Achilles Tendinopathy
What Is Achilles Tendinopathy?
The Achilles Tendon is the rope-like structure found behind the ankle. It is made of thick
bundles of collagen, the second toughest
material in your body after bone. The Achilles connects your calf muscle to your
heel with fibres inserting broadly across both
sides and from the top to the bottom of the heel bone. The achilles transmits the forces generated by your calf into your foot to allow you to stand on tip toes, walk, jump, hop and run.
Historically Achilles tendinopathy was thought to be caused by inflammation of the tendon.
A more recent understanding is that the pain in your achilles is caused by excessive load passing through the tendon which results in physical changes being made to the tendon structure. Tendons cope very well with tensile force but do not cope well with torsion or
compression. The same achilles that can support your body weight to walk or even hop with
only low grade pain ( a load much greater than your body weight) might feel significant pain with even a low grade squeeze from your fingertips. We will return to this concept later……... The management of tendon injuries can be quite complicated but the simplest way to explain it is to say that tendon injuries are all about load management. Overload a tendon and you will have problems, underloading a tendon can also bring its own set of problems. In order to master your achilles tendon rehabilitation you need to become a “Load Master”.
3 Stages of Achilles Tendinopathy
Reactive Tendinopathy
This stage is usually triggered by a sudden and large increase in loading. For runners this often relates to an increase in distance, how often you’re running or a change in the type of training (such as introducing increased speed or hills). An increase
in explosive loading such as sprinting, jumping, leaping and bounding which is common in many sports is particularly
provocative.
In this reactive stage the cells react to the increased tendon loading and release chemicals that cause pain. Treatment during this stage aims to calm the active cells down. It should be the easiest stage of tendon injury to treat but it relies on you recognising the warning signs, responding to the pain and offloading the tendon. This phase of injury is usually a short term adaptive change to the overload and is readily reversible.
Tendon Dysrepair
This stage generally follows the Reactive stage if the Achilles tendon continues to be excessively loaded. In overall presentation this phase of injury is similar to the previous phase however over a greater time period the structure of the Achilles tendon starts to break down. Think of it like the fibres of a rope starting to fray from too much stress and strain being placed on the rope. The greater the breakdown the greater the challenge of recovery.
Degenerative Tendinopathy
This is the final stage of Achilles tendinopathy. It tends to be more common in the older
athlete. This phase of injury is generally in response to your Achilles being chronically
overloaded. By this stage of Achilles tendinopathy there are numerous changes that have occurred in the tendon which result in its physical structure being broken down and making the tendon less effective at dealing with load. In this stage the tendon often feels thickened as well as lumpy in certain areas.
Although the above stages have been described as separate phases of Achilles injury, our current understanding of Achilles tendinopathy is that it presents as a continuum (a sliding scale of injury). This means that Achilles tendinopathy has the ability to present at a certain phase but can shift between the above phases as the injury improves or worsens.
Signs and Symptoms
Although the symptoms of Achilles tendinopathy will differ from person to person and which stage of injury they are in, there are some symptoms frequently reported by patients. - a burning pain through the Achilles tendon early in exercise which becomes less severe during exercise (as you have warmed up) but then worsens after the exercise (once you have cooled down).
- Achilles pain and/or stiffness potentially being worse first thing in the morning.
- tenderness in the Achilles tendon and/or a thicker and stiffer feel to the Achilles tendon.
How Does It Happen?
As outlined earlier, Achilles tendinopathy occurs as a result of overloading the Achilles tendon due to excessive training either in a short time frame
(acute) or over a longer time frame (chronic).
Your achilles is especially susceptible to explosive loading - jumping, leaping, running more than repetitive but low load like walking, cycling, kicking while swimming etc. These explosive tasks may put as much as 8 times your body weight through the tendon (more reasons not to gain weight).
Your achilles is also especially susceptible to loading that causes compression. When your ankle bends a long way forward the line of pull thru the tendon changes. The deep fibres of your tendon that attach near the bottom of your heel are compressed against the top edge of your heel especially if you have a Haglund’s deformity.
Factors that may contribute to overloading the Achilles Tendon include
- Reduced muscle strength and flexibility- Exercising in bare feet, shoes with minimal drop or appropriate shoes that have worn-out - Running up or down hills, on hard surfaces and on cambered or uneven terrain
- stretching and/or lowering your heel off a step during strengthening exercises can be highly provocative. Avoiding stretching may contradict what you have been told in the past but more recent understanding of tendon injuries is that during the Reactive stage tendons do not respond well to stretching. As the tendon begins to settle from this acute stage stretching exercises may be gradually introduced and progressed based on your response to treatment.
What Can Physiotherapy do for me?
Your physiotherapist can combine palpation and your history of the onset and behaviour of the injury to accurately diagnose the source of your symptoms so that you are sure that your Achilles is responsible. Symptoms that are felt quite low on the tendon near it’s insertion on the bone or in front of your tendon may be from a bursa in the area or may be coming from the back of your joint and will need different management than if the middle of the tendon is responsible for your symptoms.
Once you are confident that it is your achilles causing your symptoms your physiotherapist can help you work out what stage of tendinopathy you are in. Best management of an Achilles tendinopathy depends on correctly identifying which stage of tendinopathy you are in.
Achilles Tendinopathy injuries are either treated as: ● Reactive / Early Dysrepair
● Degenerative / Late Dysrepair
Managing Achilles Tendinopathy in the Reactive / Early Dysrepair phase:
The key focus for treating tendinopathy in the Reactive / Early Dysrepair phase is load management. Load management isn’t as simple as just resting the injured tendon (such as when using crutches) as this can sometimes result in a loss of strength and make return to activity difficult.
Load management is exactly as stated, managing the amount of load placed through the tendon so that there is enough load to stimulate strengthening and healing but not too much load that may potentially aggravate the tendon. Finding this balance of load is often difficult because everyone performs a variety of activities across their day which can make it difficult to isolate the most provocative activity. Furthermore tendons don’t always feel sore during activity. In some instances, tendons may pull up sore a couple of hours up to a couple of days following activity.
If you ignore a reactive tendon with minimal dysrepair for long enough it will progress to become a tendon with increasing dysrepair requiring increasing time away from your
favourite sport and an increasing challenge to recover. Don’t mess around with tendon pain, see your physiotherapist and get working on your rehabilitation sooner rather than later!
Managing Achilles Tendinopathy in the Degenerative / Late Dysrepair Phase
In order to try and stimulate healthier collagen load is an important part of managing the degenerative stage of tendinopathy.
Your body responds to increased load by strengthening the tissue involved so that it can cope better with the loading. A good example might be found looking at athletes that use one body part or one side of their body significantly more than the other. Take Roger Federer, even from a distance you can see that his right arm is significantly thicker and stronger than his left and this is true of the tendons within his right arm as well. In cases of degenerative tendinopathy we try to use your body’s natural response to our advantage. Degenerative tendons don’t cope with rapid development of force but slow speed, high force loading can be effective in settling the irritability of the tendon, stimulating the collagen within the tendon and doing what you can to help it cope with loading. Your
physiotherapist is an expert in exercise prescription and can design a strengthening program for you that will avoid aggravating your achilles and will help to improve your function.
Treatment is all about very small systematic changes to load - you need to find the
appropriate load for the stage of tendinopathy and you wait for the tendon to tell you it is OK. A good strength / endurance program underpins the management of all tendinopathy
