Achilles Tendinopathy: Symptoms, Causes and Treatment
If you have been suffering from Achilles tendinopathy or had the condition for more than 2 weeks, then you can learn more about the symptoms, causes, and potential treatment (including videos) in this article.
What is the Achilles tendon
A tendon attaches a muscle to bone. Your Achilles tendon is the biggest and the strongest tendon in the body. It is found at the back of the lower leg, just above the heel bone. It attaches your two calf muscles (gastrocnemius and soleus) to the heel bone (calcaneus) and helps you go up on to your tiptoes.
What is Achilles tendinopathy?
Achilles tendinopathy is a condition that causes pain, swelling, and stiffness of the Achilles tendon. What causes Achilles tendinopathy is still not completely understood. It is thought to be caused by repeated tiny injuries (known as microtrauma) to the Achilles tendon. After each injury, the tendon does not heal completely, as should normally happen. This means that over time, damage to the Achilles tendon builds up and Achilles tendinopathy can develop.
What causes Achilles tendinopathy?
Training or exercising wearing inappropriate footwear.
Having poor training or exercising techniques - for example, a poor running technique.
Making a change to your training programme - for example, rapidly increasing the intensity of your training and how often you train.
Training or exercising on hard or sloped surfaces.
Overuse of the Achilles tendon. This can be a problem for people who run regularly. (Achilles tendinopathy can also be a problem for dancers and for people who play a lot of tennis or other sports that involve jumping.)
How common is Achilles tendinopathy?
About 6 in 100 inactive people develop Achilles tendinopathy at some point in their lifetime. However, the chance of it developing is higher in athletes or those who train regularly or do a lot of exercise. It can be a particular problem for some runners.
Stages of tendinopathy
Tendinopathy is usually divided into stages. Initially you have a reactive stage. This is usually a response to rapid increase in activity. The tendon may visibly swell and will be painful. In more chronic cases there is often a more degenerate tendinopathy and the tendon’s structure is changed considerably. It may be thickened and develop nodules. If untreated the degeneration of the tendon can reach a level where it really can?t handle any load, as a result it fails and you develop a partial or total Achilles tendon rupture. This is a gradual process and usually a painful one but sometimes it can occur without pain with the first sign of a tendon problem being a sudden unexpected rupture. Working out the stage of the condition is important to determine the best treatment
Symptoms
There might be tightness in the calf and pain on taking weight first thing in the morning.
Athletes usually describe a gradual onset of achilles pain during or after a run. Gradually the pain becomes more frequent and can start to be a problem on a daily basis when not running.
There may be swelling initially or thickening of the tendon. Usually the tendon itself is painful if you squeeze it between 2 and 6 cm from the heel bone.
Activities that load the tendon will increase pain, such as going up or downstairs, walking on tiptoes, squatting, and of course running.
Imaging
We don’t always need to carry out x-rays or scans (imaging) to be able to diagnose Achilles tendinopathy. It can usually be confirmed by your physiotherapist/sports therapist by using examination alone. If imaging is necessary, we are likely to use a diagnostic ultrasound scan. Which uses sound waves to create an image on the screen. Although MRI is available, its use of it is rare.
Treatment of Achilles tendinopathy
Rest at first, you should stop any high-impact activities or sports (such as running). As pain improves, you can restart exercise as your pain allows. It is thought that complete rest if it is prolonged, can actually be worse for the injury.
Painkillers
Painkillers such as paracetamol or ibuprofen may help to relieve pain. Ibuprofen is from a group of medicines called non-steroidal anti-inflammatory drugs (NSAIDs). However, you should not use ibuprofen or other NSAIDs for more than 7-14 days if you have Achilles tendinopathy. This is because they may possibly reduce the ability of the tendon to heal in the long term. They may also cause symptoms of Achilles tendinopathy to be masked, or covered up, which again may delay healing.
Ice packs
Ice treatment may be useful for pain control and may help to reduce swelling in the early stages of Achilles tendinopathy. An ice pack should be applied for 10-30 minutes. Less than 10 minutes has little effect. More than 30 minutes may damage the skin. Make an ice pack by wrapping ice cubes in a plastic bag or towel. (Do not put ice directly next to skin, as it may cause ice burn.)
Orthotics
An orthotics specialist/Podiatrist may suggest changing your footwear or putting special inserts in your shoes, such as inserts to lift your heel. This may help to reduce pain and symptoms. We would suggest having a gait scan as this isolates most of the biomechanical issues arising from your feet and contributing to your Achilles tendinopathy.
Steroid injections
(NOTE) Injection of a steroid medicine is a common treatment for some tendon injuries. However, the use of steroid injections for the treatment of Achilles tendinopathy is controversial and it is not approved in the UK. If steroids are injected directly into the Achilles tendon, there is a risk of damaging the tendon further. There have been cases where they have caused the tendon to tear (rupture). Another option is to inject the steroid around the Achilles tendon. But again, this is not approved in the UK.
Exercise rehabilitation
This may include several different treatment options such as Manual techniques, Specific exercises
What happens if initial treatment fails?
For most people, the symptoms of Achilles tendinopathy usually clear within 3-6 months of starting conservative treatment, as described above. In general, the earlier the problem is recognised and treatment started, the better the outcome. If your symptoms have not improved after 3-6 months, your doctor may suggest that they refer you to a specialist or sports medicine practitioner. However, this timescale may change depending on your symptoms, your sporting activities, etc.
Extracorporeal shock-wave therapy
During this treatment, special sound waves are passed through your skin to the most painful spot on the injured site.
Injection using your own blood (PRP)
It is possible for a specialist to take some of your own blood (in the usual way) and to inject this around your Achilles tendon. This is called autologous blood injection. The idea is that this will help to promote the healing of your damaged tendon by encouraging the growth of cells involved in the healing process.
Exercise Rehabilitation for Achilles tendinopathy
Managing Reactive stage
If you have acute mid achilles pain after an increase or change in training it’s likely you have a reactive tendinopathy. Your initial aim is simply to calm it down and settle symptoms. The most important treatment is simply load management. Reduce the stress on the achilles to a level that the tendon can manage and the tendon may settle in as little as 5-10 days. For mild cases you may be able to continue some running as long as you’re able to keep it pain-free. Bare in mind though that a tendon may take 24 hours to respond to load so it may not hurt until the next day. If you can’t find a way to run pain-free then it’s usually sensible to rest for a few days until you can.
Anti-inflammatory medication - ibuprofen has been recommended for reactive tendinopathy. Although there may not be inflammation present it can help reduce the tendon’s reactive response and decrease tendon swelling. As with any medication consult your GP or pharmacist first.
Isometric calf exercises.
Isometric heel raise
in standing slowly push up onto your toes on both feet, use support if needed. Hold this position for around 5-10 seconds. Slowly lower again. Start with around 5 reps and gradually build up to 10. As you progress try to place more of your body weight on the weaker leg during the hold part of this exercise. In too painful pushing up or coming down do this part with more weight on the weaker leg.
Managing Degenerative stage
If you’re an older athlete and have had a grumbling tendon for some time with periods of flare-ups in your pain it?s likely you have more degenerate tendinopathy. Your Achilles may be chronically thickened with nodules you can feel within the tendon. That said this condition is more of a scale from reactive, through into tendon disrepair and then degeneration rather than a case of either a reactive or degenerate tendon. In fact a flare-up in symptoms from a chronic tendon problem can be a reactive response from non-degenerate parts of the tendon. If you’re in one of these flare-ups then first settle symptoms with the advice in for reactive tendinopathy above. There are aspects of degenerate tendinopathy that are irreversible. Some of the structural changes won’t resolve with exercise. That said, symptoms may well improve even despite this. If you’ve had chronic Achilles tendon problems it’s likely you’ll need an ongoing management plan to keep the symptoms under control.
Load management is an important part of degenerate tendinopathy if you continue to overload the tendon it will remain painful and may potentially lead to severe degeneration or tendon rupture.
Achilles tendon taping
Phase 1 (Mobility and early strength)
Ankle dorsiflexion/plantar flexion AROM, on a table
In long sitting on top of a table/bed or a plinth, place your ankles over the edge of the table. Now move the ankles upwards towards you and then downwards towards the floor.
Sitting, Active ankle eversion (pronation) towel slide
Sit on a chair/medball, lay a towel on the floor, and place your foot flat on the towel. Now move the towel away from you by using the outward motion of your ankle.
Long sitting, Resisted ankle plantar flexion with elastic
In long sitting, place an elastic band around your foot and hold it with your hands. Now try to push the band away from you, towards the floor.
Ankle inversion with Band in sitting
Sit on a chair and place an elastic band around your foot and hold it at the side of your body as shown in the video. NOw try to move the ankle towards the opposite foot by curling it inwards. Try not to use the movement from your knee.
Ankle Plantar Flexion-bent knee Calf Raise
Sit on a chair with your knees bent at 90 degrees. Now try to lift your heels off the floor whilst going onto your tiptoes.
Single leg Bridge
Lay on your back on the floor or a plinth. Bend one leg to 90 degrees and place it flat on the floor and keep the other leg straight. Place your arms by your side. Now lift your bottom and the straighten leg off the floor. Hold this position in mid-air for 5 seconds and lower your self.
Phase 2 (Strength- Progressive loading) The KEY STAGE IN ACHILLES TENDINOPATHY
Ankle Plantar Flexion-straight Double leg Calf Raise
Stand with your feet shoulder-width apart in a comfortable stance. Now try to lift your heels off the floor whilst going onto your tiptoes.
Double leg calf raise on a step
Stand on an edge of a step/stair with your feet shoulder-width apart in a comfortable stance. Now try to lift your heels off the floor whilst going onto your tiptoes. Make sure to complete the full range of motion of the ankle by lowering yourself below the line of the step.
Double leg calf raise with Single leg drop on a step
Stand on an edge of a step/stair with your feet shoulder-width apart in a comfortable stance. Now try to lift your heels off the floor whilst going onto your tiptoes. Now lift one foot off, balance yourself, and then lower the injured foot towards the floor. Make sure to complete the full range of motion of the ankle by lowering yourself below the line of the step.
Single leg calf raise on a step
Stand on an edge of a step/stair on one foot, in a comfortable stance. Now try to lift your heel off the floor whilst going onto your tiptoes. Make sure to complete the full range of motion of the ankle by lowering yourself below the line of the step.
Single leg Bent calf raise on a step
Stand on an edge of a step/stair on one foot, in a comfortable stance. In this position bend your standing foot to 45 degrees. Now try to lift your heel off the floor whilst going onto your tiptoes. Make sure to complete the full range of motion of the ankle by lowering yourself below the line of the step.
Bosu double leg calf raise
Stand on top of a bosu ball, Make sure you stand in a comfortable stance and then perform calf raises, whilst trying to keep your balance.
Phase 3 (Balance)
Unipodal/single leg stance with eyes open
Stand next to a chair, and try to balance yourself one foot. Try not to hinge yourself through the hip, Instead, let the ankle correct your position. Aim for 10 seconds.
Unipodal/single leg stance eyes closed
Stand next to a chair, and try to balance yourself one foot, the close your eyes. Try not to hinge yourself through the hip, Instead let the ankle correct your position. Aim for 10 seconds.
Single leg balance while throwing a ball on the wall
Stand close to a wall with a ball on your hand. Now stand one foot and try to throw the ball onto the wall and try catching the rebound. You can increase the distance covered as you progress through the exercise.
Double leg balance on Air pad
The aim of this exercise is to introduce an uneven surface to balance training. Stand on a Air pad in a comfortable stance and try to aim to keep your balance for 10 seconds.
Proprioception/balance on board (2 feet)
The aim of this exercise is to introduce an uneven surface to balance training. Stand on a balance board in a comfortable stance and try to aim to keep your balance for 10 seconds.
Standing proprio cone touches (3 points)
Place 2 cones either side of you and 12 cones in front and behind you. Now stand in the middle of the cone circle. Then balance yourself on the injured foot, and then try to reach each cone with your toes. Make sure not to yourself from the hip. Once one side is completed try the opposite side with the opposite leg.
Single leg balance on Air pad
The aim of this exercise is to introduce an uneven surface to balance training. Stand on a Air pad with one foot and try to aim to keep your balance for 10 seconds.
Proprioception / balance on board (1 foot)
The aim of this exercise is to introduce an uneven surface to balance training. Stand on a balance board with one foot and try to aim to keep your balance for 10 seconds.
Bosu Standing On 1 Foot / Stabilization
The aim of this exercise is to introduce an uneven surface to balance training. Stand on a Bosu with one foot and try to aim to keep your balance for 10 seconds.
Standing on trampoline, Unipodal/single leg stance with eyes closed
The aim of this exercise is to introduce an uneven surface to balance training. Stand on a trampoline with one foot and try to aim to keep your balance for 10 seconds.
Phase 4 (Power)
Double leg jump squats
Start the exercise by assuming a squat position. Now propel yourself upwards, towards the ceiling. Making sure to land the same way you took off. ?The key is to make sure you land with good control. If you are struggling with control, reduce the distance covered through your jump.
Double leg jump (side to side - front to back, square)
In standing, mum with your both feet towards your left and right. Now you can introduce forward and backward jumps. The key is to make sure you land with good control. If you are struggling with control, reduce the distance covered through your jump.
Single leg Hopping
Stand on one leg and try to perform a hop on the spot. Try to start with smaller hops, the progressing to increased height of the hop. The key is to make sure you land with good control. If you are struggling with control, reduce the distance covered through your hop.
Foam roller exercise
Calfs release on foam roll in a sitting position.
Additional support for Achilles Tendinopathy
At this stage you need to be thinking about visiting someone who can assess your condition and diagnosis it properly to ensure you categories your condition correctly and then you can apply the correct type of exercises for this.