Condition Spotlight: Achilles Tendinopathy

Achilles tendinopathy is a condition that causes pain in the Achilles tendon.

Before we dive deep into this condition, if you are concerned that you may have this condition or something else may be affecting your Achilles tendon, we highly recommend booking an appointment with us.  This condition can be easily misdiagnosed and may worsen, if not treated properly.

With that in mind, this blog will give you all the information you need to know about Achilles tendinopathy!

What is Achilles tendinopathy?

The Achilles tendon is a large tendon that connects your calf muscles to the back of your heel.  It creates the movement of plantar flexion, which can be seen in the image to the right.

As you can imagine, this simple movement is very important for walking, running and jumping. The tendon stores energy like a rubber band when we land from one step.  The tendon then uses this energy, along with the contraction of your calf muscles, to propel you forwards for your next step.

It is actually this mechanism of the Achilles tendon that allows a kangaroo to bounce as much as they do. Though, a kangaroo is much more efficient at this due to their unusual biomechanics!

Achilles injuries are very common amongst runners and athletes playing sports that involve running and jumping.  However, this condition still occurs in people who are not runners or athletes. And when it comes to gender and ages, middle aged men are most commonly affected by Achilles tendinopathy.

What does Achilles tendinopathy feel like?

When an Achilles injury occurs, it will cause pain and tenderness at or above the back of the heel.  This is often accompanied by swelling and weakness of the calf muscles.  It can also cause limited ‘dorsiflexion’ of the foot, which is the movement in the image to the right.

If you recall feeling a ‘pop’ from your Achilles tendon at any point, you should see a doctor immediately, as this indicates a much more serious injury, which is an Achilles tendon rupture.

As NBA player Kevin Durant (left) and ex-AFL superstar Jarryd Roughead are aware, Achilles tendon ruptures involve a long drawn out recovery to get back to playing sport.

What causes Achilles tendinopathy?

Achilles tendinopathy can be divided into two injury types.  These are ‘mid-portion’ Achilles tendinopathy or ‘insertional’ Achilles tendinopathy.

Mid-portion Achilles tendinopathy:

Mid-portion Achilles tendinopathy is generally considered to be an ‘overuse’ injury.  This is why it is so common in runners and athletes that play sports that involve running and jumping.

This injury is localised to the Achilles tendon but is at least 2cm away from the insertion of the tendon at the back of the heel. This can be seen in the image to the right.

Evidence indicates that certain components of a person’s gait cycle, or how they walk, are a large determinant of whether or not they are at an increased risk of developing Achilles tendinopathy. These factors can be assessed by a podiatrist completing a gait analysis.

Other factors include increasing levels of physical activity too quickly, and also training in poor, unsupportive footwear.

Many people have recently taken up running due to the lockdowns providing a bit of extra time.  This means that we have seen a lot of patients coming in with Achilles problems.  This has often been because they increased their running too quickly, combined with other risk factors.  The tendon will then either become inflamed or cause collagen in the tendon to break down, otherwise known as tendon degeneration.

Insertional Achilles tendinopathy:

Alternatively, insertional Achilles tendinopathy can be caused by a compression force of the tendon up against the heel bone, which is known as the calcaneus.  This can be caused by footwear with a tight collar, and is often aggravated by a deformity of the calcaneus known as a ‘Haglund deformity’.  This can be seen in the image to the right.

 

It is important to understand the difference between these two causes and locations of tendinopathy, as it affects how the condition is treated.

How is Achilles tendinopathy diagnosed?

If you visit a podiatrist for an Achilles injury, there are many assessments that will be performed.  This is to ensure that the correct diagnosis is made. It will also help to determine whether your achilles tendinopathy is a ‘mid-portion’ or ‘insertional’ injury.

The assessments you might experience are outlined below.

  • Detailed history taking:

First of all, your podiatrist will ask you about the injury, such as when the pain started and how painful it is out of 10.  You will also be asked about several other risk factors, such as, if you have previously injured the area.

  • Inspection of the area:

The area will then be visually inspected.  This is to check for signs of inflammation such as redness and swelling, as these are the typical characteristics of an inflamed tendon.  This inspection will also include checking for a Haglund’s deformity or footwear that is too tight.

  • Muscle and range of motion testing:

You may be asked to produce some force with your calf muscles, or to complete some calf raise exercises.  This helps to determine if there is a weakness present on one side of your body.  Your podiatrist may also assess your ankle joints ‘range of motion’, as reduced dorsiflexion of the ankle is often associated with Achilles tendinopathy.

  • Palpation of the tendon:

Palpation of the tendon may then be performed to determine if the tendon is the source of the pain.  This will also help to determine if the tendinopathy is a ‘mid-portion’ injury or if it is ‘insertional’.

  • Imaging:

Your podiatrist may then send you for imaging.  This can be a simple ultrasound to confirmed if the tendon inflammation or degeneration is present.  This may also indicate the presence of a small bone spur or bursitis, which all need to be ruled out as differential diagnosis.

How is Achilles tendinopathy treated?

How Achilles tendinopathy is treated will depend on the type of tendinopathy present.

Mid-portion Achilles tendinopathy:

Mid-portion Achilles tendinopathy treatment options vary greatly, but focus firstly on resting the injured area, and then working on exercises, and correcting any lower limb malalignment that may be a contributing factor.  The following treatment modalities may be used to treat your injury:

  • Eccentric loading/strengthening:

After a brief period of rest, the most important factor in treating a mid-portion Achilles tendinopathy is to get it working!

We do this by introducing a detailed eccentric calf raise program, strengthening your calf muscles and helping to return your tendon to its normal state.

  • Orthotics:

Orthotics may be an important part of your tendon rehab, as they help to correct any lower limb malalignment to place less strain on your Achilles tendon.

  • Shockwave therapy:

Shockwave therapy can help repair your tendon by producing a stimulus to create an immune response.

This style of therapy can be a bit painful, however, it often leads to fast pain relief, and evidence is pointing towards this being a great treatment option for Achilles tendinopathy.

  • Corticosteroid injections:

Corticosteroid injections will not be the first line of treatment for Achilles tendinopathy.  This is because they often will mask the pain but not fix the root of the problem, and will not always return the tendon to its pre-injured state.

This treatment has also been shown to occasionally produce negative side effects, hence this is only used as a treatment option when more conservative options have been exhausted unsuccessfully.

 

Insertional Achilles tendinopathy:

Treatment of insertional Achilles tendinopathy differs from a mid-portion injury because this injury is generally caused by compression of the tendon.

This means to reduce pain, we have to relieve this compression, and this is usually achieved by one of the following methods:

  • Footwear:

Tight fitting footwear, or a tight cuff around the back of the ankle may be compressing the Achilles tendon. First, we need to ensure that your footwear fits adequately and no extra stress is placed on the tendon.

This often leads to almost instant pain relief, so don’t be afraid to change up your shoes!

  • Orthotics:

As we mentioned above, orthotics can be an important part of your tendon rehab.  They help to correct lower limb malalignment, which can place less strain on your Achilles tendon.

  • Shockwave therapy:

Like we mentioned above, shockwave therapy can be used to help repair your tendon.  It does this by producing a stimulus to create an immune response.

Shockwave therapy can be painful, though it often leads to fast pain relief.  It’s also been showing evidence as being a great treatment option for Achilles tendinopathy.

  • Surgery:

If a Haglund’s deformity is present, and is the primary cause of the tendinopathy, surgery may be necessary to remove part of this bony prominence. This is done to allow the tendon to heal, and prevent the injury from occurring again.

  • Stretching and strengthening:

Tightness of the calves may be the cause of this tendinopathy, and putting the tendon through eccentric load has show it can return the tendon to a normal state.  However, in the case of insertional tendinopathy, we need to be very careful with stretching and exercising as it may cause further compression of the tendon.  We recommend seeing a podiatrist if you wish to complete this therapy.

 

Like we said at the start, if you think that you may have this condition, or something else is affecting your Achilles tendon, we highly recommend booking an appointment to see one of our podiatrists here at Watsonia Podiatry.  But this isn’t all we can help you with, if you’re experiencing any pain or discomfort in your feet, toenails, or lower limbs, book in to see us today – you can book an appointment online here, or you can call us on 03 9432 2689.

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