Achilles Tendinopathy, Is this you?

The winter running season is already with us and with it an influx of familiar injuries to the clinic. Today I’m just going to outline the basics of Achilles tendinopathy, some of the reasons why athletes suffer from problems in that area and what can be done about it? There is an extensive backing of boooring physiology which I’ll try not to inflict upon you and keep it simple.

What is the Achilles Tendon?

Simply the Achilles tendon is the large strong tendon which connects the muscles in the back of the lower leg to the heel bone. It is the most powerful tendon in the body and is placed under extreme stress during exercises such as running and so is a commonly injured part of an athletes’ body.

What is Achilles Tendinopathy?

Achilles tendinopathy predominately refers to an overuse injury of the Achilles tendon occurring in one of two areas.

1)      Mid-substance: The midportion of the Achilles tendon (2 – 6cm from the calcaneus or heel bone )

2)      Insertional: The insertion on the calcaneus

The mid portion of the Achilles tendon appears to be the most common site of injury with approx. 66% of injuries occurring at this location (Paavola et al, 2002). The incidence of Achilles tendinopathy is higher in elite than recreational runners, with the Achilles tendon being one of the most prone to injury. It can account for up to 18% of running related with 4% reporting to sports injury clinics (Magnusson et al, 2009).

Confusing terms???

Maffulli et al 1998, attempted to define some of the confusing terminology surrounding injuries to the Achilles tendon.

1)      Tendinopathy: refers to a diagnosis based on pain, swelling and impaired performance

2)      Tendinosis: refers to a condition where degeneration has been confirmed

3)      Tendinitis: refers to the condition where inflammation and damage are present

Considering the two sites of injury, evidence suggests that they may need to be approached differently (Fahlstrom et al 2003). For the purpose of this article we are going to look at the more commonly injured site of the mid-portion (between 2-6cm from heel bone) of the Achilles.

What is happening?

Mid-substance changes typically present with more intra-tendinous tearing, however, it is generally accepted than Achilles Pain is more neurogenic in nature. Studies show that the pathology is predominately of tendon degeneration due to a failed healing response rather than the previous historically hypothesed inflammation or tendinitis (Del Buono et al, 2011). Put simply this process occurs when the Achilles tendon does not heal adequately before repeated trauma occurs, leading to degeneration of the tendon and a vicious cycle of activity and degeneration.

This tendinosis may result in advanced underlying pathology prior to symptoms manifesting.  This has implications for treatment design and recovery prognosis and may partly suggest as to why some athletes can develop recalcitrant Achilles tendon and may progress to full rupture. Rupture is commonly seen after end stage paratenonitis (Kanus and Jonza, 1991).

What causes my tendon to degenerate?

Repetitive tensile overload of the Achilles tendon remains the prevailing cause of injury at the mid-substance of the tendon (Murrell G.A. 2002). There are many predisposing factors which can contribute to the development of Achilles tendinopathy. The following list contains many but is not exhaustive:

-          Training errors

-          Using faulty equipment

-          Sudden increase in training load

-          Excessive uphill running/stair climbing

-          Change in surface/hard surface/unsuitable surface

-          Inappropriate footwear

-          Increased age

-          Physical deconditioning

-          Reduced flexibility of the Achilles tendon, gastrocnemius and soleus

-          Poor foot biomechanics

(Mafulli et al, 2004)

Additionally co-morbidities may contribute to the etiology, co-morbidities such as obesity, diabetes, high blood pressure, high cholesterol levels, systemic inflammatory disease (Carcia et al, 2010).

Signs and Symptoms?

Symptoms can be wide-ranging and varied but there are also a host of common symptoms associated with the condition.

-          Symptoms that develop gradually increasing in intensity

-          Burning pain experienced in the tendon during or following activity

-          Increase in tendon warmth/colour and or swelling

-          Stiffness after period of inactivity and or pain upon taking initial steps e.g. prolonged sitting/sleep

As symptoms progress there may be:

-          Pain on applying pressure to the tendon

-          A nodule formation on the tendon apparent when applying pressure with hands

-          Pain at rest

-          Tendon thickening

-          Pain when moving ankle through range

(Simpson, Howard, 2009)

What to do?

Presenting to your Chartered Physiotherapist will ensure that the best course of action is taken. There are other reasons similar symptoms may exist around the location of the Achilles tendon, including:

-          Retrocalcaneal bursitis

-          Achilles bursitis

-          Referred Pain

-          Complete/Partial rupture

-          Insertional Achilles tendinopathy

-          Posterior ankle impingement

-          Achilles tendon ossification

-          Systemic inflammatory disease

(Papa J, 2012)                                           

MRI showing ruptured Achilles Tendon

X-ray, MRI and/or doppler ultrasound may be useful in ruling out other pathologies and confirming the extent of damage, as previously mentioned, the treatment for insertional and non-insertional Achilles tendinopathy differs and a Chartered Physiotherapist is the most appropriate health professional to guide treatment safely and effectively.

Treatment

There are a host of treatment options available. Through detailed history taking, thorough physical assessment, gait analysis and use of diagnostic imaging the best course of action can be confidently arrived at.

Below some of the treatment options are briefly discussed:

-          Ice: applied 2-3 times per day for 20mins per session to decrease pain levels

-          Pain relief/Anti-inflammatory: may help where inflammation exists and will have an effect on decreasing pain

o   Currently anti-inflammatory prescription for achilles tendinopathy is controversial as it may have an adverse effect on the healing process and can lead to peptic ulcers and bleeding.

-          Heel lifts in footwear: directed by the Physiotherapist and specific to the patient it may help to de-stress the tendon

-          Manual techniques (deep tissue massage, trigger point therapy) applied to the muscles of the lower leg

-          Stretching program: to decrease pain and improve function. Traditional stretches for the gastrocnemius and soleus muscles do not work as effectively in the population with altered foot biomenchanics. Stretches specific to the individual need to be designed to get maximum benefit from the stretching program

-          Strength exercises: The effects of eccentric training of the calf are well researched and considerable evidence exists to suggest that it should form part of the early rehabilitation process where possible.

-          Steroid Injections: May be indicated in specific cases where good management is put in place. Controversial however as use of steroids around the Achilles tendon may lead to rupture

-          Platelet Injections: Injection of platelet rich plasma into the achilles tendon which releases growth factors into the tendon has been shown to improve associated symptoms in studies

-          Surgery/Plaster cast: where full rupture is suspected surgery may be the remaining option available. Additionally, surgery can be indicated in cases where there is substantial tendon calcification or where conservative approaches have failed.

Early weight bearing and movement within an orthotic is a new treatment technique which has gathered momentum through recent research for Achilles tendon rupture also.

-          Custom Insoles: Is a pillar of the multi-factorial treatment intervention where altered biomechanics exist. They work to minimize abnormal foot position during walking/running and reduce abusive forces from damaging the tendon.

(Sussmilch-Leitch, 2012)

Summary:

Achilles tendinopathy can be a complex condition with the need for specialist intervention. Due to the increased stresses being placed on the tendon during running, combined with training schedules athletes are at greater risk of developing Achilles tendinopathy (Padhiar, 2010).

Poor blood supply which increases healing time can lead to extensive scar tissue development. This combined with poor management of acute Achilles tendinopathy will often see progression to a more serious and challenging chronic tendinopathy (Baravarian, 2011).

An extensive differential diagnosis list exists in relation to Achilles Tendinopathy and a visit to Chartered Physiotherapist is advised to receive both an accurate diagnosis and effective and safe treatment.

Rehabilitation may be required ranging in time from a couple of months to a year depending on the severity and site of injury. The treatment modalities available are wide ranging and include pharmacotherapy, physiotherapy, medical and surgical aspects. Physiotherapy interventions which benefit Achilles tendinopathy include hydrotherapy, electrotherapy, strength and conditioning, flexibility training, manual soft tissue techniques, ankle mobilisations, acupuncture, dry needling, thermotherapy, bracing and splinting (Sussmilch, Leitch, 2012). With custom orthotics often prescribed for positive outcomes also (Najjarine, 2009).  

If the conservative treatment fails then more invasive surgical options may need to be explored. Your Chartered Physiotherapist can help you make an informed decision and take the best course of action, don't risk anything less.

For more information contact:
Physio Central           e: info@physiocentral.ie
Ardan Surgery,           t: 057 9322720
Ardan Rd,
Tullamore,
Co. Offaly