Achilles Tendinopathy
Achilles tendinopathy is a common overuse injury that can happen to athletes in a wide variety of sports and to recreational exercisers and inactive people alike. Runners are most commonly affected, with 30% of all runners experiencing Achilles tendinopathy at some point in their lives. Repetitive stress put on the Achilles tendon can lead to sudden injury resulting in pain, stiffness and swelling down the back of the lower leg. So – what is it, where is it, and can you still run with Achilles tendinopathy?
The Achilles Tendon
A tendon is a band of tough connective tissue that anchors muscle to bone. Tendons work together with your bones, muscles and joints to help you move. The Achilles tendon is the thickest and strongest tendon in your body and runs down the back of the lower leg, attaching the calf muscles (gastrocnemius and soleus) to the heel bone (calcaneus). When your calf muscle flexes, the Achilles tendon pulls on your heel, allowing you to stand on your toes while you walk, run, or jump. This movement is referred to as plantar flexion, as seen in the arrow pointing down in Figure 1. Tendons are made of strong collagen fibers that are very resistant to tearing, however, they are not very flexible and can sometimes be overstretched and injured. They also have fewer blood vessels compared to muscles which commonly slows healing compared to other types of tissue your body
Tendinopathy vs tendonitis – what is the difference?
These two terms are often used interchangeably, however, they are different injuries and therefore require different treatments. Tendonitis is used to refer to inflammation of the tendon. It is generally the result of an acute injury in which the tendon is forced to stretch beyond its normal range of motion, resulting in pain, swelling and inflammation.
Tendinopathy is a term used to describe injuries caused by the deterioration of the tendon (particularly the collagen proteins that form the tendons) and are not associated with inflammation. This type of injury is typically the result of long-term overuse. While initial symptoms between these conditions are similar, it is important to get an accurate diagnosis, as the inflammation of tendonitis is treated differently than the chronic tendon changes associated with tendinopathy. The latter typically requires a longer treatment course as the injury has been slowly developing over a longer period of time.
How does it happen?
Achilles tendinopathy is thought to be caused by the buildup of repeated microtears in the Achilles tendon. If these microtears fail to heal correctly, they cause the tendon to get weaker.
You may be more likely to get Achilles tendinopathy if you participate in a sport that requires repetitive movements or jumping, such as running, dancing or playing tennis. In athletes, common training errors that can increase your risk of Achilles tendinopathy include poor training techniques, exercising in inappropriate footwear, or increasing the frequency or intensity of your training too quickly.
This type of injury can also occur in nonathletes. Additional factors that can increase your risk of Achilles tendinopathy include:
Age: the Achilles tendon becomes less flexible as you age, increasing your risk of developing microtears.
Weight: Being overweight or obese places more strain on the Achilles tendon.
Genetics: A family history can increase risk of tendinopathy.
Certain medical conditions or medications: Achilles injuries are more common in individuals who have high cholesterol levels, hypertension, type II diabetes, or are taking certain types of antibiotics known as quinolones.
Symptoms and diagnosis
The main symptoms of Achilles tendinopathy include localized pain and stiffness around the damaged tendon. The pain can come and go and may be worse first thing in the morning or after exercising. The location of the pain can also inform your diagnosis; mid-portion (or non-insertional) tendinopathy will cause pain in the upper portion of the tendon (closer to the calf), while insertional Achilles tendinopathy affects the lower part of the Achilles where the tendon attaches to the heel bone.
Pain caused by Achilles tendinopathy can make it difficult to do everyday activities such as walking, moving around at work, or participating in your usual athletic programs. If you think you have injured your Achilles tendon, it’s best to reach out to a sports medicine doctor as correct diagnosis is critical to your treatment and recovery. Achilles tendinopathy can usually be diagnosed from your symptoms and through careful examination of the lower leg for swelling, tenderness, limits in normal range of motion, decreased strength and flexibility. Diagnostic ultrasound performed during an office visit can demonstrate chronic changes in the tendon including tears, scar tissue formation and calcifications. An MRI scan may also be recommended to further evaluate the extent of the injury.
A guide to Achilles tendinopathy treatments
If you’ve experienced any kind of foot or ankle pain, there is one question that often comes to mind: “what shoes should I be wearing”? The truth is, there are no best shoes to wear for Achilles tendinopathy!
Studies show that shoes with customized arch support or heel lifts can reduce the amount of load on the Achilles tendon. This may be helpful for preventing the incidence of Achilles tendon injuries or even for treating other conditions of the foot or ankle, however there is conflicting evidence that these approaches are effective treatments for Achilles tendinopathy. In one randomized trial, patients with Achilles tendinopathy reported reduced pain and improved function after wearing a 12 mm in-shoe heel lift for 12 weeks. However, other studies (including a systemic review of 12 different studies) have shown little clinical effect of custom orthotics for reducing symptoms and improving function for people with this type of injury.
The good news is, there are several other non-surgical options you can try that aim to reduce stress on the tendon, promote repair, and minimize the risk for future injury. An initial treatment plan will likely include a combination of:
Rest: In the early stages of treatment, you should avoid any high-impact activities or sports (such as running or jumping). Activity can gradually be increased as your pain subsides. It is important to talk to your sports medicine doctor to come up with a treatment plan that’s right for you, as maintaining some level of exercise is important for your recovery.
Pain-relievers: Over-the-counter medications such as ibuprofen or other non-steroidal anti-inflammatory drugs (NSAIDs[KT1] ) may help reduce the pain around your Achilles tendon. However, it is important to know that these will not actually treat the deterioration of tendinopathy. In contrast, they can treat the inflammation of tendonitis. As such, these medications will only help relieve the pain and should not be used for an extended period of time.
Stretching: Achilles stretches can be done to help lengthen the two muscles (soleus and gastrocnemius) that are connected to your heel bone by the Achilles tendon. This will help reduce tightness and increase flexibility across the tendon.
Strength-training: Incorporating an eccentric exercise program is considered a gold standard in the rehabilitation for tendon injuries. This refers to exercises where you contract while the muscle is lengthening, as opposed to a concentric action, where the muscle shortens while you are contracting. For example, when you rise up on your tiptoes, the calf muscle shortens (concentric), and as you lower back to the ground, the muscle lengthens (eccentric). So why are eccentric exercises effective for Achilles tendinopathy? An eccentric exercise program allows you to gradually increase the stress you put on the tendon over time. It is thought that this type of exercise may help in part by increasing the production of type I collagen – a type of protein that serves as a building block for tendons. This should be a slow and controlled movement, and while you may experience moderate pain, this should not be disabling and the pain and swelling should go away over time. An eccentric exercise program can take between 3 and 6 months to significantly improve your symptoms, and many people are able to return gradually to their normal activities by around 3 months. See below for one of the best exercises for Achilles tendinopathy.
Extracorporeal shockwave therapy (ESWT): This is a specialized noninvasive treatment that can be used for people who do not respond to the conservative measures above. During ESWT, repetitive shockwave impulses are applied to stimulate the healing process in the damaged tendon tissue. One study showed that shockwave therapy was as effective as an eccentric loading program for the management of Achilles tendinopathy.
Additional treatments including platelet rich plasma injection and the Tenjet or Tenex procedure also have utility in the treatment of Achilles tendinopathy. They are typically employed once other conservative treatments have been tried and failed. These treatments can be further discussed with your sports medicine physician to see if they may be right for you.
There are a variety of other approaches that can be used to treat patients who fail to respond to initial treatment options. Read more about medical management of Achilles tendinopathy here.
Unlike tendonitis, which usually goes away after a couple of days of rest, recovery from Achilles tendinopathy is slow. However, in most people, symptoms usually subside within 3-6 months of starting treatment. Your sports medicine doctor will be able to determine the severity of the injury and develop an appropriate rehabilitation program in order to get you on the path to recovery as soon as possible.
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