What is Achilles tendinopathy?
Achilles tendinopathy is an overuse injury, characterised by localised pain to the back of the heel where the tendon inserts on to the bone or tendon pain 2-6cm above the heel insertion, which is associated with activity. Cumulative microtrauma to the tendon can occur over time, from repetitive overloading of the tendon through activity, leading to degeneration of this tendon’s structure. There may be an associated inflammatory response, whereby it would be referred to as Achilles Tendonitis.
Signs and symptoms
Signs and symptoms will vary for each individual, so a Physiohealth physiotherapist will be able to provide an accurate diagnosis for you. The clinical presentation may include the following:
- History of activity-related heel/achilles pain lasting four weeks or more;
- Nagging ache and stiffness which is often worse during the first few steps after inactivity;
- Tenderness and thickening of the Achilles tendon just above the bony insertion;
- Reduced walking tolerance and capacity for running and jumping;
- Limited flexibility and increased pain on stretching calf, running uphill or descending steps;
- Once your calf muscle becomes warm, pain and stiffness subsides (Dressendorfer, Lombara & Richman, 2012).
Who is at risk of Achilles tendinopathy?
Achilles tendinopathy can be prominent amongst the young active population, particularly those involved in running and jumping sports, with a lifetime incidence of 24% in competitive athletes, many of whom are below the age of 45 (Kujala, Sarna & Kaprio, 2005). However the epidemiology ranges right through to sedentary older adults who may experience symptoms from walking.
Risk factors
There are numerous factors which place individuals at greater risk of developing Achilles tendinopathy, these can be categorised in to intrinsic and extrinsic risk factors:
1 – Intrinsic risk factors
- Calf muscle dysfunction;
- Stiff ankle joint capsule;
- Valgus/Varus deformity of the Achilles;
- Pes cavus foot;
- Lateral ankle instability;
- Excessive pronation;
- Poor propriocepion;
- Gender (F>M);
- BMI.
2 – Extrinsic risk factors
- Sharp increase in training load (intensity, frequency or volume), particularly with sprints or hills;
- Poor running technique;
- Inappropriate footwear;
- Training surfaces (Maffulli, Sharma & Luscombe, 2004).
Treatment
As Achilles tendinopathy is a multifactorial condition, it is important to seek the support of a Physiohealth physiotherapist to guide you through a step by step rehabilitation program tailored to your individual needs. The rehabilitation will address three key components:
1 – Improving the energy absorbing capacity of the musculotendinous unit
An important property of tendons is viscoelasticity. This means that a tendon has the ability to absorb energy whilst being stretched and return energy in to the system during shortening, much like the recoil of spring. This is particularly important for the Achilles tendon given its major role in explosive activities such as running and jumping. In pathology, the tendon make-up is altered making it less stiff, which in turn reduces its ability to absorb and release energy during this stretch-shortening cycle. Thus a key to rehabilitation is improving the tendon’s stiffness, however this element of rehabilitation may not be achievable in the older population.
In addition, improving the power output of the calf muscles, further improves the energy absorbing capacity of the musculotendinous unit.
Methods that may be employed to achieve this, may vary dependent on the unique requirements of the individual and the stage of rehabilitation, but may include:
- Isometric strength training;
- Concentric-eccentric strength training;
- Eccentric strength training;
- Plyometric training (Malliaras, Barton, Reeves & Langberg, 2013).
2 – Improve all else with and surrounding the musculotendinous unit
This may require methods to address inflammation, bursitis, improved healing response as well as any of the intrinsic risk factors listed above. Physiotherapy modalities that be utilised may include:
- Education;
- RICE – Rest, Ice, Compression, Elevation;
- Use of crutches and/or a heel wedge;
- Soft-tissue massage;
- Dry-needling;
- Trigger Point therapy;
- Tendon friction;
- Electrotherapy (e.g. ultrasound);
- Stretches;
- Joint mobilisation;
- Heat treatment;
- Core stability and balance exercises;
- Muscular endurance exercises;
- Hydrotherapy;
- A graded return to activity/running program;
- Weight loss advice.
3 – Alter functional patterns
A biomechanical analysis will also allow your Physiohealth physiotherapist to address problematic functional patterns, by way of:
- Correct running/jumping technique;
- Orthotics to correct foot mechanics;
- Advice for appropriate footwear.
Prevention
As with all conditions, prevention is always better than a cure. Therefore steps that you can take to prevent the onset or recurrence of Achilles tendinopathy include:
- Visit a Physiohealth physiotherapist for an athlete screening;
- Wear activity appropriate professionally fitted footwear;
- Complete appropriate warm up prior to exercise;
- Perform cool down following exercise including light stretches;
- Progress exercise program gradually;
- Follow weight management strategies.
References
Dressendorfer, R., Lombara, A. & Richman, S. (2012). Achilles Tendinopathy. CINAHL Information Systems: Glendale, USA.
Kujala, U.M., Sarna, S. & Kaprio, J. (2005). Cumulative incidence of achilles tendon rupture and tendinopathy in male former elite athletes. Clinical Journal of Sports Medicine, 15(3), 133-135.
Maffulli, N., Sharma, P. & Luscombe, K.L. (2004). Achilles tendinopathy: aetiology and management. Journal of the Royal Society of Medicine 97(10), 472-476.
Malliaras, P., Barton, C.J., Reeves, N.D. & Langberg, H. (2013). Achilles and Patellar Tendinopathy Loading Programmes: A Systematic Review Comparing Clinical Outcomes and Identifying Potential Mechanisms for Effectiveness. Sports Medicine, 43(4), 267-286.
