Achilles Tendinopathy in Depth
AKA: Achilles Tendonitis

Common Signs & Symptoms
Pain	Swelling	Stiffness	Weakness	Instability	Locking

Injury in Brief

Injury in Depth

Rehabilitation

Achilles Tendinopathy Explained

Anatomy of achilles tendon Achilles Tendinopathy is commonly known as Achilles Tendonitis, although AchillesTendinopathy is the more correct medical term. Achilles Tendinopathy is a common source of Achilles pain that can also produce lower Calf pain or heel pain. It is common running injury that is most frequently due to overuse.

The Achilles tendon, as referred to in Greek mythology, is situated above the Heel and forms the lower part of the Calf muscles. It is a continuation of the Gastrocnemius and Soleus muscles of the Calf and attaches to the heel bone. It is the strongest tendon in the human body and its function is to transmit the force of these muscles to produce the push-off during walking and running.

Achilles Tendinopathy is usually characterised by degeneration (Tendonosis) of the tendon – this can be seen when people have Achilles Tendon surgery. Achilles Tendonosis is a breakdown in the Achilles Tendon, with small, focal lesions within the tendon without an inflammatory response. The degeneration means that the tendon does not possess its normal tensile strength and may be liable to rupture with continued sporting activity.

Until a tissue sample is taken at surgery to determine whether there is Achilles degeneration (Tendonosis) or Achilles inflammation (Tendonitis), this condition is referred to as a 'Tendinopathy'. Achilles Tendinopathy can be associated with ageing. As we get older our ability to regenerate damaged tissue decreases and the quality of the tendon deteriorates.

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Achilles Tendinopathy Signs & Symptoms

Achilles Tendinopathy usually comes on gradually, and is more common in those aged over 40. There is Achilles pain, which is worsened by activity, and the focal areas of degeneration often feel tender to touch. Often the Achilles Tendon feels very stiff first thing in the morning. The affected tendon may appear thickened in comparison to the unaffected side.

Crucially, the differentiating feature of Achilles Tendinopathy compared to Achilles Paratendinopathy is that the painful area moves slightly when the ankle is moved up and down. This is because the Achilles Tendon moves during ankle movement, but the Achilles Paratendon doesn't move.

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Achilles Tendinopathy Treatment

What you can do

	Consult a sports injury expert
	Apply ice packs/cold therapy
	Wear an Achilles strap to relieve symptoms
	Wear an Aircast AirHeel to relieve heel pain
	Use a buoyancy aid for pool exercises

Because Achilles Tendinopathy is rarely an inflammatory condition, the use of anti-inflammatory medication (NSAIDs) is not appropriate. The action of the NSAIDs can actually be counter-productive, as these drugs inhibit the action of naturally occurring chemicals that mediate a healing response, thus dulling the body's ability to regenerate the damaged tissue.

Ice therapy is a very effective form of pain relief (never apply ice directly to the skin). The PRICE protocol - protection, rest, ice, compression and elevation can relieve the symptoms of a painful, swollen Achilles Tendon. Ice Packs for a period of twenty minutes every couple of hours may help with the swelling and pain, but pain-relieving medication may also be necessary.

The Aircast AirHeel can provide instant relief of symptoms if the pain is felt at the Heel bone, at the point where the Achilles Tendon inserts. In more mild cases of Achilles Tendon discomfort an Achilles Strap can relieve the symptoms and allow continued activity, although Achilles Tendinopathy requires medical treatment if it is to be totally alleviated without the risk of a tendon rupture.

The key to fully recovering from Achilles Tendinopathy is in trying to elicit healing by gradually overloading the tendon. This can require rest from high impact activities for up to three months. This is because the Collagen tissue, which the body produces to repair damaged Achilles Tendon tissue, takes three months to lay down and mature. Non impact training, such as pool running with a buoyancy belt, can maintain fitness during this period.

During this time, the healing process may be assisted by treatments that increase the temperature of the tendon, increasing the metabolic activity and thus the healing process in the tendon. As the tendon is healing, a Chartered Physiotherapist may gently mobilise the soft tissue by providing gentle stress, to help the tendon to adapt and gain tensile strength.

Published research has suggested that recovery is optimised by using a very gradually progressed strengthening programme for the Achilles tendon and Calf muscles. This strengthening programme uses what is called 'eccentric muscle work'. Eccentric muscle work refers to a muscle that is lengthening while contracting. Maximum tension is generated in the muscle and tendon during the eccentric contraction. Gradually increasing the load by increasing the number of sets and reps of eccentric Calf contractions causes the Achilles Tendon to adapt and get stronger.

A physiotherapist will also look at underlying body alignment to see if there is a biomechanical cause of Achilles Tendinopathy. An 'over pronated' foot position (tendency to flat feet) can place excessive strain on the Achilles and lead to Achilles Tendinopathy. In this case it is often very beneficial to have a full biomechanical assessment. If flat feet are present it is usually effective to insert an Orthotic (shoe insert) which will help to correct the problem. If the ankle or joints of the foot are stiff, the physiotherapist can mobilise them to restore the normal range of movement. These measures have the effect of removing the excessive load from the tendon and normalising the biomechanics of the lower leg.

In persistent cases of Achilles Tendinopathy, an injection of Aprotinin around the tendon may help to prevent further tendon degeneration. Aprotinin is a protein that inhibits the enzyme 'metalloprotease', which breaks down the protein that makes up tendon tissue. This drug is useful as it has been shown that in tendinopathies there is an imbalance between different types of metalloprotease, and Aprotinin addresses this imbalance. Also, Aprotinin does not have the serious side effects of corticosteroids, and, if necessary, can be injected several times.

Another approach, which is currently being pioneered in Scandinavia, is based on the theory that new blood vessels growing into the diseased tendon are the source of pain. The treatment, which has shown very promising results from the initial studies, is to inject a 'Sclerosant' drug into these blood vessels under the control of an ultrasound scanner which shows the blood vessels. Sclerosant drugs destroy the new blood vessels and hence the proposed source of pain. However, if there is tendon degeneration there may still be a mechanical weakness in the tendon, so there is a lot of research yet to be done on this approach.

In severe cases of Achilles Tendinopathy, which have failed to respond to six months of supervised rehabilitation with a physiotherapist, then surgery should be considered. However, this is very much a last resort because the success of surgery, even with the best surgeons, is not 100%.

Surgery involves removing degenerate tendon tissue and trying to restore a tendon to a good level of tensile strength. This means that, following surgery, the tendon still doesn't have its normal strength and careful rehabilitation is essential. The eccentric program under the supervision of a chartered physiotherapist is indicated. As mentioned earlier, the slow rate of collagen tissue production means that it takes three months to produce new healthy tendon tissue and at least six months before a return to sporting activities can be resumed.

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Achilles Tendinopathy Prevention

What you can do

	Maintain a running log to avoid training errors
	Wear shock absorbing insoles to reduce stress on the Achilles Tendon

Training errors should be avoided. The intensity, duration and frequency of training should be carefully monitored and gradually progressed. Sudden increases should be avoided, as abrupt increases in training load are the number one cause of Achilles Tendinopathy. Maintaining a Running Log is an effective way to avoid training errors.

Imbalance of strength and flexibility can lead to mal-alignment that can put too much stress on the Achilles Tendon. Muscle strength and flexibility should be maintained through regular strengthening and stretching sessions.

The surface should be appropriate to your sport and it is important to wear the correct footwear. A sudden change of training surface - e.g from grass to artificial turf during bad weather may be enough to overload the Achilles Tendon and produce pain. Shock Absorbing Insoles are very effective at reducing the load on the Achilles Tendon, and should be used when training on hard surfaces.

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We'd like to thank Professor Nicola Maffulli for his contribution to this article.
An update on tendinopathies by Professor Nicola Maffulli

Achilles Tendinopathy Injury Rehabilitation

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