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Achilles tendinopathy is a condition that affects the Achilles tendon, which is the tendon connecting the calf muscle to the heel bone.

The Achilles tendon is the strongest and biggest tendon in our body and has the ability to resist large tensile forces. It originates from a distal joining of the gastrocnemius and soleus muscle and inserts at the bottom of the calcaneus.

The blood supply throughout the tendon is poor due to the small number of blood vessels that exist, especially in the region just above the calcaneus. This poor blood supply can result in a slower healing rate after injury or trauma.

The Achilles tendon is responsible for helping us walk, run, jump, and perform other physical activities. When running, the Achilles tendon experiences a force approximately 6-8 times of a person’s body weight every step. Due to this repetitive overload, the Achilles tendon is highly vulnerable to overuse injuries, such as Achilles tendinopathy.

Achilles tendinopathy is caused by repetitive stress to the tendon, which can result in changes of the tissue in the Achilles or sometimes small tears. The most common cause of the condition is overuse, particularly in athletes who engage in high-impact sports such as running. However, it can also occur in individuals who have been inactive for a long period of time and then suddenly increase their physical activity. When it becomes painful and inflamed, it can greatly affect an individual’s daily activities.

Causes of injury (aetiology)

The causes of Achilles tendinopathy are complex and multifactorial, meaning the development of Achilles tendinopathy is often a result of multiple factors, and individual risk factors may interact with one another to contribute to the development of the condition. However, some commonly identified causes include:

  1. Overuse/Overload: Overuse is one of the primary causes of Achilles tendinopathy. Repetitive stress on the Achilles tendon from activities such as running, jumping, or playing high-impact sports can cause small tears in the tendon, leading to microtrauma, degeneration, and ultimately tendinopathy.
  2. Training errors: Sudden increases in training intensity, duration, or frequency can place excessive stress on the Achilles tendon, leading to tendinopathy.
  3. Foot structure: People with flat feet or high arches are at a higher risk of developing Achilles tendinopathy because their foot structure can place more stress on the Achilles tendon.
  4. Poor footwear: Wearing shoes that do not facilitate adequate foot shape, position and biomechanics can contribute to the development of Achilles tendinopathy.
  5. Altered Biomechanics: poor foot and lower limb mechanics may increased the strain placed on the Achilles.
  6. Age: As we age, the tendons in our body become less elastic and more prone to injury. This can increase the risk of developing Achilles tendinopathy.
  7. Systemic factors: Certain systemic factors, such as diabetes or rheumatoid arthritis, can also increase the risk of developing Achilles tendinopathy.
  8. Medications: Some medications, such as corticosteroids, have been associated with an increased risk of Achilles tendinopathy.
  9. Genetics: There may be a genetic component to the development of Achilles tendinopathy, as some people may be predisposed to the condition due to their genetic makeup.

Identifying and addressing these risk factors is an important part of managing and preventing Achilles tendinopathy.

Common signs and symptoms

Some of the common signs and symptoms of Achilles tendinopathy include:

  1. Pain: Pain is one of the most common symptoms of Achilles tendinopathy. The pain is typically located in the back of the heel and may be mild at first, but it can become more severe over time. The pain may be worse with physical activity and improve with rest.
  2. Stiffness: Stiffness in the calf muscle or the ankle joint is another common symptom of Achilles tendinopathy. The stiffness may be worse in the morning or after periods of rest.
  3. Swelling: Swelling around the Achilles tendon is also a common symptom of tendinopathy. The swelling may be mild at first but can become more severe over time.
  4. Tenderness: Tenderness around the Achilles tendon is also a common symptom of tendinopathy. The area may be tender to the touch and may feel warm or inflamed.
  5. Reduced range of motion: Reduced range of motion in the ankle joint is another symptom of Achilles tendinopathy. The reduced range of motion can make it difficult to perform physical activities that require ankle movement.
  6. Weakness: Weakness in the calf muscle or the ankle joint is also a common symptom of Achilles tendinopathy. The weakness may be more noticeable when trying to push off the ground or climb stairs.

TREATMENT

The goal of Achilles tendinopathy treatment is to improve the ability of the tendon and associated muscles to work and manage load, which is known as the energy storage capacity. This allows the tendon to act like a ‘spring’ in storing and then releasing energy. The three key exercises for Achilles tendinopathy are:

 

  1. Isometric loading – Achilles tendon holds.

Isometric tendon loading has pain-relieving effects, while also maintaining some baseline strength.

Depending on the symptoms and tendon irritability, Achilles tendon holds can either be performed double leg or single leg and can either be held mid or end of the range.

  1. Isotonic loading – Calf raises.

The goal of isotonic loading is to develop strength in the tendon and the surrounding muscles. In Achilles tendinopathy, the strength of the soleus and gastrocnemius muscles plays a major role.

These exercises are often commenced once the patient’s pain level and the tendon’s irritability reduces.

Isotonic seated calf raises can be performed with a gradual increase in loading. Each repetition should take 3-6 seconds to develop tension in the tendon.

Isotonic standing calf raises should be performed at the mid-range of the muscle’s movement. This ensures the tendon is not compressed, which can occur at the end of the range when exercising with heavier loads.

  1. Energy storage loading – Plyometric exercises

These exercises help the tendon to regain its capacity to absorb and then release energy via the stretch-shortening cycle.

These exercises are crucial to rehabilitation and can be commenced when the patient is progressing well with isotonic calf raises, has very mild tenderness when the Achilles tendon is touched, and has been able to tolerate light running without a flare-up in symptoms.

Plyometric exercises include:

o   Double-leg hop

o   Single leg hop

o   Single leg step hops

o   Hopscotch with activation band

Along with soft tissue occupational therapy, other treatment options include:

Load Management: Reducing the amount of stress on the Achilles tendon is the first step in treating tendinopathy. This can be achieved by modifying the amount of stress/load placed on the tendon. However, completely stopping any exercise/load should be avoided as it can cause atrophy and doesn’t fix the issue.

Manual therapy: Joint mobilisation can be used if joint restriction is present, and soft tissue techniques can be used to facilitate increased healing of the tissues as well as pain modulation.

Taping: Rigid taping can be used to decrease the strain on the Achilles tendon and/or alter foot posture in patients with Achilles tendinopathy.

Dry needling: Dry needling can be utilised in combination with exercise rehab.

Medication: Over the counter pain medication, may be an option is some cases but shouldn’t be the first line of treatment.

CONCLUSION

Achilles tendinopathy can be a painful and debilitating condition, but with proper treatment, it can be managed. It is important to seek medical attention as soon as possible if you are experiencing symptoms in order to start the recovery process. With the correct rehab, Achilles tendinopathy can be rehabilitated well and efficiently.

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