficits. Gym equipment or weights may be required for best outcomes, and exercises need to be challenging.

As you become stronger and your pain remains settled, higher load activities will be slowly introduced. Finally, after your physiotherapist is happy that your tendon capacity is sufficient, you will be gradually eased back into whatever sport or activity you were performing.

It is very important that exercise loading forms the basis for all treatment of Achilles tendinopathy, as complete rest will often only make things worse. Massage of the calf, ice and other treatments are adjunct treatments, and alone will not be effective. There are no ‘quick-fixes’ for Achilles tendinopathy and the following treatments are not supported:

• injections (no evidence exists for cortisone, platelet rich plasma (PRP), blood injections or stem cells)
• ultrasound, laser or electrotherapy
• stretching (these put the tendon into compressive positions).

--How effective is physiotherapy for Achilles tendinopathy?

Exercise should form the main element of all treatment for Achilles tendinopathy, and is recommended as a first line treatment in published research. Previously, eccentric exercises (contracting muscles while lengthening them) were thought to be better; however, new research has shown that as long as exercises are heavy enough, both eccentric and concentric (contracting muscles while shortening them) exercises are effective treatments for Achilles tendinopathy. Doing eccentric only exercises may be painful for some people too. Isometric exercises (holding exercises) have also been shown to be effective at reducing pain as well as improving altered control of muscles from the brain that results from pain.

--What can I do at home?

As mentioned above, exercise loading forms the cornerstone of rehabilitation of Achilles tendinopathy. You will need to complete a number of exercises at home and in the gym to improve your strength and capacity. Your physiotherapist will advise you on what exercises to complete based on your individual findings, and how often to do so.

A way to monitor your progress is to follow how your symptoms are first thing in the morning. If they are the same or better than the previous day, then what you did the day before was appropriate. If your stiffness and pain is worse the next day, then the activity you have done the day before overloaded the tendon.

--How long until I feel better?

Achilles tendinopathy requires lengthy rehabilitation, and depends on the level of your pain and dysfunction and what activity you want to return to. Exercise loading needs to be heavy and challenging for you, and be done for an extended period. At minimum, 3–6 months of strengthening will be required to get back to your activity, and in more complex cases it is often longer than this.