Achilles Tendinopathy

Achilles tendinopathy is a condition that causes pain, swelling and stiffness of the Achilles tendon that joins your heel bone to your calf muscles. It is thought to be caused by repeated tiny injuries to the Achilles tendon. These may occur for a number of reasons, including overuse of the tendon – for example, in runners. Treatment includes rest, ice packs, painkillers and special exercises to help to stretch and strengthen the Achilles tendon. For most people, the symptoms of Achilles tendinopathy usually clear within 3-6 months of starting treatment.

What is the Achilles tendon?
Your Achilles tendon is an important part of your leg. It is found just behind and above your heel. It joins your heel bone (calcaneum) to your calf muscles. The function of your Achilles tendon is to help in bending your foot downwards at the ankle.

What is Achilles tendinopathy and what causes it?
Achilles tendinopathy is a condition that causes pain, swelling and stiffness of the Achilles tendon. It is thought to be caused by repeated tiny injuries (known as microtrauma) to the Achilles tendon. After each injury, the tendon does not heal completely, as should normally happen. This means that over time, damage to the Achilles tendon builds up and Achilles tendinopathy can develop.

There are a number of things that may lead to these repeated tiny injuries to the Achilles tendon. For example:
Overuse of the Achilles tendon. This can be a problem for people who run regularly. (Achilles tendinopathy can also be a problem for dancers and for people who play a lot of tennis or other sports that involve jumping.)
Training or exercising wearing inappropriate footwear.
Having poor training or exercising techniques – for example, a poor running technique.
Making a change to your training programme – for example, rapidly increasing the intensity of your training and how often you train.
Training or exercising on hard or sloped surfaces.

Achilles tendinopathy is also more common in people who have certain types of arthritis, such as ankylosing spondylitis or psoriatic arthritis. It is also thought that your genetic ‘makeup’ (the material inherited from your parents which controls various aspects of your body) may play a part for some people who develop Achilles tendinopathy. It is also more common in people who have high blood pressure, high cholesterol or diabetes

People who are taking medicines from a group called fluoroquinolones (for example, the antibiotics ciprofloxacin and ofloxacin) also have an increased risk of developing Achilles tendinopathy.

Achilles tendinopathy used to be known as Achilles tendonitis. In general, ‘itis’ usually refers to inflammation, so tendonitis would mean inflammation of a tendon. However, Achilles tendinopathy is now thought to be a better term to use because it is thought that there is little or no inflammation that causes the

How common is Achilles tendinopathy?
About 6 in 100 inactive people develop Achilles tendinopathy at some point in their lifetime. However, the chance of it developing is higher in athletes or those who train regularly or do a lot of exercise. It can be a particular problem for some runners.

What are the symptoms of Achilles tendinopathy?
The main symptoms include pain and stiffness around the affected Achilles tendon. Pain and stiffness tend to develop gradually and are usually worse when you first wake up in the morning.

Pain due to Achilles tendinopathy may actually prevent you from being able to carry out your usual everyday activities such as walking to the shops, etc. You may notice that you have pain when you touch the area around your Achilles tendon. There may also be some swelling around this area.

Do I need any investigations?
Your doctor / physiotherapist will usually diagnose Achilles tendinopathy because of your typical symptoms and from examining your Achilles tendon. They may feel for swelling or tenderness of the tendon. They may also ask you to do some exercises to put some stress on your Achilles tendon.

X-rays or other tests are not usually needed to diagnose Achilles tendinopathy. However, an ultrasound scan or an MRI scan may sometimes be suggested by a specialist if the diagnosis is not clear.

What is the initial treatment for Achilles tendinopathy?
There are a number of treatments that may help. The treatments below are usually suggested first. They are all considered as conservative treatments. This means treatments that do not involve surgery.

Rest and time off from sporting activities are important if you have Achilles tendinopathy. At first, you should stop any high-impact activities or sports (such as running). As pain improves, you can restart exercise as your pain allows. It is thought that complete rest, if it is prolonged, can actually be worse for the injury. Talk to your doctor or physiotherapist about when you should start exercising again.

Painkillers such as Paracetamol may help to relieve pain. NSAIDs are a group of drugs that may help the inflammation. These however must not be used for more than 7-14 days if you have Achilles tendinopathy. This is because they may possibly reduce the ability of the tendon to heal in the long term. They may also cause symptoms of Achilles tendinopathy to be masked, or covered up, which again may delay healing.

Ice packs
Ice treatment may be useful for pain control and may help to reduce swelling in the early stages of Achilles tendinopathy. An ice pack should be applied for 10-30 minutes. Less than 10 minutes has little effect. More than 30 minutes may damage the skin. Make an ice pack by wrapping ice cubes in a plastic bag or towel. (Do not put ice directly next to skin, as it may cause ice burn.) A bag of frozen peas is an alternative. Gently press the ice pack on to the injured part. The cold from the ice is thought to reduce blood flow to the damaged tendon. This may reduce pain. Do not leave ice on while asleep.

Achilles tendon exercises & Treatment
Some special exercises to help to stretch and strengthen your Achilles tendon have been proven to be helpful. You should aim to do these every day. Such exercises may help with pain control and stiffness. A physiotherapist may be able to help you with these exercises as needed. They may also use other treatments such as ultrasound , shockwave , acupuncture and massage to help relieve symptoms and promote healing of your Achilles tendon.

The following Eccentric Exercises can be used to help treat Achilles tendinopathy:
Stand on both feet. Use your unaffected leg to raise up on to tiptoes. Transfer your weight across to your affected leg and lower yourself down slowly to the count of 6 seconds. Repeat and aim for three sets of 15 repetitions twice each day. The standing on tiptoe exercise should be performed with your knees straight and with your knees bent. There is then a weekly progression that follows and this exercise regime will go on for many weeks. It could be a 12 week process.
Keep a towel (or a long piece of elastic) by the side of your bed. First thing in the morning, before you get out of bed, loop the towel around the ball of one of your feet. Then pull the towel towards you, keeping your knee straight. Hold the pull for about 30 seconds. This exercise will pull your toes and the upper part of your foot towards you. Repeat this exercise three times for each foot.

An orthotics specialist may suggest changing your footwear or putting special inserts in your shoes, such as inserts to lift your heel. This may help to reduce pain and symptoms.

Specialist treatments that are not surgery
There are some treatments that some specialists may suggest to help treat Achilles tendinopathy.

Extracorporeal shock-wave therapy – during this treatment, special sound waves are passed through your skin to your Achilles tendon. A Physiotherapist at a large Medical Centre should have a Machine. It usually requires 6-8 treatment sessions with this modality , with treatments weekly apart. This treatment sparks the healing process of the tissues .

Injection using your own blood – it is possible for a specialist to take some of your own blood (in the usual way) and to inject this around your Achilles tendon. This is called autologous blood injection ( PRP injections ). The idea is that this will help to promote healing of your damaged tendon by encouraging the growth of cells involved in the healing process. The specialist may use an ultrasound scan to help guide their injection.

Surgery for Achilles tendinopathy
Around 1 in 4 people who have persisting pain due to Achilles tendinopathy has surgery to treat the condition. Most people have a good result from surgery and their pain is relieved. Surgery involves either of the following:
Removing nodules or adhesions (parts of the fibres of the tendon that have stuck together) that have developed within the damaged tendon.
Making a lengthways cut in the tendon to help to stimulate and encourage tendon healing.

Complications from surgery are not common but, if they do occur, can include problems with wound healing.

Are there any complications of Achilles tendinopathy?
There is a risk of tearing (rupturing) your Achilles tendon if you have Achilles tendinopathy. This is because the tendon is damaged and weaker than usual. However, this risk is usually quite low. Severe pain around the Achilles tendon that develops suddenly may be a sign of tendon rupture. See a doctor urgently if you think that you may have ruptured your Achilles tendon.

If you do have problems with one Achilles tendon, there is also an increased chance that you will develop problems with the other over time.