Achilles Tendinopathy

What is Achilles Tendinopathy?

The Achilles tendon connects the calf muscle to the back of the heel bone. Achilles tendinitis, also known as achilles tendinopathy, is when the tendon becomes injured. This will often happen as a result of doing too much activity too soon or due to a sudden spike in activity where the tendon has not had enough time to adapt.

There are two types of presentations:

1. Mid-portion Achilles tendinopathy. Pain is located just behind the ankle just above the heel bone.
2. Insertional Achilles tendinopathy. Pain is located directly behind the heel.

Sometimes people may experience both but usually it’s one or the other. It is important to distinguish which type of Achilles tendinopathy you have as the treatment approach can vary slightly which can affect the outcome.

Getting the proper treatment and advice is important in order to help manage pain and improve function. Without effective treatment this may lead to loss of tendon structure and loss of function.

Treatment

Firstly, do not rest a tendon. Tendons need load in order to maintain structure which is why loading a tendon is so beneficial.

Rest will result in:

• Loss of tendon structure
• Loss of function
•  Change brain function

Treatment should consist of a staged loading program.

This may involve:

1. Unloading the tendon initially to settle the pain i.e. cutting back on volume, frequency, and intensity of activity.
2. Gradually reload to the level needed for your activity. We will be able to guide you on different types of exercises that expose the Achilles tendon to different types of loads which will be aimed at enhancing strength, energy storage and release loads, endurance and compression loads.
3. When returning to a certain activity it is also important to listen to your body. If you are sore the day after performing an exercise, that means you have done too much and need to rest.

Should I see a Podiatrist or Physio?

Fundamentally, exercise and restoration of function is the key foundation in the treatment of Achilles tendinopathy so this aspect of treatment should be handled by a physiotherapist or a podiatrist who is well versed in exercise therapies and rehabilitation. It is important that you see a healthcare professional that has an in-depth understanding of tendons and tendon pathology and will, therefore, be able to guide you on what exercises are the most beneficial for your situation.

If there is any biomechanical involvement that may potentially be abnormally loading the Achilles tendon then seeing a podiatrist for further assessment may also be beneficial.

Physiotherapists who understand what podiatrists do from a biomechanical standpoint will know when to refer to on and vice versa, but at the core, a staged loading program is the most critical part of the treatment plan. Failing to incorporate load will lead to poor outcomes and reduced tendon capacity.

Does manual and adjunct therapies help my tendon?

Manual therapy can provide temporary relief of pain which can make it a useful adjunct treatment in conjunction with an individualised rehabilitation plan.

Tendons are designed to transmit force between muscle and bone, so, therefore, treatment should predominantly be focused on loading the tendon.

Examples of manual therapy include but is not limited to:

• Massage
• Rubbing
• Mobilisation/manipulation
• Dry needling
• Acupuncture
• Injection therapy
• Laser Therapy 
• Shockwave therapy

Why do exercises fail?

Let's face it, exercises aren't that sexy.

All too often when a person is in pain or cannot perform a certain activity this can make them potentially vulnerable to lower quality treatments.

Exercises will often fail for the following reasons:

•  It's not new
•  It’s slow
•  It's low cost 

Tendinopathies are not a simple issue. All too often people think that because there has been a reduction in pain that the treatment they are receiving is working. This is isn’t necessarily always the case.

In order for pain to improve, the tendons capacity to tolerate load must be enhanced. This will take time so you give yourself a minimum of 6-8 weeks for strength changes to take effect.

Also, be wary of weird and wonderful promises. Do not rely on quick fixes, recipe style treatments or treatments which attempt to “fix” or “repair” a tendons structure as no such treatments exist.

Key takeaways  

• Tendon injuries are complex so treatments must be tailored to the individual.
• Do not rest a tendon. Rest will result in diminished tendon structure and strength. The strength of any tissue is only as great as the load placed upon it.
• Tendons respond extremely well to progressive load which leads to greater tissue capacity.
• Poor function = persistent tendon pain
• Restoring function = eliminates pain
• Find a clinician who is up-to-date with the latest evidence who understands tendons, tendon pathology, and pain science.
• A good therapist will be able to help restore tendon function and eliminate pain by progressively loading the tendon using exercises.
• Foot and lower limb mechanics may play a role but will depend on the individual. A referral to an experienced podiatrist who is well versed in how loads affect the foot and lower limb may be beneficial. 
• Manual therapies are not essential but can be helpful. If they are going to be utilised they should always be used in conjunction with a loading program.