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Achilles Tendinopathy

What is it?

The Achilles tendon is the largest and strongest tendon in the body, however is a very vulnerable tendon from the load that is put upon it during activity. The tendon’s structural capacity is confronted by functional demands that can be up to 12 ½ times a person’s body weight while running.


The Achilles tendon may be acutely strained or ruptured as a result of an excessive stretch or eccentric force. Acute injuries that cause inflammation are characterized by repeated overload, microtearing, failed healing, and tendon degeneration.


Gait pattern mechanics is important to understanding Achilles tendon injuries. When the foot has become ineffective with shock absorption it will result in stress on the ligament attachment at the calcaneus.


Most people affected are middle-age males in their third to fourth decade of life. Patients who have already suffered from an Achilles tendon rupture are at a significantly higher risk for contralateral tendon rupture.


Two-thirds of all Achilles tendon injuries involve athletes. Runners are up to 10 times more likely to suffer Achilles tendon injuries. One in twenty recreational runners will develop some type of Achilles tendinopathy.


Some risk factors for Achilles injury include improper warmup, overtraining, cold weather training, running on a hard surface, excessive stair or hill climbing, improper arch support or bad footwear, poor conditioning, and abruptly returning to activity after a long period of time with inactivity. Wearing high heels can predispose patients to Achilles issues due to the heels causing a shortening of the gastrocnemius and the soleus.


Some systemic risk factors for Achilles injury include diabetes, hypertension, inflammatory arthropathy, gout, and the use of corticosteroids or fluoroquinolone antibiotics. Obese patients carry a 4-6 times higher risk of deveoping Achilles tendinopathy.


Symptoms

Some chief complaints include pain or tenderness in the tendon or heel that increases with activity, especially walking or running. Patients may tell the clinician they have problems with standing on their toes or walking steps, particularly going down the steps. Pain and stiffness in the morning are commonly reported with patients with Achilles tendinopathy. Patients may report warmth and swelling that increases throughout the day and with activity.


The clinician may palpate along the Achilles tendon to locate the site of the injury. Those with pain near the insertion or where the Achilles attaches to the calcaneus, there may also be evidence of bony enlargement or spurring on the back of the heel.


Range of motion testing will likely reveal deficits in passive dorsiflexion and pain with resisted plantar flexion. Clinicians


Repetitive irritation of either tendon may lead to inflammation, scar tissue formation, and adhesions.


Clinicians should assess all areas of the kinetic chain to see if there are any functional deficits that may be contributing to the issue. They will look for weakness of the posterior tibialis by observing the patient’s heel position when they are standing. Gastroc and soleus flexibility will also be assessed, along with hamstring and knee flexor strength in order to help catch risk factors of Achilles tendon issues.


Diagnosis

Radiographs are often unnecessary for the diagnosis of Achilles tendinopathy. The diagnosis of tendinopathy is based on clinical findings, and imaging should be reserved for special cases. Radiographs may be used with trauma or if the patient has an altered gait due to pain.


Management

Nonoperative treatment is the main course of action with Achilles tendinopathy. The current standard of treatment is a combination of rest, eccentric rehabilitation, and correction of mechanical issues. Studies show that conservative care has excellent results in up to 85% of patients.


Initially, patients may need to limit some of the previous activities they were doing before.


Studies have shown that standing eccentric exercises that incorporate maximal dorsiflexion are most effective. Evidence supports a slowly progressive loading program, rather than complete rest.


Rehabilitation should begin with moderate effort and low repetitions. The response to the amount of load given to the patient’s body can be assessed through change at night. An increase in night pain usually indicates that the current rehab load is too much.


Soft tissue manipulation, stretching, and myofascial release techniques are necessary to promote flexibility of the calf muscles. Stretching of the calf muscles should be performed with the knee straight to access gastroc and performed with knee bent to access the soleus. Acupuncture may be beneficial for a patient with Achilles tendinopathy.


The clinician should consider the use of IASTM (instrumented assisted soft tissue mobilization) to release adhesions within the Achilles tendon. IASTM may help accelerate healing, through controlled microtrauma.


Manipulation may be needed to eliminate restrictions in the kinetic chain, particularly within the ankle.


Arch orthotics may be necessary to correct hyperpronation.


Cortisone injections are unproven for a treatment for Achilles tendinopathy and carry a possible increased risk of a tendon rupture. Surgical management is often considered only for Achilles ruptures.


Athletes should introduce new activities slowly and avoid increasing activity, especially running, by more than 10% per week. Runners should begin on smooth surfaces and start out at a lower intensity and distance. They should increase their distance first then their pace. Athletes with Achilles tendon should avoid activities on an unlevel surface, including hills.





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