Hello and welcome back to the ThreeSpires Physiotherapy blog where we take a look at all things physiotherapy and health related. In this blog we are going to take a look at a fairly common problem for many people that is well known but is also extremely problematic to treat: Achilles Tendinopathy.
Usually when looking at a new condition in our physiotherapy blog I try to firstly define exactly what the condition is. Now, for Achilles Tendinopathy it is easier to ask the question “what is it?” than actually to provide a clear answer without first having a quick look at some anatomy an also considering what tendons are and the ways of describing injury to tendons such as tendonitis, tendonosis and tendinopathy.
What is the Achilles Tendon?
So, firstly before thinking about how it gets damaged we first need to know a bit of anatomy. The Achilles Tendon (often shortened to TA) is the strongest and thickest tendon in the body. It is located at the back of your ankle and connects your calf muscles to your foot. Specifically it is formed by the calf muscles of gastrocnemius and soleus joining together to form the tendon which inserts into the heel bone the calcaneus. It is relly easy to find your Achilles Tendon: simply reach down to the back of your ankle and pinch yourself about 2-3 inches above the heel and you will feel your Achilles Tendon. A tendon is a non-contractile piece of tissue that joins muscle to bone – the main point to note here is that it is non-contractile which means it does not do any of the actual pulling itself – that is done by the muscles. The tendon simply connects the muscles to the bone that needs pulling. Tendons are made of collagen and in general have very low blood flow (unlike muscles) and as such have a tendency to heal and repair slowly. Certainly when assessing anyone with a tendon injury such as Achilles Tendinopathy one of my main roles as a physiotherapist is to talk them through the likely recovery timeframes which are always much longer than they are expecting. The Achilles Tendon is a vital structure in all movement on your feet and is responsible for your being able to push up onto your toes, sprint quickly and also land well after a jump. It is a huge store of energy during walking or running and takes an enormous load each time your run, walk or jump. All in all it is actually surprising that the Achilles Tendon does not get injured more often considering how much it is used.
What is a Tendinopathy?
So, now we have a reasonable notion of where the Achilles Tendon is located, what it does and what a tendon actually is, we need to have a brief look at the terminology describing injury or damage to a tendon such as the Achilles Tendon. Here, we are not helped by the fact that there has been an enormous amount of research and change over the years and the way we now describe tendon injuries is different to how they were described in the past but the older terms are still very much in current usage. In fact with patients I have a tendency to use whichever term they are most familiar with and to be honest unless you are a researcher into tendon pain it is unlikely to be important. The modern and most (nowadays) accepted way of describing damage to a tendon is tendinopathy. This indicates that there is pain and damage to the tendon but does not infer that there is actual inflammation there whereas the word tendonitis indicates that inflammation is an important part of the problem (itis – in medicine indicates inflammation). In the past it was thought that the tendon was actually inflamed and that inflammation was an important part of the ongoing pain that patients with Achilles Tendon pain felt. Currently although there may be some inflammation this is no longer thought to be an important part of the problem and so the phrase Achilles Tendinopathy is preferred.
What is Achilles Tendinopathy?
Okay I think we have looked at enough anatomy and discussed the terminology enough so that we can now get onto actually looking at what Achilles Tendinopathy is in more detail. So Achilles Tendinopathy is generally accepted as a pain in the Achilles Tendon (at the back of the ankle) that persists over a number of weeks. It is different from an actual rupture of the Achilles Tendon in that the tendon is still intact. It is thought that an initial overload causes some initial damage which then instead of healing as it may well have done in the past has a poor healing response. The tendon instead of just getting sore and then repairing itself becomes degenerative and fails to heal as it should causing ongoing pain and difficulties. As discussed earlier it used to be called Achilles Tendonitis as it was thought that there was inflammation causing the problem but studies have shown that although there might be a small amount of inflammation that is not the real problem here with the Achilles Tendon.
What are the Symptoms of Achilles Tendinopathy?
In general the symptoms of Achilles Tendinopathy are:
- Pain, stiffness or burning in the back of the ankle or bottom of the calf.
- The pain in general worsens with activity and being on your feet.
- The Achilles Tendon itself may be red and have a lump which is sore to touch.
It is important to note though that these could be the symptoms of quite a few other conditions and not just Achilles Tendinopathy and it is important that you get it confirmed by a professional (such as a physiotherapist) that you actually do have Achilles Tendinopathy.
What Causes Achilles Tendinopathy?
Achilles Tendinopathy is an overuse injury which means that in general patients have simply been using it more than it could cope with for example they may have been running or walking more than their Achilles Tendon could cope with. It is especially common in runners or joggers and in those who have recently taken up running and starting increasing the distance that they run. Some common causes of Achilles Tendinopathy are:
- A large increase in volume of running, jogging or walking. This is an especially common cause of Achilles Tendinopathy in those that have recently taken up running and are aiming for a marathon or in those who have begun doing lots of walking and have a particular challenge in mind such as doing the Three Peaks.
- Too much speed or intensity. Sometimes runners will have changed their training and introduced more speed work and this will then introduce a load to their Achilles Tendon that it has not been accustomed to and cause Achilles Tendinopathy.
- Poor Choice of Footwear: sometimes a walker or runner will have changed their footwear recently and found that this rubs or irritates their Achilles Tendon. This irritation can in turn cause Achilles Tendinopathy.
- Hills: walking up hill places quite a different strain on the Achilles Tendon than walking or running on the flat and if introduced without a sufficiently slow build up can cause overload and Achilles Tendinopathy.
- A change in running surface: if you have mostly been running on grass and cross country and then you swap over to running on tarmac or the track this can cause a large change in the load placed on the Achilles Tendon.
The main point to note about all of these potential causes of Achilles Tendinopathy is that they involve the Achilles Tendon being subject to a new stress or change that it has not been allowed sufficient time to adapt to. Whenever I personally, as a physiotherapist, am assessing a patient who I suspect of having Achilles Tendinopathy I spend a long time discussing their symptoms and any changes to their running, walking or footwear. To me this is one of the key parts of any assessment of Achilles Tendinopathy as by giving the patient a clear idea of what has gone wrong and caused their Achilles Tendinopathy they can then in the future avoid and manage the issue.
Who is at Risk of Getting Achilles Tendinopathy?
Basically anyone can get Achilles Tendinopathy but there are some risk factors that make people more prone to overloading their Achilles Tendon and developing Achilles Tendinopathy:
- Men: Achilles Tendinopathy is one of a few conditions out there that being male is risk factor for. This is in general because men are more likely to run and also more likely to decide randomly that they need to do a marathon next month without considering that they may need to build up to it!
- Age: being over 30 is a risk factor. A large amount of Achilles Tendinopathy occurs in those between the ages of 30 and 50. There is an easy explanation for this: between the ages of 30 and 50 most people will at some point decide that they have got unfit and decide that they need a challenge and will try to do some kind of walking or running challenge such as a marathon. They often do this with little preparation and subsequently overload their Achilles Tendon.
- Diabetes: being a diabetic has a tendency to lower the integrity of tendons and this make someone more prone to Achilles Tendinopathy.
- Weight: this is a fairly simple one! The heavier you are the more load you will place through your Achilles Tendon.
- General Leg Weakness: not having good control or strength in your hip or knee can often place an increased load on your Achilles Tendon. Sometimes the problem will occur on the opposite leg to the one that is actually weak.
How is Achilles Tendinopathy Diagnosed?
In general Achilles Tendinopathy is diagnosed from symptoms and a physical assessment. There is rarely a need for imaging such as an ultrasound scan or MRI. Often patients will initially attend their GP complaining of ankle and heel pain and then be referred on to a physiotherapist. The physio will take a full history, do a physical assessment and based on the combination of these factors make a diagnosis of Achilles Tendinopathy. It is important to get an accurate and early diagnosis of your Achilles Tendinopathy as this allows the best management and treatment plan to be devised and for your to get back to your activity as soon as possible. Delaying a diagnosis and letting things worsen will only lengthen the rehab process needed for your Achilles Tendinopathy.
Treating Achilles Tendinopathy
The best treatment for Achilles Tendinopathy will depend upon the exact nature and stage of your Achilles Tendinopathy and things have changed a great deal over the years in terms of how it should be managed. Below is a rough guide to options and ideas of when it would be appropriate to use the particular strategies. Most of this is based on research but some is based upon my own experience as a physiotherapist seeing patients with tendinopathies:
- Rest: if you have only recently injured your Achilles Tendon – say last week, then a short period of rest will be by far your best strategy as your Achilles Tendon is currently in a reactive phase and needs a bit of rest and then a slow reintroduction back to activity. This allows your Achilles Tendon to repair and then you can go back to your previous training with potentially a few changes to allow your Achilles Tendon to adapt and strengthen.
- Exercises: It used to be that eccentric exercises were considered the gold standard of treatment in terms of exercises for Achilles Tendinopathy. However things have moved on a bit and certainly my own experience suggests that the most important thing in terms of exercises for Achilles Tendinopathy is progressive and well managed loading. I will go int more details about the specifics of exercises for Achilles Tendinopathy later.
- Activity Modification: sometimes with Achilles Tendinopathy one of the best approaches is to simply modify some of the activities that are causing issues. This could be easing back on hill work, returning to a previous running surface or stopping any sprinting or speed work. This can sometimes take a bit of trial and error and will involve you discussing this with your physiotherapist.
- Footwear and orthotics: sometimes (especially if you are a runner) your footwear can be causing problems or it could be that you would benefit from some orthotics that would support your foot better during running and reduce the load on your Achilles Tendon. In these cases a physiotherapist can make a referral on to a podiatrist who can make a more detailed assessment of your foot.
- Strengthening: If one of your legs or possibly your core is not strong enough then it may be possible that your opposite leg is becoming overloaded through the gait cycle. In these cases it is essential that alongside specific exercises for your Achilles Tendinopathy that you do some strengthening and control work to reduce the impact and load on your Achilles Tendon in the future.
- Other Treatments: there are currently numerous other options such as plasma rich platelet (PRP) injections and high volume injections but most of these are very much unproven and are at the experimental stage.
Specific Achilles Tendinopathy Exercises
The specific exercise regime that is best for treating Achilles Tendinopathy will depend upon the exact nature and stage of the tendinopathy. Also there has been a large amount of research into Achilles Tendinopathy and a lot of change in the way it is managed and as such you may find that the information below does not match other information out there about Achilles Tendinopathy and which exercises are best. Lastly, it is important that if you have Achilles Tendinopathy that you have an assessment with a physiotherapist who can then advise you on which particular exercises would be best for your Achilles Tendinopathy. That being said below is a general guide to exercises for Achilles Tendinopathy based on both research and my own experience as a physio.
- Isometric Exercises: isometric simply means contracting a muscle but not allowing it to change length and in this case means putting weight through the Achilles Tendon without allowing the calf muscle to move up or down. I generally give this one out to patients whose Achilles Tendon is extremely painful and they do not seem to be able to tolerate eccentrics or concentrics and are finding most day to day activities painful. In this case I ask patients to lift themselves up onto the toes of their good foot and then put down their injured foot and hold themselves up on that foot without moving for about 30seconds. I ask them to repeat this 3 times and do it a couple of times a day if tolerated.
- Eccentric Exercises: these involve contracting a muscle but allowing it to lengthen which in terms of the Achilles Tendon simply means lowering yourself down from tip toes to flat. These are really good for when you are doing the isometric exercises and are getting minimal symptoms and feel that your Achilles Tendon needs pushing on further. When advising my patients to do these I ask them to raise themselves up on their good foot into a tip toed position, place their affected foot down and then lower down slowly (taking 1 -2 seconds to lower down). I like them to repeat this 10 times.
- Concentric Exercises: these are very simple and are just your basic heel raises from a flat position on the floor to up on your toes. For me these are a natural progression from the first two and take the Achilles Tendon through a good range and put it under a bit more load than the other two exercises. Being able to do these exercises well and without significant symptoms is a good sign and usually indicates that the patient is ready to move onto further loading of the tendon.
- Weighted Heel Raises: once someone can do simple heel raises without much discomfort it is important to continue loading and strengthening the tendon further as just being able to do some heel raises pain free is unlikely to have fully rehabbed the Achilles Tendon sufficiently to make it strong enough to fully return to training. So, I generally like patients to progress onto weighted heel raises. These can be done really simply by putting a rucksack on your back, sticking some weight in to it and then doing your concentric heel raises as described earlier.
The most important idea to take on board when considering these exercises for Achilles Tendinopathy is that they attempt to progressively build up the load on the tendon. There are many specific protocols out there for rehabbing Achilles Tendinopathy and generally they will all help but in my experience the actual protocol is not as important as following the general principles of progressively increasing the load upon the tendon.
Are My Achilles Tendinopathy Exercises Meant to Hurt?
This is an important issue that a patient trying to strengthen their Achilles Tendon will face and one that is difficult initially to be certain of but needs some thinking about when trying to decide which exercises are best and what level to start with. So, the short answer to the question above is that yes, some pain is acceptable when doing Achilles Tendon rehab but you need to be careful about how much pain and your symptoms worsening after the exercise. As the exercises are provoking and strengthening your Achilles Tendon it is likely (especially in the early days of recovery) that they will be uncomfortable but they should not make it worse afterwards or in the night after. My general advice to patients with Achilles Tendinopathy is that their exercises are allowed to be uncomfortable but they should not exceed 4-5/10 on a pain scale and more importantly they should not flare symptoms afterwards. So, I always advise going easy on the exercises for the first few days so that they can get an idea of how their Achilles Tendon will react to the exercises. For example if they are doing eccentric heel raises and they feel okay with a slight bit of discomfort (2/10 pain scale) and do not worsen pain or stiffness afterwards then this is a good sign that they can progress their exercises and either do some more reps or move onto the next stage.
One thing to consider is that I would strongly advise getting an assessment with a physiotherapist who has experience of Achilles Tendinopathy and who can then guide you on the best exercises and how hard to push things. No amount of information here can really replace that assessment and guidance process by the physio for your Achilles Tendinopathy and nor should it. This information is really only for those trying to get a bit more information about their Achilles Tendinopathy.
How Long Will it Take for My Achilles Tendinopathy to Heal?
This is a question I get asked a lot and the answer to this will very much depend upon how severe your pain is, how long you have been in pain with your Achilles Tendon and the stage that the tendon itself is at. If you catch things early and do not let the pain in your Achilles Tendon become too severe then recovery is much quicker. Usually if caught early enough then it is possible to get the pain under control quickly (say a week or so) but the tendon itself is still likely to be very sensitive to training and load and so load management and good rehabilitation is vital at this stage. A reasonable timeframe if caught early enough would be 8 – 12 weeks before you will be fully fit again but obviously this very much depends upon the stage that your tendon is at.
What Exercises or Activities Should I Avoid for my Achilles Tendinopathy
Mainly it is important to avoid aggravating your tendon any more than is necessary, usually this will involve avoiding steep hills, doing any deep squats, stretching your ankle or heel down over a step (this is likely to compress your tendon which will aggravate it). You also need to avoid any footwear that particularly squashes or compresses your Achilles Tendon or just simply feels uncomfortable.
How Can ThreeSpires Physiotherapy Help with My Achilles Tendinopathy?
Physiotherapy is extremely helpful if you have developed Achilles Tendinopathy and one of our physiotherapists who is experienced with managing and treating Achilles Tendinopathy will be able to help. We can help in a number of ways:
- Assessment & Diagnosis of Achilles Tendinopathy: this as mentioned earlier is a vital part of healing your tendinopathy and the sooner you have an assessment the sooner you will know what you are dealing with. Our physiotherapists will be able to comprehensively assess your Achilles Tendinopathy, make a diagnosis and also identify underlying biomechanical causes of your Achilles Tendinopathy such as hip weakness.
- Load Management Plan: once a diagnosis of Achilles Tendinopathy has been made it is vital that you get a clear and comprehensive plan to reduce the load and irritation on your tendon and begin healing and recovering. Your physiotherapist will be able to identify which stage your Achilles Tendon is at and what the appropriate load will be to promote recovery. They will be able to assess and guide you through this process to optimise your return to training and activity.
- Exercises for Achilles Tendinopathy: your physiotherapist will be able to determine which are the most appropriate exercises for your Achilles Tendinopathy and will be able to prescribe the optimum number and frequency to promote recovery.
- Treatment for Achilles Tendinopathy: In conjunction with load management and exercises your physio will be able to use soft tissue and hands on techniques to treat any areas of your legs that have become overloaded and tight.
- Supplementary Exercises for Achilles Tendinopathy: as part of your assessment for Achilles Tendinopathy your physiotherapist will also look at strength and biomechanics in your legs and see if there are any imbalances or weaknesses that might be contributing towards your tendon getting overloaded. As such they will likely prescribe a series of other exercises designed to improve strength and control and reduce the likelihood of you developing Achilles Tendinopathy in the future.
Okay, I hope that you have found this article about Achilles Tendinopathy helpful, over the next few months we will be doing a series of further articles about other tendinopathies and the best exercises and some of the latest research surrounding tendinopathies. Should you or anyone you know have developed Achilles Tendinopathy please get in touch and one of our physios would be happy to help.
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