What is Achilles Tendonitis? (Tendinitis)
Achilles heel pain is a common complaint our podiatrists encounter. It’s often called achilles tendonitis or achilles tendinopathy. It can be described as inflammation of the achilles tendon, or pathology of the achilles tendon. The achilles tendon is the large tendon at the back of the lower leg that anchors the calf muscles to the heel bone (calcaneus). Repetitive use of the calf muscles and, subsequently, the achilles tendon can lead to microscopic tears within the substance of the tendon. To repair these microscopic tears, the body commences an inflammatory response.
The tendon will present as swollen, painful and inflamed due to injury or most commonly, overuse. Pain can sometimes be replicated with tension or squeezing along the tendon at the back of the ankle or lower leg into the heel.
Early intervention and treatment is recommended as, left untreated, further injury can develop including tendon rupture or chronic achilles tendinosis. Achilles tendon injures can be painful and quite debilitating, often reducing free movement and activity.
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What is the difference between Achilles Tendonitis and Achilles Tendinosis?
The difference between achilles tendinosis and tendinitis is primarily time. Tendinitis is an acute condition in which inflammation is caused by a direct injury to a tendon. By contrast, tendinosis is a chronic degeneration of the achilles tendon without the typical intratendinous inflammation. Achilles tendinosis is usually seen when acute achilles tendinitis fails to heal completely and the condition becomes chronic. Achilles tendinosis will usually require more stimulation of the blood supply in an effort to promote healing.
Early intervention and treatment is recommended as, left untreated, further injury can develop including tendon rupture or chronic achilles tendinosis. Click To Tweet
What Causes Achilles Tendonitis?
Common causes include:
- Overuse injury to the tendon. This occurs when the achilles tendon is loaded excessively and constantly stressed. Inflammation and swelling can occur as a result of the constant stress and small tears can also develop.
- Poorly functioning feet and an increase in mechanical stress through the achilles tendon. Flat feet (feet that turn inwards) create a bow of the tendon and creates a tight constant strain on the heel, resulting in painful inflammation. This abnormality should be neutralised using foot orthotics to reduce the strain on the tendon and to help stop recurrence of injury.
- Certain types of training and maximum load training may also lead to inflammation to the Achilles tendon. A sudden increase in training, excessive hill running, and speed work can also lead to inflammation of the achilles tendon. High load sports (i.e. basketball, netball) can also contribute to stress on the tendon. Jumping and high volume running can overload the achilles tendon and increase inflammation.
- Footwear choice is very important. Choosing the correct footwear which suits your foot type, your sport and your exercise level is vital. Wearing inappropriate shoes (minimal support) while walking or running can increase the risk of achilles tendonitis. Sandals and high heels can also increase the load through the tendon and potential for inflammation. Cushioned shoes or innersoles which are worn out can cause the heel to sink into the shoe and no longer provide sufficient shock absorption. This increased aggravation through straining and pulling the tendon can aggravate and trigger pain.
- Tight calf and hamstrings (posterior chain) may also contribute to prolonged achilles troubles. The continual strain they exert on the tendon could be inhibiting any treatment management options.
- Being overweight can also increase the risk of achilles tendonitis. Holistically, it can put a strain on all parts of the body. Often the increase in load and forces through the tendon can cause inflammation if stressed. This can be a vicious cycle as once the level of exercise increases, so does the load and strain which causes the pain which then ceases exercise levels.
- Inflammatory conditions like arthritis can cause achilles tendonitis. These can cause generalised inflammatory arthritis, such as ankylosing spondylitis or psoriatic arthritis.
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Diagnosis of Achilles Tendonitis
If you have or suspect you have achilles tendinopathy, you should consult your podiatrist.
Initially, it’s important to diagnose the problem and establish the severity. We will determine an appropriate treatment plan and time frame for improvement.
Assessment methods include:
- Medical and injury history – where, when, footwear, exercise habits, other important factors (job, previous/other injuries)
- Imaging may be requested – X-ray, ultrasound and potentially MRI scan of the problematic tendon(s). Occasionally blood tests can be used to assess inflammatory conditions
- Physical biomechanical examination and assessment – foot posture, gait analysis, hands on approach (thickness and tenderness of the tendon)
How is Achilles Tendonitis Treated?
Like many conditions, Achilles tendonitis responds well to early conservative treatment. If ignored and disregarded, the symptoms can continue, and the condition can become chronic. The aim is to reduce strain and load on the tendon and reduce inflammation, in turn, reducing pain.
Like many conditions, Achilles tendonitis responds well to early conservative treatment. Click To Tweet
There is no solo treatment to reduce symptoms of achilles tendonitis, it is important to follow a specific treatment combination once the diagnosis has been confirmed.
Achilles tendonitis treatment and management strategies include:
- Training or Activity Modification. This is important to reduce strain on the achilles tendon. Whilst it is important to keep moving, the change of load (i.e. high volume jumping) will allow healing to commence. This will also aid in successful treatment and rehabilitation of the affected tendon. Avoiding activities that increase pain will reduce aggravation to the inflamed area.
- Heel raises are a temporary short-term measure. The aim is to decrease load and strain on the achilles tendon in the short term during tendon rehabilitation.
- Orthoses (shoe inserts) aid in the correction of body mechanics. The are designed to allow the foot to function within a desired range and to reduce excessive load or damaging forces. The aim is to realign the forces on the rear foot and to reduce tendon overload. This will help to promote healing in the longer term.
- Extracorporeal Shock Wave Therapy (ESWT) – This form of treatment is widely used for treatment of soft tissue conditions. ESWT is best used as part of the treatment plan for chronic conditions such as achilles tendinosis. ESWT helps to increase blood flow and healing to the chronically injured achilles tendon. Radial shock waves are high energy sound waves which help to increased blood flow and metabolic activity around the site of pain, accelerating the healing process. Shock wave therapy also effectively reduces pain by increasing analgesic effects in the area. Studies have shown best results are achieved by applying 3 to 4 treatments at 7 to 14 day intervals.
- Stretching and strengthening exercises will be prescribed where appropriate and will vary depending on whether your achilles tendon injury is acute or chronic. Correctly performed eccentric strengthening exercises may be appropriate for achilles tendinosis but not at all suitable for a ruptured achilles tendon. Progressive loading of the tendon is important in restoring function and strength. Reducing pain and inflammation . An eccentric loading program can be shown by your podiatrist.
- Massage can help with restoring the extensibility of the tendon, increase strength and promote full recovery.
- Dry Needling/Trigger Point Therapy can also be very helpful as part of your treatment program.
- Anti-inflammatory medication is again, a short-term option. Non-steroidal anti-inflammatory drugs can be used (if it is safe to do so) to reduce inflammation to the Achilles tendon.
- Surgery is only recommended if all other conservative treatment options have failed after a prolonged time. However, if the tendon has ruptured then surgery is necessary to re-attach the tendon.
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