Achilles Tendinopathy is a degenerative condition characterised by pain and stiffness in the Achilles tendon. It is different from it cousin Achilles Tendinitis because in a tendinopathy there is an absence of an acute inflammatory response and therefore it is often poorly responsive to Non-Steroidal AntiInflammatory (NSAID) medications.
A misconception is that as a tendon degenerates it becomes thinner and more prone to tearing like a cartoon rope but this is an inaccurate image and one that can lead to chronic pain behaviours.
Degenerative tendons look more like old rope which has thickened. Micro tears have occurred but the overall effect is that the tendon is thicker
Thats often why the tendon feels thicker than on the non affected side and may contain focal nodules.
It’s important to realise that this does not mean that your Achilles is going to snap…far from it, in fact there is no evidence that shows that achilles tendinopathy progresses into tears.
So…thats all well and good….but what to do about it?
Well..lets look at it from a microscopic perspective…if we want the tissues to heal and recover we have to cease irritating it. ACTIVITY modification is therefore an important step….In other words REST…take it easy. Even the use of heel raises can offload the tension in the system, this can be especially useful in the more painful early stages.
Kinesiotape (stretchy elastic tape) can be used…and it looks so cool too!! (thats me being sarcastic!). Use it if it creates at least a 50% reduction in symptoms, if it doesn’t don’t worry.
Application of ice and ice cube massage has been shown to cause a local vasoconstrictive response which can reduce neovascularisation (or the creation of useless small blood vessels that impede the healing process). It’s worth a try.
Current evidence supports the use of extracorporeal shockwave (ESWT) therapy (a machine that works like a mini jack hammer!) and eccentric exercise. Although the link just posted shows the patient dropping from a normal step, new research indicates there may be additional benefit from having a rolled towel placed underneath the toes to further increase the windlass effect of the foot. There appears to be benefit in adding loading to the exercise, even if it induces some pain.
Dynamic calf stretching and foam rolling have also been shown to have some beneficial outcomes for some so they are worthwhile adding into management program, but the mainstay of management still needs to be eccentric exercise.
Despite implementing these strategies some people may suffer from persistent or recalcitrant pain. For these it may be worthwhile discussing with their doctor whether glycerin trinitrate (GTN) patches would be a worthwhile addition. The jury is still out as to whether injections should play a role in management with a 2015 Cochrane Review reporting that there was little evidence to suggest injection therapy (including Cortisone and Plasma Rich Protein (PRP) injections) was worthwhile. It seems the key is
1. let it settle
2. address any biomechanical dysfunction
3. load it progressively over time. But the most important thing?….
Be patient and be positive.
A final note from a Sports Physician John Orchard who has a special interest in tendons
The body – eventually – does a good job of curing the pain of Achilles tendinopathy itself in the vast majority of patients, probably with the help of the patient being advised or stumbling upon the formula of moderately loading the tendon just enough to strength it but not enough to overload it.