Achilles Tendon Pain

The majority of Achilles tendon pain is of a slow onset, over-use nature – compared to a sudden acute tear or rupture of the tendon. Recent research however suggests this type of injury does not involve inflammation and is most likely due to a series of microtears and degeneration that weaken the tendon (tendinosis).

The achilles tendon is the large tendon located in the back of the leg that connects the calf muscle to the heel. Enormous load goes through this tendon as it gives us the ability to toe off during walking, running and jumping activities.

Achilles tendon pain (tendinopathy) is most common among middle-aged people and athletes.

Signs and symptoms

• Gradual onset without initial injury
• Initially pain may only be felt during exercise, as injury worsens pain may also be present during normal daily activities.
• Pain, tenderness and swelling around tendon
• Pain and stiffness most noticeable in the morning upon arising and after rest periods during day
• Weakness when jumping, hopping or skipping on affected leg

Causes

The primary cause of mechanical achilles tendon pain is the result of an irrational placement of load exceeding the capacity of the tendon (too much, too soon!):

• Change in training intensity
• Introduction of hill running, speed work
• Return to training after a period of rest or inadequate rest between training sessions
• Poor warm up, stretching, cool down

Other factors affecting the capacity of the tendon to take a load:

• Foot posture- a rigid high arched foot has reduced ankle dorsiflexion which increases compression load at Achilles tendon.
• Foot posture – a pronated foot type has a smaller volume of tendon which reduces the capacity to take load.
• Poor muscle flexibility (eg tight calf muscles); decreased joint range of motion (stiff ankle joint) which increases compression load at achilles tendon.
• Wearing unsupportive or incorrect footwear or lots of barefoot walking
• Systemic factors- reactive disease such as Rheumatoid arthritis, or genetic makeup affecting the integrity of collagen fibres.
• Age- 30+
• Insulin resistance, Type 2 Diabetic, overweight
• Some medicines (eg. steroids, antibiotics) may increase the risk of Achilles tendon injury.

Treatment

Treatment for chronic Achilles tendinopathy depends on the location of injury and whether it is in the reactive or degenerative stage of injury.

Insertional Achilles tendinopathy – at the insertion of the tendon into the heel bone (back of heel). This tendinopathy is due to excessive compression load on the tendon. The primary concern in the reactive stage is to reduce the compressive load of the tendon:

• Heel lifts inside shoe or externally is an immediate reversal of compressional load – (so avoid barefoot and flat shoes)
• Do not drop heel over a step (calf stretch) as this increases compression load on tendon
• Modify training to a level that allows the tendon to recover – but DO NOT completely rest
• Gentle range of motion exercises before weight-bearing in morning
• Massage and Western medical acupuncture into calf muscle and around tendon (avoid tendon in reactive stage)
• Address contributing foot mechanics with improved footwear and/or Customised Foot Supports (Orthotics)

The next stage of management is progressive load rehabilitation to improve the energy storage and release capacity of the tendon. Starting with eccentric loading calf raises and slowly increasing tendon load via little jumps > single leg hops > power hops etc.

Midportion Achilles tendinopathy– within tendon normally 2-3cm above insertion into heel.

• Modify training to a level that allows the tendon to recover – but DO NOT completely rest
• Gentle range of motion exercises before weight-bearing in morning
• Night splint if morning stiffness is significant
• Massage and Western medical acupuncture into calf muscle and around tendon (avoid tendon in reactive stage)
• Address contributing foot mechanics (high arch or over-pronation) with improved footwear and/or Customised Foot Supports (Orthotics)
• Eccentric loading exercises – allowing heel to drop over a step.
• Continue to slowly increase the tendon load via little jumps > single leg hops > power hops etc.

Because of the progressive nature of Achilles Tendinopathy, it is best to seek treatment as soon as possible. Early treatment allows for a much greater prognosis and minimises the risk of chronic tendon degeneration or rupture.

If you do not respond to the above treatment, Shockwave Therapy would be the next recommended treatment option as it is non-invasive, highly effective and relatively pain-free.

Cortisone injection is not recommended and if left untreated for a long time surgery may be necessary.

Don’t hang up the boots due to unrelenting Achilles tendon pain affecting your game – give Foundation Podiatry a call today!