Achilles Tendinopathy

Signs and Symptoms

Achilles tendinopathy usually comes on gradually, and is more common in those aged over 40. There is pain, which is worsened by activity, and the focal areas of degeneration feel tender to touch. Often the tendon feels very stiff first thing in the morning. The affected tendon may appear thickened in comparison to the unaffected side.

Achilles Tendinopathy Treatment

Because Achilles Tendinopathy is rarely an inflammatory condition, the use of anti-inflammatory medication (Non-steroidal anti-inflammatory drugs - NSAIDs) is not appropriate. The action of the NSAIDs can actually be counter-productive, as these drugs inhibit the action of naturally occurring chemicals that mediate a healing response, thus dulling the body's ability to regenerate the damaged tissue. Ice can be used for analgesia (never apply ice directly to the skin).

The key to recovering from Achilles Tendinopathy is in trying to elicit a healing response without overloading the tendon. This requires rest from sporting activities for up to three months. This is because the collagen tissue, which the body produces to repair the tissue damage, takes three months to lay down and mature. This process may be assisted by treatments that increase the temperature of the tendon, increasing the metabolic activity and thus the healing process in the tendon. As the tendon is healing, a registered Physiotherapist may gently mobilise the soft tissue by providing gentle stress, to help the tendon to adapt and gain tensile strength.

Once the tissue has regenerated, the physiotherapist may begin to stretch and strengthen the calf muscles. If the ankle or joints of the foot are stiff, the physiotherapist can mobilise them to restore the normal range of movement. These measures have the effect of removing the excessive load from the tendon and normalising the biomechanics of the lower leg.

It is thought that an 'over pronated' foot position (tendency to flat feet) can place excessive strain on the achilles and lead to Achilles Tendinopathy. In this case it is often very beneficial to visit a Physiotherapist who will carry out a biomechanical assessment. If flat feet are present it is usually effective to insert an orthotic (shoe insert) which will help to correct the problem.

In persistent cases of Achilles Tendinopathy, an injection around the tendon can help to prevent further tendon degeneration. An injection of a special protein can inhibit the enzyme 'metalloprotease', which breaks down the protein that makes up tendon tissue. This has been shown that in tendinopathies there is an imbalance between different types of metalloprotease, and the injection can address this imbalance. Also, it does not have the serious side effects of corticosteroids, and, if necessary, can be injected several times.

Another approach, which is currently being pioneered in Scandinavia, is based on the theory that new blood vessels growing into the diseased tendon are the source of pain. The treatment, which has shown very promising results from the initial studies, is to inject a 'Sclerosant' drug into these blood vessels under the control of an ultrasound scanner which shows the blood vessels. Sclerosant drugs destroy the new blood vessels and hence the proposed source of pain. However, if there is tendon degeneration there may still be a mechanical weakness in the tendon, so there is a lot of research yet to be done on this approach.

Published research has suggested that recovery is optimised by using a program with a Physiotherapist that uses what is called 'eccentric muscle work'. Eccentric muscle work refers to a muscle that is lengthening while contracting - a contraction that occurs during movements such as landing and decelerating. Maximal tension is generated in the muscle during the eccentric contraction and this causes the tendon to adapt and get stronger.

Your local IPA physiotherapist will be able to explain and demonstrate these exercises as part of your rehabilitation. Simply phone 1300 PHYSIO to be transferred directly to their practice.

In severe cases of Achilles Tendinopathy, which have failed to respond to six months of supervised rehabilitation with a registered physiotherapist, then surgery should be considered. However, this is very much a last resort because the success of surgery, even with the best surgeons, is not 100%.

Surgery involves removing degenerate tendon tissue and trying to restore a tendon to a good level of tensile strength. This means that, following surgery, the tendon still doesn't have its normal strength and careful rehabilitation is essential. The eccentric program under the supervision of a registered physiotherapist is indicated. As mentioned earlier, the slow rate of collagen tissue production means that it takes three months to produce new healthy tendon tissue and at least six months before a return to sporting activities can be resumed.

Prevention of Achilles Tendinopathy

Research has suggested that in order to reduce the risk of a recurrence of the injury, a program should be followed that uses what is called eccentric muscle work. Eccentric muscle work refers to a muscle that is lengthening while contracting - a contraction that occurs during movements such as landing and decelerating. Maximal tension is generated in the muscle during the eccentric contraction and this causes the tendon to adapt and get stronger.

Training errors should be avoided. The intensity, duration and frequency of training should be carefully monitored and gradually progressed. Sudden increases should be avoided. Muscle strength and flexibility should be maintained through regular strengthening and stretching sessions. The surface should be appropriate to the sport and it is important to wear the correct footwear.