Achilles tendon pain is stubborn, but it can be treated!

In this post, I am going to talk about Achilles' tendinopathy. I will summarize the clinical prediction guidelines again so that we can make sure we are creating the most effective treatment plans for our clients, and clients can make sure they are receiving evidence-based treatments.


Continuing with my current running interest, ankle and foot injuries make up between 21-38% of running-related injuries (Arnold & Moody, 2018), and if you are a long-distance runner there is a lifetime risk of 52% for developing Achilles tendinopathy. However, 30% of Achilles tendon patients have a sedentary lifestyle (van Sterkenburg & van Dijk, 2011). Similar to PFPS (read here), Achilles tendinopathy really can present in any individual and it is a common one we will see in the clinic.


What is the Achilles tendon?

The Achilles tendon is the biggest and strongest in the human body, making it suitable for a large amount of force. This is important for our walking, running, and jumping activities. It attaches to both the gastrocnemius and soleus muscles that make up the calf. When these muscles contract, they pull on the Achilles tendon that is attached to the bottom of the heel (calcaneus) and produces the action of plantar flexion (pointing your toe). The blood supply throughout the tendon is very poor, and this is one of the reasons for slow healing and a long recovery process.


When we examine and treat the Achilles, we think about the “mid-portion” and the “insertion” (where it attaches to the heel), as the anatomy and management is different depending on pain location. For the rest of this post, I will be focusing on mid-portion Achilles tendinopathy.


What is Achilles tendinopathy?

First of all, I should mention briefly the terminology. This could get very detailed, so I will keep it simple.


Tendinitis is the common term people will still use to describe tendon issues. However, this did change a long time ago now as we got a better understanding of what is happening in the tendon. Tendinitis describes inflammation, related to acute trauma or overload to the tendon. There will be swelling, redness, and warmth to the area. This is actually very uncommon to the tendon and what we know is that it is usually more of a "tendinosis". This describes a change to the structure and formation of the tendon related to repetitive microtrauma and inadequate recovery time for the tendon. This is a non-inflammatory process.


Tendinosis is a better description of Achilles tendon issues and helps us to understand why it takes multiple months for recovery. It is not an inflammatory problem, but there are structural changes related to repeated stress and strain on the tendon without enough recovery, ie overload.


Tendinopathy is an umbrella term to describe any problem with the tendon, and this is now the term most clinicians will use.


To keep it simple, Achilles tendinopathy is a pain in the tendon, which is due to an overload of force and stress and there hasn’t been enough recovery time. This can happen quickly, or over a long period of time.


Risk factors for Achilles tendinopathy?

There is no way to predict the onset of Achilles pain, but these are common findings and risk factors.


1. reduced ankle range of movement

2. reduced strength of calf muscles

3. increased pronation

4. abnormal tendon structure (long term use of certain medications may be a cause of this)

5. obesity

6. hypertension

7. hyperlipidemia

8. diabetes

9. training error

(Martin et al., 2018)


Symptoms

The most common complaint and the one that usually gets people to go and see a professional is pain in the tendon area. Pain is often at the start of exercise, and then worse again afterward. Commonly the Achilles can feel better during exercise.


Other symptoms include

· Swelling in the mid part of the Achilles

· Thickening of the tendon, or a nodule

· Stiffness (with or without pain) when getting up after a rest period (ie the morning and after sitting for a long time).


Achilles tendinopathy is one of those conditions that a lot of people will self diagnose, and Dr Google is quick to suggest it. However, there are a lot of other reasons to get pain in that area, and it is always important to get a thorough assessment from a professional so that the treatment plan is correct.


Other diagnoses may include


· Calcaneal stress fracture

· Ankle arthritis

· Achilles tendon rupture

· Plantar fasciopathy

· Severs disease

· Posterior ankle impingement

· Bursitis

· Local nerve entrapment

· Sciatica and low back referral

· Deep Vein Thrombosis (DVT)


And I am sure there are many more.


Physiotherapy Treatment


Here is a table summary of the revised clinical prediction guidelines from 2018 (Martin et al., 2018). Remember that the clinical prediction guidelines are a summary of the research, and gives recommendations on management. It is NOT GOLD STANDARD. It would be much easier if it were. Everybody is different and will respond to techniques differently. Clinical prediction guidelines should guide our treatment plans, but if something has low evidence it does not mean it doesn’t work, it just means it shouldn’t be the main technique and should be complemented with other techniques. The best treatment plans are comprehensive; evidence-based, personalized towards the individual, and will often use a combination of strategies.



Changes from 2010.


This 2018 guideline is an update from 2010. Noticeable changes are the addition of neuromuscular exercise and dry needling as recommendations for treatment.


Low-level laser therapy, orthotics, and heel lifts were all recommended in 2010, but research now is contradictory on their benefit and so they can no longer be recommended for treatment of mid-portion Achilles tendinopathy.


What does this mean?

Achilles tendon rehab should have a focus on strengthening and loading of the calf and Achilles, and complete rest is not the best practice. If you are struggling with Achilles tendon pain and you are not strengthening it and you have stopped your activity, then the plan has to change.


The use of tape, dry needling, neuromuscular exercise for lower body mechanics, manual therapy, and stretching can all be used to help in certain individuals.


My treatment of Achilles tendinopathy has always been very heavily focused on strengthening and loading. However, one thing I will start doing differently is using rigid tape over the elastic tape to reduce the strain on the tendon. I do not always use tape on Achilles tendons, but if they are very sore and limited then the tape can be nice to help settle the symptoms down.


Other options

There are other common treatments out there for Achilles tendinopathy that are review in a different section of the guidelines. This is because they are not all in the scope of physiotherapy, or available in all clinics.


Corticosteroid injection- the short-term benefit is not maintained at medium and long term follow-ups.


Shockwave therapy- no benefit when used by itself, good effect when combined with eccentric exercises for chronic cases (longer than 20 months). The optimal dosage is unclear.


PRP injections- not supported for use in mid-portion Achilles tendinopathy based on the return to sport, ultrasound measures and function measures.


In summary…

If you have Achilles tendon pain- go and see a health professional (like a physio) to get a clear diagnosis of your Achilles tendinopathy and design a treatment plan around strengthening and loading of the tendon. Alongside this, there are some other physiotherapy techniques that can help alongside the strengthening program. Be patient, it takes a long time to recover. I will tell clients that 3-6 months is a good time frame for recovery, but depending on a number of factors related to the health of the tendon it can easily be longer than this.


If you do not have Achilles tendon issues- then reduce your risk factors. Lose some weight, strengthen the calf muscles, keep your ankles mobile, and train smart!


Thanks for reading, hope it was useful!


References

Arnold, M.J., & Moody, A.L. (2018). Common Running Injuries: Evaluation and Management. American Family Physician. 97(8), p510-516.

Martin, R.L., Chimenti, R., Cuddeford, T., Houck, J., Matheson, J. W., McDonough, C., Paulseth, S., Wuckich, D.K., Carcia, C.R. (2018). Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018. Journal of Orthopaedic and Sports Physical Therapy. 2018;48(5):A1-A38.

Van Sterkenburg, M.N., van Dijk, C.N. (2011). Mid-portion Achilles tendinopathy: why painful? An evidence-based philosophy. Knee Surg Sports Traumatol Arthrosc. 2011;19(8): 1367-1375.

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