What is Achilles tendonitis?
Achilles tendonitis refers to a condition where the Achilles tendon, which connects your calf muscle to your heel bone, becomes overloaded and painful. Tendinopathy is the more common and correct term used today currently as the –itis in tendon-itis means inflammation, which is often not true. There is a continuum of tendinopathy that was first put forward by some very clever physiotherapists and researchers (Cook & Purdham, 2016). They classified tendons as being in a reactive, dysrepair, or degenerative stage. The stage that the tendon is in is important as it will guide the treatment approach. A physiotherapist experienced in managing tendons will be able to advise on this.
What are the causes of Achilles tendonitis/tendinopathy?
Achilles tendinopathy/tendonitis is almost always caused by a sudden increase in exercise that causes overload of the tendon. Tendons love being exercised, but they don’t like sudden spikes in the amount of work they do compared to their recent history. Examples of activities that commonly preceded the onset of an Achilles tendon problem include running or jumping sports. However, a sudden increase in the amount of walking that somebody does could also trigger it. The take home message here is not that exercise is bad, but sudden large increases in exercise risk overloading the tendon which makes it painful. Other less common causes of Achilles tendinopathy include activities with repetitive frictioning of the Achilles such as can occur in cycling or with new foot wear. Sudden weight gain may be a contributing factor as the tendon is obviously working harder if more weight/force is placed through it.
How to diagnose Achilles tendonitis//tendinopathy?
Patients will usually point with one finger to a point on the Achilles that is painful. There are 2 common sites: at the insertion of the Achilles on to the heel bone (insertional tendinopathy), or 3-5cm above this (mid portion Achilles tendinopathy). It is important to know whether it is an insertional or a mid-portion Achilles tendinopathy as the treatment will differ slightly. The tendon may have some thickening around the area that is tender.
Pain will usually be reproduced with a calf raise either in a flat surface or over the edge of a step. If this is not painful, then hopping will usually reproduce the symptoms. Patients often report that the tendon ‘warms up’ with exercise and is very stiff and sore first thing in the morning.
Treatment for Achilles tendonitis/tendinopathy?
There a several phases of treatment that an Achilles needs to undertake in order to fully recover. The first stage consists of settling down the pain levels. Isometric exercises will often be prescribed during this phase based on research that has shown they are effective in reducing pain (Rio et al., 2016). Adjunct therapies such as Extracorporeal Shockwave Therapy has been shown to be helpful in reducing pain and are even more effective when combined with specific exercises to load the tendon (Mani-Babu et al., 2015). Raising the heel up, using either a higher heeled shoe or building up the heel externally, can be an extremely effective early intervention as it reduces the amount of stretch on the tendon. Tendons that are overloaded do not like being stretched as it compresses them.
The second stage of treatment consists of strengthening the tendon. This is a crucial stage and is often overlooked by patients once their pain settles. If you do not strengthen and condition your tendon for the activities it needs to perform, it will not have the tolerance for them and will likely get overloaded again when the patient returns to the activity that flared them up in the first place. A physiotherapist experienced in managing tendons can guide you about the right exercises for your tendon depending on the stage of rehab.
The third and fourth stages of rehabilitation refer to exercises that condition the patient for ‘energy storage and release’ activities. Running and jumping are examples of these type of activities. Sport specific exercises will also be prescribed in these stages where appropriate. Not all patients will need to do stage 3 and 4 exercises if their goal is walking and they are not returning to running/jumping/hopping activities.
Should I stretch my tendon?
Stretching is generally not advised as it compresses the tendon and an irritated does not like compression. This is particularly relevant for patients suffering from insertional Achilles tendon problem. As mentioned earlier, raising the heel to avoid stretch is an effective treatment technique in early rehab.
I have a degenerative Achilles tendon, what should I do?
Ultrasound reports of patient with Achilles pain will often show that there are areas of the tendon that have degeneration. However, the whole tendon is never in a degenerative state. In fact, a recent study showed that patients with painful Achilles tendons actually have more healthy tendon than patients without Achilles problems (Docking & Cook, 2016). This is great news and a clever adaptive mechanism our body has and it means that the area of ‘degeneration’ doesn’t matter as you have lots of healthy tendon that will respond to treatment. This is why we use the saying “treat the donut, not the hole” when it comes to tendons. A final note on degenerative tendons: patients often worry that their tendon may completely tear because it has degeneration found on ultrasound. There is no research evidence to suggest that there is a relationship between degeneration and rupture (tearing) of the tendon.
It is important to understand that rest is not an effective method of rehabilitation. If you don’t use your tendon you probably won’t feel pain, but you will rapidly become deconditioned. This is a vicious cycle that patients often fall into (see the diagram below). You will likely need to modify your activities, but exercises to strengthen the tendon are crucial for recovery. Recovery from Achilles tendinopathy/tendonitis will typically take 8-12 weeks. This is because strengthening is a progressive process and you cannot take short cuts as you risk overloading the tendon. However, for a longer standing problem, the muscles and tendon have likely become very weak and deconditioned, so it can take 6 months in these cases.
What exercises can I do to avoid getting Achilles Tendonitis?
A progressive increase in your exercise load (volume, intensity, and duration) is the key to avoiding overload and risking getting Achilles tendinopathy. As a general rule, maintaining your training loads between 80-130% of your average has been shown to have the lowest risk of getting injured, including Achilles problems (Gabbett, 2016). If you have not exercised for a while or are resuming exercises that you have not done for a long time, take your time in building up your exercise workload gradually. Remember, tendons love being loaded, they just don’t like sudden spikes in exercise workloads.
Cook et al. (2016). Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research? BJSM, 0, 1-7
Docking, S. & Cook, J. (2016). Pathological tendons maintain sufficient aligned fibrillary structure on ultrasound tissue characterization (UTC). Scand J Med Sci Sports, 26, 675-683
Gabbet, T. (2016). The training-injury prevention paradox: should athletes be training smarter and harder? BJSM, 50, 273-280
Mani-Babu et al. (2015). The effectiveness of extracorporeal shockwave therapy in lower limb tendinopathy: a systematic review. AJSM, 43, 752-761