What is Achilles Tendinitis?
The Achilles tendon runs from the back of the heel & connects to the calf muscles above. The Achilles tendon assists in pushing up onto the toes (plantar flexion). Problems can arise in the Achilles tendon when it is overloaded, especially where an athlete suddenly increases their running mileage in preparation for a race. Because a tendon takes time to adapt to load, any sudden changes can predispose to overload induced pain. The pain may increase rapidly if the athlete continues to train & ignores the pain. This may necessitate a prolonged period of rest or time out from sport.
An Achilles tendinitis can mimic a partial Achilles tendon tear & therefore it is vital to undergo a physiotherapy evaluation to differentiate between the two conditions. Many still refer to achilles tendinopathy as achilles tendinitis; however, the word ‘itis’ means inflammation & it is now thought that inflammation is not the main driver of Achilles pain; therefore, the term achilles tendinopathy is now thought to be more appropriate.
Both neurological & vascular adaptations have been shown to take place within the tendon substance of those suffering with Achilles tendinopathy Glutamate, which is a neurotransmitter, is found in high levels in painful tendons (Alfredson et al. 2001). This suggests that there are chemical, neurological & vascular factors playing a role in the development of Achilles pain. Histologically, tendinopathy is characterised by collagen degeneration, fibre disorientation and thinning.
What are the symptoms of Achilles Tendinitis?
Achilles tendinopathy generally presents as an ache at the back of the heel that presents during or after a run. As the condition progresses, the symptoms tend to come on earlier during the run & will last for longer afterwards. As Achilles tendinopathy is a degenerative rather than an inflammatory condition, pain may arise due to a combination of mechanical & biochemical factors
A prolonged ache first thing in the morning is suggestive of a chronic condition. The longer this pain lasts after getting up from bed the more challenging the rehabilitation process.
Causes of Achilles tendinitis/tendinopathy
- Rapid increase in training load
- Poor biomechanics
- Inadequate ankle range of motion
- Prior injury to the Achilles; calf muscles or foot
- Impaired muscle control at the hip or knee
- Training on a hard surface
- Decreased calf muscle strength
Treatment of Achilles Tendinitis/Tendinopathy
Clinical examination will firstly take place to rule out a traumatic rupture. Orthopaedic tests such as the Thompson test can help to rule this out.
Treatment is focused on correcting underlying biomechanical causes & restoring normal joint motion. Because of the large load taken at the ankle during impact while running, a period of rest or alteration of the training regime may be advised in order to allow the tendon to recover. A loaded exercise programme will generally commence immediately.
Manual muscle techniques will be used to address areas of muscle dysfunction & to restore normal calf muscle condition. Progressive strengthening & flexibility exercises are important to increase the tendons ability to withstand load. Adaptations occur over a number of weeks to months & tendon injuries generally have a longer healing window than muscle injuries.
NSAIDs showed little or no effect on outcome in patients with Achilles tendinopathy (Astrom & Westlin 1992; Almekinders et al. 1998)
Negative thoughts can influence the way a person walks eg “limping takes the pressure off my heel”; therefore, this movement pattern becomes a habit. Maintaining this movement pattern can give rise to wasting of the muscles and tendon and can prevent recovery if the person does not learn how to walk and run properly again.
Plantaris Muscle as a Source of Calf Pain
The plantaris muscle is a commonly overlooked source of calf & heel pain. It runs from the back of the knee under the calf muscle to insert into the achilles tendon. With plantatis involvement the pain is normally medial to the achilles. The pain is often 6-8cm above the achilles as opposed to above the heel where the midportion of the achilles is located. Foot pronation may increase the strain on the medial aspect of the Achilles and cause compression of the Plantaris on the Achilles.
What Strengthening Exercises Should I do for an Achilles Tendinitis?
Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy: A Randomized Controlled Trial.
Previous research has suggested that eccentric training (lowering the heel) is superior to standard resistance training in the rehabilitation of achilles tendinopathy but there are few randomised controlled trials to back up the conclusion that eccentric training is superior to other forms of loading exercise.
This study compared the effectiveness of 12 weeks of eccentric training (ECC) and heavy slow resistance training (HSR) among 58 patients with midportion Achilles tendinopathy of greater than 3 months.
The authors concluded that eccentric training and heavy slow resistance training provide equally effective results in the management of achilles tendinopathy
Research by Couppe et al. (2015) supports this view. They state that ‘Future studies should control for these loading parameters, evaluate various exercise dosages, and think beyond isolated eccentric exercises to arrive at firm recommendations regarding rehabilitation of individuals with tendinopathies.’
- Alfredson H, Forsgren S, Thorsen K. et al In vivo microdialysis and immunohistochemical analyses of tendon tissue demonstrated high amounts of free glutamate and glutamate receptors, but no signs of inflammation, in Jumper’s knee. J Orthop Res 2001. 19881–886.886
- Astrom M, Westlin N. No effect of piroxicam on Achilles tendinopathy. A randomized study of 70 patients. Acta Orthop Scand 1992. 63631–634.634
- Almekinders L, Temple J. Etiology, diagnosis, and treatment of tendonitis: an analysis of the literature. Med Sci Sports Exerc 1998. 301183–1190.1190
- Beyer et al. (2015). Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy: A Randomized Controlled Trial.
Am J Sports Med. Jul;43(7):1704-11. http://www.ncbi.nlm.nih.gov/pubmed/26018970
- Couppe et al., (2016). Eccentric or Concentric Exercises for the Treatment of Tendinopathies? Journal of Orthopaedic & Sports Physical Therapy.
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