Achilles Tendinopathy

Tendinopathy describes an unhappy Achilles tendon.  This means the Achilles tendon has failed to heal itself following injury. In the early phases of disease there may be inflammation of the lining around the tendon and this is known Achilles tendonitis.

After a while the tendon is no longer inflamed but starts to degenerate (meaning the normal tendon structure becomes disorganised) and this is then known as Achilles tendinopathy. The body attempts to repair the microdamage within the tendon and then often the result is a swollen bump on the heel.

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What causes Achilles tendinopathy?

There are two types of Achilles tendinopathy, insertional at its lower end, where it attaches to the heel bone, and non-insertional (or midsubstance) within the centre of the tendon (away from the heel).

Achilles tendinopathy is most likely to be an overuse injury, which is where the forces applied to the tendon, are more than the tendon can withstand. These small ‘micro tears’ can occur after injury. Such problems often follow an increase in activity or a change in training pattern, but could occur if you change your training or work shoes.

With age, tendons become less stretchy (or less elastic) and also the blood supply to the mid-portion of the Achilles tendon reduces, and this means that in the mid 30’s to mid 40’s, Achilles tendon problems become more common.

Are there any risk factors for Achilles tendon problems?

There are a number of risk factors for Achilles tendon problems. These include:

  • Tightness of the calf muscles and hamstrings.
  • Flat feet (or collapsing arches whilst walking, known as ‘overpronation’)
  • High arches
  • Change in training levels
  • Poor running technique
  • Problems with footwear.

What are the Symptoms?

The main symptom is pain. This can be felt as a burning ache in the heel, but sometimes a stabbing pain, and often occurs the day after a bout of activity.

You may feel a bump in your Achilles tendon and this is usually about 3-5cm above the heel bone and this represents a swollen tendon (non insertional).

In insertional Achilles tendinopathy you may have a ‘pump bump’ which is where the swelling is close to where the tendon inserts into the bone and may represent a swollen fluid filled sac, called a bursa.

How is Achilles Tendinopathy Diagnosed?

It is diagnosed based on the history and findings of a clinical examination. It is not always necessary to perform further investigations but an ultra-sound scan or an MRI scan, can be helpful in certain cases.

How is Achilles tendinopathy treated?

The vast majority of patients with Achilles tendinopathy do not require surgery.

The aims of treatment are to find any underlying cause and treat it and to get the tendon to try and repair itself.

Initial Treatment:

During the initial stages of disease, you should rest and ice the area, and consider the use of ‘over the counter’ anti-inflammatory medication (such as ibuprofen). This also prevents further damage. Do not try to train during this period.

Physiotherapy

After the initial acute pain and swelling has gone down, physiotherapy can be very effective in trying to retrain the remaining ‘normal’ tendon to compensate for the damaged area of tendon. The regime that has been shown to be effective is known as ‘eccentric exercises’. These exercises should really only be performed under the guidance of a specialist musculoskeletal physiotherapist and you must be prepared to be patient as it takes between 6-12 weeks for this treatment to be effective.

Your physiotherapist will also assess your general posture and core stability and teach you specific exercises to help with this.

Orthotics

In some patients insoles (orthotics) with a supportive arch can be helpful in preventing collapsed arches and can help to offload the Achilles tendon. A temporary heel lift may be also be used in the early stages of treatment to help off load the Achilles tendon.

Shockwave therapy

This is a non-invasive treatment, which is normally used as a second line treatment after physiotherapy has been tried or can be used in conjunction with physiotherapy.shockwave

Shockwave therapy is applied over the painful area by your doctor and high frequency pulses are passed through the skin to the affected region. The treatment lasts about 5 minutes and is repeated three times, at weekly intervals.

Its use has been approved by NICE (National Institute for Health and Clinical Excellence), providing it is part of an audited practice. No anaesthetic or surgery is required.

Steroids and Snake Oils?

We do not recommend the use of steroids for Achilles Tendinopathy due to the risk of tendon rupture. Just occasionally an injection of steroid can be helpful for tenosynovitis where the lining of the tendon is inflamed, but this must be carried out by an expert, under ultrasound control.

There are many treatments recommended in the private sector, which are not listed here. These include platelet rich plasma (PRP), cryotherapy, and high volume saline injections. We cannot recommend any of these treatments at this stage, and caution you against undergoing these until better medical evidence is available to justify their use. Where clinical studies have been carried out, they in the main have shown none of these treatments to be any more effective than placebo (Magnussen et al, 2009).

Stem Cells are being tested for Achilles tendinopathy in an MHRA registered clinical study. This is a formal study being funded by the UK Stem Cell Foundation and volunteers are recommended to visit the UKSCF website.

Surgery

Surgery is only advised in those who have failed to improve with non-surgical treatments, this is because the results of surgery are unpredictable and carries a small risk of complications. Advice from a specialist orthopaedic foot and ankle specialist is recommended.

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